Vestibular Rehabilitation

In the US 35% or 69 million people have a vestibular disorder(1). Eighty percent of people 65 or older experience dizziness(2). BPPV is the most common vestibular disorder and accounts for 50% of dizziness in older people(3).

BPPV occurs when the otoconia (crystals) fall off the otolithic membrane (hairs) in the semi- circular canal. (Fig 1) Sometimes the crystals continue to float in the canals and other times the crystals will embed themselves to the walls of the canal.

For example sitting up, rolling in bed, and looking up will cause moderate to severe room spinning. BPPV symptoms can include nausea especially with changes in position.

Usually the displacement of crystals occurs in one ear and is rare that it occurs in both. There are various tests that can be done in order to re-create the nystagmus associated with BPPV. These tests include testing the eyes and moving the head and body in various positions. The most definitive test is the Hallpike test. This test entails having the therapist tilt the patient back quickly with the head rotated to the effected side. A positive test will reproduce the vertigo symptoms and eye nystagmus. In most cases BPPV has an unknown cause. Other reasons include head trauma or damage to the inner ear.

BPPV is a treatable condition. Often an anti-nausea medication is prescribed which will help to reduce the symptoms. The most effective treatment is the Eply’s maneuver along with habituation exercises. The Eply’s maneuver is a technique done immediately following the Hallpike test. The therapist places the head in various positions in order to reposition the crystals (otoconia) in the semi-circular canal to an area where they will be less symptomatic. Habituation exercises are then given. This involves performing and repeating positions that induce the patient’s symptoms. Balance exercises are also recommended as a retraining tool.

CERVICOGENIC DIZZINESS - This is often misdiagnosed for BPPV. Patients often complain of dizziness but their dizziness does not involve the severe room spinning and nausea that accompanies BPPV.

Their symptoms often involve more of a light headedness or a “woozy” feeling. Symptoms can come about even without sudden head movements. Historically these patients present with whiplash, decreased cervical ROM secondary to degeneration or prolonged immobilization. The damage that occurs secondary to these issues often occurs the first 2 levels of the cervical spine. At these levels there is a direct impact on the vestibular and visual systems. There is miscommunication between these systems giving the sense of dizziness.

The tests for cervicogenic dizziness are the same for BPPV because there will be abnormal eye movements and balance problems also. The Hallpike test will be negative and does not reproduce room spinning symptoms or eye nystagmus.

This type of dizziness can be treated successfully utilizing a multi-treatment approach. Treatment to the neck muscles and joints along with balance and visual exercises for optimal results.

Agrawal Y, Carey JP, Della Santina CC, Schubert MC, Minor LB. Disorders of Balance and Vestibular Function in US Adults. Arch Intern Med 2009; 169 (10): 938-944

Ator GA. Vertigo - Evaluation and Treatment in the Elderly

Fife TD, Iverson DJ, Lempert T, Furman JM, Baloh RW, Tusa RJ, Hain TC, Herdman S, Morrow MJ, Gronseth GS. Practice Parameter: Therapies for Benign Paroxysmal Positional Vertigo (an evidence based review): report of the Quality Standards Sub- committee of the American Academy of Neurology. 2008; 70: 2007-2074