Vestibular Rehabilitation Therapy (VRT)

Introduction

Recent literature including double-blinded placebo controlled trials has generally supported the utility of vestibular rehabilitation in a variety of conditions associated with dizziness.

Why might Vestibular Rehabilitation be useful? Here we will consider the “generic” type of vestibular rehabilitation in which ataxic or vertiginous individuals are provided with a series of tasks to perform that require them to use their eyes while their head is moving, and possibly when their body is also moving. There are many processes that might be usefully influenced by experience and motion (see Hain, 2011 for more details)

    1. Plasticity — changes in central connections to compensate for peripheral disturbances. It would be nice if plasticity could handle everything. Unfortunately, there appears to be limits on how much the brain can compensate. Although conventional wisdom holds that older persons adapt less well than younger, a recent study suggests that there is no difference in benefit of vestibular rehabilitation according to age (Wriseley et al, 2002)
    2. Formation of internal models — a cognitive process where one learns what to expect from ones actions. Internal models are critical for predictive motor control, which is essential when one is controlling systems that have delays. Much of the benefit of vestibular therapy may depend on internal models. An example of this is a recent study by Herdman et al (2007) showing recovery of better vision in persons with bilateral vestibular loss was attributed to “centrally programmed eye movements”.
    3. Learning of limits — another cognitive process involved with learning what is safe and what is not. Someone who does not know their limits may be overly cautious and avoid dangerous situations. Someone who does not realize that, for example, they can’t figure out which way is up, may drown in a swimming pool.
    4. Sensory weighting — a cognitive process in which one of several redundant senses is selected and favored over another. Classically, selection occurs between vision, vestibular and somatosensation inputs when one is attempting to balance. People with unreliable vestibular systems, such as those in Meniere’s disease, sometimes seem to unable to switch off their visual reliance, causing them distress in certain situations where vision is an incorrect reflection of body movement (i.e. in the movies). (Lacour et al, 1997)

The “best” way of going about this is generally thought to be to find a specialized vestibular rehabilitation therapist. Our advice is to find the most specialized person available and that you can afford or your insurance will cover, and see them twice a week, for 1 – 2 months. Aetna, Humana Insurance, Florida Blue, United Health Care, Blue Cross Blue Shield, United Health Care, as well as Medicare and Medicare Advantage Plans, and Cigna Insurance all cover the treatment of balance and vertigo/dizziness. A quite good alternative to doing these somewhat boring exercises, supervised or not, is to take up an active sport. The sport should involve a lot of head movement and visual stimulation (such as basketball, dancing, volleyball). You probably won’t be very good at this but it might be easier to motivate yourself.

General Interventions:

One of the first “general” interventions for vestibular problems were the Cawthorne-Cooksey exercises. We will call these the “CC” exercises. These are a one page handout of activities that progress from simple head movement to complex activities such as throwing a ball. The major advantage of the Cawthorne-Cooksey exercises is that they are very low cost and often effective (see extensive reference list at end). The main disadvantage of the CC exercises is that they don’t work for BPPV, which is the most common type of dizziness.

When combined with an accurate diagnosis and use of BPPV maneuvers instead of these exercises, if appropriate, the CC approach can be very effective. We also like the idea of having the patient see a therapist on an occasional basis to act as a “coach”, as not all individuals are able to move through the exercises without help.

Individualized Vestibular Therapy

In the 1990s, an effort began, led by several academic physical therapists, to advocate exercises customized to individual diagnoses or at least functional patterns (e.g. Horak et al, 1992). Therapists performed an “evaluation”, a physical examination, which allowed them to adjust their treatment program. For example, for BPPV, in most cases it might seem irrational to treat with anything other than specific interventions, such as the Epley maneuver (although general exercises seem to help a little too — Fujino et al, 1994). This was an important development as prior to this time, therapists often treated all dizzy patients with the same protocol (e.g. the Cawthorne-Cooksey). The major advantage is greater efficiency. Reliable controlled studies showing that anything fancier than separating out the BPPV patients for special handling is significantly better than, for example, the Cawthorne-Cooksey exercises (see above) are presently hard to come by, although there have been some attempts (Smith-Wheelock et al, 1991). There is also evidence for a considerable positive effect of rehabilitation for chronic neurological disorders (Solari et al, 1999), suggesting that the general idea is worthwhile.

The disadvantage of individualized therapy is the higher cost compared to the Cawthorne-Cooksey or other “do it yourself” regimes. Usually eight sessions of therapy are prescribed, but sometimes as many as 16 sessions or ongoing treatment is recommended.

Treatments that may be offered in Vestibular Rehabilitation

At Preferred Physical Therapy we treat all types of Vestibular diagnoses with varying symptoms which include vertigo and dizziness. We accept all types of insurances including Humana, Aetna, Blue Cross Blue Shield, Florida Blue, United Health Care, Medicare and Medicare Advantage Plans, and Cigna Insurance. We have listed various procedures that can be offered as part of vestibular rehabilitation. Excepting for treatment of BPPV, in general, the outcome of these procedures have not been studied to a great extent, and a recurring theme is that more research is needed.

