Physical Therapy
for Vestibular Disorders

Physical Therapy for Vestibular Disorders (Dizziness and Imbalance)

What is a vestibular (inner ear) disorder?
Do I need vestibular physical therapy?
What should I expect during a vestibular physical therapy evaluation?
What exercises will I do in vestibular physical therapy?
What is Benign Paroxysmal Positional Vertigo (BPPV) and how do we treat it?
What is Persistent Postural-Perceptual Dizziness (PPPD) and how do we treat it?

What is a vestibular (inner ear) disorder?
Approximately 35% of adults over age 40 in the United States have experienced dizziness and/or imbalance due to some type of vestibular disorder; that’s approximately 69 million Americans! Your vestibular system is a specialized and delicate “balance center” located within your inner ear. It has a special connection to your brain to keep you balanced and upright when walking and moving around. It also helps to keep your vision stable when your head and eyes are moving around so that you can see things clearly. A disease or injury affecting the vestibular system causes vestibular disorder.

Vestibular disorders can result in symptoms including, but not limited to:

• Vertigo: the perception of movement/spinning, either of the self or environment
• Dizziness: general term that describes light-headedness, floating sensation or feeling faint
• Imbalance: the feeling of being off-balance or a loss of equilibrium
• Visual changes: blurry, distorted or jumping vision – often when moving head or body quickly
• Hearing changes: tinnitus (ear ringing), hearing loss, ear fullness

Dizziness is even more common among older adults. 80% of adults over age 65 have experienced dizziness with 50% being due to a vestibular disorder known as Benign Paroxysmal Positional Vertigo (BPPV). 

Other diagnoses that can create vestibular dysfunction include:

• Vestibular hypofunction
• Labyrinthitis
• Vestibular neuritis
• Bilateral vestibulopathy
• Vestibular schwannoma (acoustic neuroma)
• Benign Paroxysmal Positional Vertigo (BPPV)
• Concussion and post-concussion syndrome
• Traumatic brain injury
• Vestibular migraine
• Persistent postural-perceptual dizziness (PPPD)
• Stroke
• Cerebellar disorders (ataxia)
• Multiple Sclerosis

Reference:
Agrawal, Y., Carey, J. P., Della Santina, C. C., Schubert, M. C., & Minor, L. B. (2009). Disorders of balance and vestibular function in US adults: data from the National Health and Nutrition Examination Survey, 2001-2004. Archives of internal medicine, 169(10), 938-944.

Do I need vestibular physical therapy?
You may benefit from vestibular rehabilitation if you answer yes to any of the questions below.

• Do you lose your balance and fall?
• Do you feel like the room is spinning or you get dizzy when you lay down or roll over in bed, bend over to the floor or look up onto the top shelf?
• Do you feel like you are moving when you are standing or sitting still?
• Do you feel light-headed?
• Do you have blurred vision when you quickly move your head?
• Do you feel dizzy or off balance when you move your head or turn around?

You may also benefit from vestibular rehabilitation if you have been diagnosed with one of the following disorders or conditions:

• Vestibular hypofunction
• Labyrinthitis
• Vestibular neuritis
• Bilateral vestibulopathy
• Vestibular schwannoma (acoustic neuroma)
• Benign Paroxysmal Positional Vertigo (BPPV)
• Concussion and post-concussion syndrome
• Traumatic brain injury
• Vestibular migraine
• Persistent postural-perceptual dizziness (PPPD)
• Stroke
• Cerebellar disorders (ataxia)
• Multiple Sclerosis

You should be evaluated by your physician before starting physical therapy for dizziness or imbalance. You can request a referral for therapy from a primary physician, otolaryngologist (ENT), or neurologist.

What should I expect during a vestibular physical therapy evaluation?
Our physical therapists have advanced vestibular training in examining how your inner ear (vestibular system) and brain are processing balance and vision.

Your examination will begin with a detailed description of your symptoms and medical history to determine multifactorial contributions to your symptoms. We will then utilize advanced technology, using infrared goggles, to further assess your vestibular function that cannot typically be assessed in usual daylight.

Examination may assess the following based on your needs:

• Neck mobility and strength
• Positional testing
• Inner ear exam with and without infrared goggles
• Visual stability and mobility
• Walking stability
• Standing balance
• Leg strength

We will then develop a physical therapy plan of care tailored to your examination findings, with a focus on alleviation of symptoms and return of function. See the section below on specific vestibular rehabilitation treatments to learn more!

What exercises will I do in vestibular physical therapy?
Vestibular rehabilitation involves active exercises involving both repeated head and eye movements as well balance exercises to increase the function of your vestibular system, which is your major “balance center.”

Each patient receives a treatment plan tailored to their needs based on the evaluation findings, with a focus on alleviation of symptoms and return of function. Treatments for vestibular rehabilitation may include, but are not limited to:

• Patient education
• Home exercise program
• Repositioning maneuvers for Benign Paroxysmal Positional Vertigo (BPPV)
• Habituation exercises (movements and activities to desensitize the brain to dizziness- provoking stimuli)
• Gaze stability exercises (repeated eye and head movements to improve dizziness and vision with head movements)
• Balance exercises
• Conditioning exercises
• Functional activities (walking, stairs, lifting)

What is Benign Paroxysmal Positional Vertigo (BPPV) and how do we treat it?
As mentioned above, dizziness is common among older adults. 80% of adults over age 65 have experienced dizziness with 50% being due to a vestibular disorder known as Benign Paroxysmal Positional Vertigo (BPPV).

