Treatment for vertigo, imbalance
Treatment for vertigo, imbalance, and dizziness due to vestibular dysfunction
The form of treatment prescribed for vestibular disorders depends upon symptoms, medical history and general health, diagnostic test results, and a physical examination by a qualified doctor.
Treatment can include vestibular rehabilitation therapy (physical therapy or VRT), canalith repositioning maneuvers (e.g., the Epley maneuver), a change in activity levels, medication, dietary adjustments, talk therapy, surgery, and treatment for any underlying disease that may be contributing to the balance disorder.
Vestibular Rehabilitation Therapy (VRT)
Why is therapy needed?
If the brain cannot rely on the information it receives from the vestibular system, a person’s ability to maintain posture and coordinate balance can become overly dependent on vision or on the information received from the muscles and joints (proprioception).
This can lead to developing new patterns of movement to compensate for the change and to avoid head movements that are apt to create symptoms of dizziness and nausea. For example, a person might adopt an exaggerated hip sway as a method of balancing, might swivel the entire body rather than just the head in turning to look at something, or might always look down at the floor to avoid what appears as a confusing swirl of activity.
Unfortunately, these types of adaptation can result in headache, neckache, muscle stiffness, general fatigue, and a decrease in the ability to retrain the brain to adjust to the vestibular problem, hence making the symptoms much worse.
The goal of VRT is to retrain the brain to recognize and process signals from the vestibular system in coordination with information from vision and proprioception. This often involves desensitizing the balance system to movements that provoke symptoms.
What happens during vestibular therapy?
A qualified therapist will first perform a thorough evaluation. This includes observing posture, balance, movement, and compensatory strategies.
Using the result of this evaluation, the therapist will develop an individualized treatment plan that will include exercises to be performed both in the therapy department and at home and that combine specific head and body movements with eye exercises. Many times, treatment may also include increasing activities and exercise in order to strengthen muscles and increase tolerance for certain stimuli.
Some of the exercise and activities may at first cause an increase in symptoms, as the body and brain attempt to sort out the new pattern of movements. But with time and consistent work, the coordination signals from the eyes, proprioception, and vestibular system will occur.
How does therapy help?
In most cases, balance improves if the exercises are correctly and faithfully performed. Muscle tension, headaches, and fatigue will diminish, and symptoms of dizziness, vertigo, and nausea will decrease or disappear. Many times, vestibular VRT is so successful that no other treatment is required.
If surgery is required to correct an inner ear problem, therapy will also be an important part of treatment. A therapist may perform a vestibular evaluation before surgery, make daily visits during the hospital stay to help with the temporary increase in balance problems that often accompanies surgery, and may provide a series of simple exercises to do for home care after discharge from the hospital. Often, therapists provide further therapy after a person has recovered from the surgery.
From VEDA publications M-5: Vestibular Therapy, and F-26: Vestibular Injury: Compensation, Decompensation, and Failure to Compensate. VEDA’s online store offers these and other related publications such as VEDA publication F-7: Vestibular Rehabilitation, by Anne Shumway-Cook, PhD, RPT, who addresses questions such as:
General Guidelines
▪ What is vestibular rehabilitation?
▪ Which patients need therapy?
▪ Does therapy succeed?
▪ Is a physician’s referral needed to enter therapy?
▪ How will the therapist assess my problems?
▪ What happens in the exercise program?
Canalith Repositioning Procedure (CRP)—for Treatment of BPPV
In BPPV, dizziness and other symptoms with certain head movements is due to debris (small crystals of calcium carbonate, also referred to as a “canalith”) which has detached from the utricle in the vestibule of the inner ear and has collected within a part of the inner ear. The goal of canalith repositioning procedure (CRP) is to move the displaced debris out of one of the semicircular canals so that they don’t send false signals to the brain about spatial movement.
John M. Epley, M.D., first described the canalith repositioning procedure in a medical journal in 1992. The original procedure and many variations are currently in use and are referred to, at times, as the Epley maneuver or maneuvers.
Through a series of head position changes, the CRP moves the canaliths from the canal to the utricle. Once in the utricle, the canaliths may re-adhere to the otolithic membrane, dissolve, be broken up, or move some place where they can’t cause symptoms.
These maneuvers involve a series of specifically patterned head and trunk movements performed by a trained professional who closely watches eye movements with each position change. CRP can be performed in the doctor’s office with medication such as diazepam to help block nausea during the procedure that takes about 15 minutes to accomplish. Precautions are provided for the days immediately following the procedure in order to ensure that the canaliths don’t have the opportunity to return to their formerly problematic location in one of the semi-circular canals.
CRP is very effective, with an approximate cure rate of 80%. The recurrence rate for BPPV after these maneuvers is low. However, in some instances additional treatment(s) may be necessary.