BPPV Treatment

Treatments for BPPV are dealt with in detail under the BPPV page system. In our opinion, BPPV should nearly always be treated with vestibular rehabilitation, using specific maneuvers for the type of dizziness that patients experience.

Balancing Exercises

Dynamic balancing exercises are appropriate for nearly all vestibular disorders.

Gaze Stabilization Exercises

An object is held stable at eye level. The patient maintains their gaze on the object while they move their head from left to right in 45° angles.

Physical conditioning Exercises

One should not neglect physical conditioning.

What is important is that every patient must be individually assessed, to not use a cookie cutter approach in trying to improve their health. Whether a patient’s insurance is Cigna, Aetna, Humana, United Health Care, Florida Blue (the new Blue Cross Blue Shield), Medicare or are on a Medicare Advantage Plan, the patient has to have an in-depth evaluation to diagnose the etiology and then the correct treatment that can be applied.

Benign positional paroxysmal vertigo (BPPV) is a common, typically self-limited but recurrent disorder characterized by episodes of vertigo precipitated by certain head movements. Typically, the patient reports sudden vertigo associated with movements such as rolling over in bed, looking up suddenly, or straightening after bending over. BPPV can be clinically diagnosed on the basis of the Hallpike-Dix maneuver, in which the patient is rapidly moved from a sitting to a supine position with the head turned so that the affected ear is 30° to 45° below the horizontal plane. The Hallpike-Dix test is considered positive if vertigo and nystagmus are noted.

The etiology of BPPV is thought to be related to the presence of dense canaliths that collect in the dependent portion of a semicircular canal. A change in head position relative to gravity causes the canaliths to move through the canal, causing movement of the endolymph within the canal. Canalith repositioning maneuvers have been investigated as a technique to move the canaliths back into the utricle of the semicircular canal, where they will remain stationary. The most common maneuver is called the Epley maneuver. The Sermont maneuver, also called the liberatory maneuver, has also been investigated. Aetna, Humana Insurance, Florida Blue, United Health Care, Blue Cross Blue Shield, United Health Care, as well as Medicare and Medicare Advantage Plans, and Cigna Insurance all cover the treatment of vertigo.

The Epley maneuver starts with the Hallpike-Dix maneuver and then the patient’s head is turned to the opposite side before the patient sits up, with 6 to 13 seconds between position changes. The treatment may be repeated during the same treatment session until no nystagmus is observed. The Sermont maneuver uses a different sequence of head positioning, with 1 to 2 minutes between changes in position. Canalith repositioning maneuvers may be repeated over a series of treatment sessions if symptoms do not resolve or recur.

Note:

Canalith repositioning maneuvers must be distinguished from vestibular rehabilitation exercises. Vestibular rehabilitation describes a series of exercises designed to correct maladaptive postural control strategies, or to overcome poor central nervous system compensation after an acute injury to the vestibular system. In contrast, canalith repositioning procedures are designed to address the underlying cause of BPPV. What is important is that every patient must be individually assessed, to not use a cookie cutter approach in trying to improve their health. Whether a patient’s insurance is Cigna, Aetna, Humana, United Health Care, Florida Blue (the new Blue Cross Blue Shield), Medicare or on a Medicare Advantage Plan, the patient has to have an in-depth evaluation to diagnose the etiology and then the correct treatment can be applied.

Research

A large number of case series have investigated the treatment efficacy of canalith repositioning maneuvers, with the majority focusing on the Epley maneuver or a modified version of it. These studies have reported a broad range of efficacy, from 95% reported by Epley himself to no treatment effect. (1-4) However, the majority of studies report success rates greater than 80%. The variation in results may be related to modifications in the treatment methods, documentation of treatment success, and the natural history of disease. Given the self-limited nature of BPPV in many patients, placebo-controlled randomized trials are necessary to confirm that any proposed treatment effect is not due to spontaneous improvement. In addition, in many instances patient selection is based on a positive finding in the Hallpike-Dix maneuver. Since this test incorporates elements of the Epley maneuver, results may be solely related to the initial diagnostic procedure. Finally, outcomes ideally should be based on a follow-up Hallpike-Dix maneuver, which demonstrates resolution of nystagmus. Reliance on patient’s subjective symptoms alone may overestimate treatment effects, since patients may become adept at avoiding those positions associated with vertigo.

Post-maneuver Instructions

Another area of divergence among experts involves the use of activity limitations after repositioning maneuvers. Epley asked his patients to remain upright for 48 hours after the CRP. In addition to remaining upright, certain investigators also request that their patients avoid lying on their affected side for 7 days. A study by Nuti and colleagues examined 2 sets of patients following the liberatory maneuver. One group of patients were asked to remain upright for 48 hours, whereas a second group of patients were not given any post-maneuver instructions. These 2 groups were compared retrospectively and no difference was found in short-term vertigo control. This finding is consistent with an earlier prospective study by Massoud and Ireland, who also demonstrated that post–liberatory maneuver instructions were not efficacious.