BPPV is characterized by brief episodes of vertigo (spinning), typically lasting less than one minute. This often occurs when one moves their head or body against gravity such as getting in and out of bed or rolling over. It also occurs with bending over to the floor or looking up onto a top shelf. People often note these vertigo episodes to occur when gardening, moving in the dentist chair or getting their hair washed at a salon.

Additional symptoms include imbalance when walking or moving your head, nausea and uncontrolled eye movements.

The cause for this vestibular disorder is head trauma from a concussion, motor vehicle accident or a fall and can also occur after an acute bodily infection of the respiratory or gastrointestinal systems. However, it can also occur without cause as we age.

BPPV occurs when tiny crystals, known as calcium carbonate, break off in the inner ear and fall into areas where they do not belong within the canals of the vestibular system. This creates a false sensation that things in the environment or one’s head are moving when they are not. 

Physical therapy treatment for BPPV can be highly successful with a treatment known as canalith repositioning maneuvers. Your physical therapist will determine where the crystals are loose in the canals by placing you in different positions on the examination table. Once this is determined, the treatment involves a few simple head and body position movements to ultimately move the crystals back to their home where they belong. This results in resolution of your vertigo and imbalance!

Research has shown that 85% of patients will benefit from this type of treatment for BPPV and often is resolved in 1-3 treatment sessions!

Reference:
Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolary–Head and Neck Surgery 2017;156(3S):S1–S47.

What is Persistent Postural-Perceptual Dizziness (PPPD) and how do we treat it?

Persistent Postural-Perceptual Dizziness (PPPD) is a condition that can cause a constant feeling of non-spinning dizziness or unsteadiness following a sudden triggering event. 

The triggering event could be any condition that causes sudden disruption in balance, fainting, or vertigo (spinning sensation). These events include any of the following:

• A peripheral or central vestibular disorder (e.g. BPPV, vestibular neuritis, Meniere’s disease, stroke)
• Vestibular migraine
• Panic attacks with dizziness
• Mild traumatic brain injury (concussion or whiplash)
• Dysautonomia (disease of the autonomic nervous system)

What causes PPPD?

The brain and body integrates three balance senses (eyes, body position sense, and inner ear) to maintain uprightness. When individuals experience an inner ear crisis, their brains are forced to rely on visual input until the crisis resolves. For patients with PPPD, the brain and body remains focused on heightened use of visual cues long after the initial insult or crisis has resolved. This dampens the use of the inner ear (vestibular system) and body position sense (proprioception) leading to chronic imbalance and dizziness.

Clinical signs and symptoms of PPPD

• The primary symptoms of PPPD are persistent sensations of rocking, swaying, unsteadiness, and/or dizziness without vertigo lasting 3 months or more
• Symptoms are present on more days than not (at least 15 of every 30 days); most patients have daily symptoms
• Symptoms are typically worse with:
  • Upright posture (standing or sitting upright)
  • Head/body motion OR motion of the environment
  • Exposure to complex or motion-rich environments (malls or grocery stores, busy patterns on walls or floors, scrolling on phones/computers)

Diagnosis of PPPD

Physical exams, laboratory tests, and neuroimaging are NOT used to diagnose PPPD itself, but to identify other coexisting conditions. The absence of other neurological or inner ear disorders increases the likelihood of PPPD.  Physical examination and laboratory testing are often normal or may show a current or previous vestibular problem that does not fully explain the patient’s ongoing symptoms.

Treatment of PPPD

Proper treatment requires a multi-modal approach. Research indicates that with proper treatment, patients get better with an overall 80% sustained reduction or resolution of PPPD symptoms and disability.

1. Medication: use of SSRIs (selective serotonin reuptake inhibitors) are effective in reducing PPPD symptoms and comorbid anxiety and depression. Other vestibular suppressants, such as Meclizine, are NOT effective in the primary treatment of PPD.
2. Vestibular Balance Rehabilitation Therapy (VBRT): a specialized area of physical therapy involving balance exercises and repeated head and body movements to reduce symptoms of dizziness and imbalance.
   1. VBRT reduces the severity of vestibular symptoms by 60-80%, resulting in increased mobility and enhanced daily functioning.
   2. VBRT may be effective in reducing anxiety and depression in PPPD patients.
   3. Patients should continue VBRT for 3-6 months to receive maximum benefit from the treatments.
3. Counseling: Cognitive Behavioral Therapy (CBT) has been found most effective in the early stages of PPPD to help prevent chronicity of symptoms. CBT can be helpful in addressing understandable fears of falling and other sources of anxiety as well as changing habits that many people with PPPD get into with respect to their symptoms.

References:

• Holmberg, J.M. Pathophysiology, Differential Diagnosis, and Management of Persistent Postural- Perceptual Dizziness-A Review. Persp-19-00105. pubs.asha.org/doi/10.1044/2019 PERSP-19-00105
• VEDA- Vestibular Disorder Association. www.vestibular.org

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