There are two primary maneuvers: the Semont-Liberatory maneuver and the Epley maneuver. The choice of maneuver depends on results of the Dix-Hallpike test (revealing which canal is involved) and whether or not the debris is inside the canal (canalithiasis) or hung up on the cupula of the canal (cupulolithiasis).
CRP is thought to be effective in canalithiasis, because it can help move the free-floating debris from the sensitive area (semicircular canal) into a place where it won’t cause vertigo. It can be used to treat BPPV of the posterior semicircular canal or the anterior semicircular canal. Most people undergoing the procedure do so for posterior canal BPPV.
These maneuvers must only be performed by a professional who is trained in the maneuvers and safeguard against possible neck or back injury, and who can determine whether certain health conditions (such as perilymph fistula, detached retina, vertebrovascular insufficiency, esophageal reflux, and others) excludes a person from being a candidate for this procedure.
Potential complications from this procedure include the possibility of neck/back injury or debris moving into another canal,
Based on the cupulolithiasis theory of BPPV, the Brandt-Daroff Exercises were introduced in 1980 by Drs. T. Brandt and R.B. Daroff. They suggested a set of exercises for BPPV to be done multiple times over a period of time extending until two days after the bouts of positional vertigo had ended. The goal of these exercises was to loosen and disperse particles from the cupula of the posterior semicircular canal. Some have suggested these exercises also might work through their habituation, where the repetitive stimulus to the brain reduces the brain’s response to it.
The procedure involves sitting on the edge of a bed, moving into a side-lying position until the vertigo ends, returning to the sitting position for a fixed interval, and then moving into a side-lying position on the opposite side, and so on. These exercises are repeated in multiple sets throughout each day until two days after vertigo has not been experienced for two days.
As with the CRP maneuver described above for canalithiasis, a trained professional should be involved in determining whether these are appropriate exercises for each individual, and will also help ensure that the exercises are being performed properly and effectively.
Dietary Considerations
Many people with Meniere’s disease, secondary endolymphatic hydrops, and migraine-associated dizziness find that certain modifications in diet are helpful in managing their disorder. Avoidance of non-dietary substances such as nicotine and some types of medications may also reduce symptoms.
Inner Ear Fluid Balance
The fluid-filled hearing and balance structures of the inner ear normally function independently of the body’s overall fluid/blood system. The fluid that bathes the sensory cells of the inner ear (known as endolymph) maintains a constant volume and contains specific and stable concentrations of sodium, potassium, chloride, and other electrolytes.
With injury or disease, the volume and composition of endolymph may fluctuate with changes in the body’s fluid/blood. This fluctuation is thought to cause the symptoms of endolymphatic hydrops or Meniere’s disease—pressure or fullness in the ears, tinnitus (ringing in the ears), hearing loss, dizziness, and imbalance. Thus, for people with Meniere’s disease (primary idiopathic endolymphatic hydrops) or secondary endolymphatic hydrops, (which may follow damage to the inner ear) maintaining stability in the body’s fluid/blood system is important.
General Guidelines
Dietary strategies for regulating fluid balances involve modifying the amount of certain substances consumed (and reducing fluctuations in those amounts), as well as reducing or eliminating other substances that can adversely affect the inner ear. Components of these dietary strategies include:
▪ Distributing food and fluid intake evenly throughout the day and from day to day.
▪ Avoiding foods and beverages that have a high sugar or salt content. Foods with complex sugars (e.g., those found in legumes and whole grains) are better choices than foods with a high concentration of simple sugars (e.g., table sugar and honey). Sodium intake also affects body-fluid levels and their regulation. Each individual’s physician will be the best judge of appropriate levels of sodium intake.
▪ Drinking adequate amounts of fluid daily. If possible, fluid loss from exercise or heat should be anticipated, and extra fluids drunk before and during exercise and in hot weather.
▪ Avoiding foods and beverages with caffeine. Caffeine is a stimulant that can make tinnitus louder. Its diuretic properties also cause excessive urinary loss of body fluids.
▪ Limiting or eliminating alcohol consumption. Alcohol can directly and adversely affect the inner ear by changing the volume and composition of its fluid.
▪ Avoiding migraine triggers including foods that contain the amino acid tyramine. Examples of such foods include red wine, chicken liver, smoked meats, yogurt, chocolate, bananas, citrus fruits, figs, ripened cheeses (e.,g., cheddar and Brie), and nuts.
Non-dietary substances
Some non-dietary substances can increase symptoms of vestibular disorders as well. Aspirin can increase tinnitus, and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, can interfere cause water retention or electrolyte imbalance. Nicotine (found in tobacco products and some cease-smoking aids) can increase symptoms, because it decreases the blood supply to the inner ear by constricting blood vessels; it also causes a short-term increase in blood pressure.
Many of these guidelines are commonly recommended to people with Meniere’s disease, endolymphatic hydrops, or vestibular migraine. A physician or dietician may incorporate some of these principles into an individualized treatment plan.
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