At Preferred Physical Therapy we treat all types of Vestibular diagnoses with varying symptoms which include vertigo and dizziness. We accept all types of insurances including Humana, Aetna, Blue Cross Blue Shield, Florida Blue, United Health Care, Medicare and Medicare Advantage Plans, as well as Cigna Insurance.

Vertigo Facts:

  • Vertigo describes the sensation of the patient or the room spinning. It may be associated with intense nausea and vomiting.
  • Benign paroxysmal positional vertigo is the most common reason to develop vertigo, but it is often uncertain what might cause BPPV.
  • Diagnosis of vertigo is usually made after the health care practitioner performs a history and physical examination. It is important to consider a central problem with the brain as a potential cause.
  • BPPV and labyrinthitis are treated with Sermont or Epley maneuvers to clear debris that causes inflammation from the semicircular canals of the inner ear.
  • People with vertigo or who have multiple episodes of vertigo should not drive or do other activities that would endanger themselves or others.

Vertigo Introduction

Balance is defined as a state of equilibrium. It takes significant amount of work for this to occur in the body. The brain uses input from many sources to understand where the body is located in relationship to the world and to allow it to function. Sensory information from the eyes, ears, and position receptors in the rest of the body help keep the body upright and allow it to move in a coordinated fashion.

Vertigo, a feeling of spinning movement and sometimes accompanied by nausea and vomiting, occurs when any part of the system breaks down. However, people tend not to use that word to describe their symptoms but instead use the word dizziness or lightheadedness. It is up to the health care practitioner to understand the person’s symptoms and define vertigo as the cause of their situation.

Dizziness is a difficult word to understand and needs to be divided into two categories, either lightheadedness or vertigo. Lightheadedness is the feeling that a person might faint while vertigo is most often described as a spinning sensation with loss of balance. The direction of care is markedly different since lightheadedness may suggest to the health care practitioner to investigate decreased oxygen or nutrient supply to the brain due to a variety of causes including heart rhythm disturbances or dehydration, while vertigo sends the health care practitioner looking for a neurologic or inner ear cause.

The most important initial step in helping a person with vertigo is to take a history and understand that the person is complaining of spinning symptoms that may be associated with nausea and vomiting and loss of balance among other symptoms. Once the diagnosis has been made, the patient can be treated effectively. Aetna, Humana Insurance, Florida Blue, United Health Care, Blue Cross Blue Shield, United Health Care, as well as Medicare and Medicare Advantage Plans, and Cigna Insurance all cover the treatment of balance and vertigo/dizziness.

Benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is probably the most common cause of vertigo in the United States. It has been estimated that at least 20% of patients who present to the physician with vertigo have BPPV. However, because BPPV is frequently misdiagnosed, this figure may not be completely accurate and is probably an underestimation. Since BPPV can occur concomitantly with other inner ear diseases (for example, one patient may have both Ménière disease and BPPV at once), statistical analysis may be skewed towards lower numbers.

The patient is placed in a sitting position with the head turned 45° towards the affected side and then reclined past the supine position.

BPPV is a complex disorder to define because an evolution has occurred in the understanding of its pathophysiology, an evolution has also occurred in its definition. As more interest has focused on BPPV, new variations of positional vertigo have been discovered. What was previously grouped as BPPV is now subclassified by the offending semicircular canal (SCC; ie, posterior superior SCC vs lateral SCC) and, although controversial, further divided into canalithiasis and cupulolithiasis (depending on its pathophysiology).

BPPV is defined as an abnormal sensation of motion that is elicited by certain critical provocative positions. The provocative positions usually trigger specific eye movements (ie, nystagmus). The character and direction of the nystagmus are specific to the part of the inner ear affected and the pathophysiology.

Although some controversy exists regarding the 2 pathophysiologic mechanisms, canalithiasis and cupulolithiasis, agreement is growing that the entities actually coexist and account for different subspecies of BPPV. Canalithiasis (literally, “canal rocks”) is defined as the condition of particles residing in the canal portion of the SCCs (in contradistinction to the ampullary portion). These densities are considered to be free floating and mobile, causing vertigo by exerting a force. Conversely, cupulolithiasis (literally, “cupula rocks”) refers to densities adhered to the cupula of the crista ampullaris. Cupulolith particles reside in the ampulla of the SCCs and are not free floating.

At Preferred Physical Therapy, we treat all types of vestibular diagnoses with varying symptoms which include vertigo and dizziness. We accept all types of insurances including Humana, Aetna, Blue Cross Blue Shield, Florida Blue, United Health Care, Medicare and Medicare Advantage Plans, and Cigna Insurance.