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Vestibular & Balance Disturbances

Dr. Habib Rizk talking with nurse

We see and manage hundreds of patients with balance and vertigo complaints each year. There are numerous causes of these symptoms, and we have developed a comprehensive team led by Habib G. Rizk, M.D. to treat such patients. We are equipped to provide the most up-to-date diagnostic testing and medical and surgical treatments for all causes of dizziness.

Definition of Dizziness

Various categories of dizziness, ranging from lightheadedness to vertigo.

Testing

Various testing procedures that are used for the diagnosis and treatment of vestibular and balance disturbances.

Vestibular Rehabilitation

Vestibular Rehabilitation Therapy (VRT), the role of physical therapy services and expectations for your first visit.

Conditions We Treat

Causes and symptoms of vestibular and balance disturbance conditions.

Definition of Dizziness

Lightheadedness/Presyncope

Sensation of impending loss of consciousness. Multiple sensory disturbances, orthostatic hypotension, cardiac arrhythmias, and panic attacks.

Disequilibrium

Imbalance or unsteadiness experience while standing or walking. Caused by diminished vision, loss of vestibular function, defects in proprioception, and motor dysfunction from the Central Nervous System (CNS), and Peripheral Nervous System (PNS). Also related to visual vertigo, presyncopal faintness, and somatoform phobic postural vertigo.

Oscillopsia

Subjective illusion of visual motion. Happens only when eyes are open. Acquired nystagmus can cause retinal slip. Bilateral vestibular loss.

Vertigo

Illusion of movements of oneself or the environment: typically spinning.

Testing

Computerized Dynamic Posturography (CDP)

Our bodies use our inner ears in conjunction with the senses of vision and somatosenses (sense of touch or vibration) in order to help us maintain our balance and orientation. We will evaluate each of these three systems as they work together and in isolation in order to identify any weaknesses.

What to expect: A harness will ensure your safety as you maintain your balance on a platform. This test typically lasts 15 minutes. Please be sure to notify the Audiologist of any knee, hip or back pain as well as any recent surgeries prior to testing.

Videonystagmography (VNG)

Videonystagmography is a test battery that consists of multiple subtests. The purpose of this evaluation is to determine whether or not your vestibular system, housed within the inner ear, is responsible for the symptoms you have been experiencing.

What to expect: The VNG test lasts approximately 60 minutes. You will wear goggles that allow the Audiologist to record your eye movements throughout the duration of the evaluation. You will be asked to follow a target on the video monitor with your eyes in order to determine the timing and accuracy of eye movements. Additionally, your head and/or body will be moved into different positions in order to determine whether changes in head and/or body position are related to your symptoms.

Rotational Chair

Rotational chair tests are typically included in the VNG test battery in order to determine whether dizziness may be due to a disorder of the inner ear or brain. Rotary chair tests provide specific information regarding whether or not both vestibular systems are impaired at the same time and/or a level of compensation (recovery from an insult).

What to expect: While wearing goggles, you will be secured in a chair. The chair will rotate at various speeds. It is common to experience a sensation of movement as your whole body is rotated in the chair.

Calorics  

Calorics involve the irrigation of both ears, one at a time, with either air or water. A total of 4 irrigations will be performed. The purpose of caloric testing is to compare the functionality between the right and left vestibular systems.

What to expect: Each ear will receive both warm and cool irrigations. Irrigations last anywhere from 20-60 seconds. It is not uncommon for people to experience a sensation of movement during this test. It is important to remember that the sensation will subside within a few minutes after the test is complete.

VEMP Testing

The vestibular myogenic evoked potential (VEMP) test is used to evaluate the utricle and saccule, the organs of the inner ear that are responsible for our perception of tilt and linear acceleration relative to gravity. These organs respond when you move forward, backward, up or down and when you tilt your head side-to-side, up or down. The VEMP test is valuable in the evaluation of inner ear function and can support a diagnosis of Meniere’s disease, superior canal dehiscence or vestibular migraine.

What to expect: This noninvasive test utilizes electrodes, which are placed on the surface of the skin around the eyes and on the neck to measure responses from the muscles. Responses are evoked by a clicking sound presented through insert-style earphones; these clicks translate vibrations to the inner ear organs. You will be asked to flex the muscles around your eyes by looking up or your neck by turning your head during these tests. This test is not affected by medications or hearing loss due to inner ear damage.

Video Head Impulse Testing (vHIT)

The Video Head Impulse Test is an objective measure of the vestibular ocular reflex (VOR), which is an important component of a healthy vestibular system. The VOR allows for gaze stabilization during head movements and when impaired, can result in altered visual acuity when in motion. The vHIT measures the VOR in response to head movements representative of every-day head motion and can allow for ear-specific information to be obtained regarding vestibular function.

What to expect: The duration of the vHIT is about 15 minutes. You will wear lightweight video goggles and focus on a light in front of you. The examiner will hold your head and or chin with both hands and make a quick movement up, down, right or left. The video goggles will track any eye movement away from the target. A computer system will analyze this movement and provide information about VOR function.

Vestibular Rehabilitation

What is Vestibular Rehabilitation Therapy? 

Vestibular Rehabilitation Therapy (VRT) is an exercise-based program for reducing symptoms related to vestibular (inner ear/balance) disorders. Patients suffering from vestibular disorders often experience problems with vertigo, dizziness, visual disturbance and/or imbalance. Secondary problems can also arise, such as nausea and/or vomiting, reduced ability to focus or concentrate, fatigue, anxiety and depression. The aim of VRT is to address these problems.

Vestibular disorders can directly impact a patient's quality of life. Patients often develop a more sedentary lifestyle to avoid making their symptoms worse. This sedentary lifestyle can contribute to a decrease in physical health, becoming weaker, developing joint stiffness and having an overall decrease in endurance to perform daily activities.

A common approach for managing such symptoms is to prescribe medication that suppresses vestibular function. However, in the long term, such suppressants can interfere with a person’s ability to make the necessary adaptations for reducing symptoms. Additionally, these medications can cause drowsiness that may further contribute to a person’s ability to be active. VRT is an alternative treatment involving specific exercises to eliminate or significantly reduce both the primary and secondary symptoms caused by vestibular disorders by promoting central nervous system compensation for inner-ear deficits. The goal is to decrease the identified dizziness and visual symptoms, increase balance and walking and increase general activity levels as well as quality of life.

Why a Physical Therapist?

If you are dizzy and or/imbalanced the cause may be due to inner ear, or vestibular disorder. Physical therapists often specialize in an area of therapy called vestibular rehabilitation, in which therapist's work to improve the symptoms of dizziness and balance problems that you may also experience.

Much of a therapist’s job is to help get a person moving again and manage the dizziness at the same time. Exercise and performing daily activities are the primary ways of accomplishing this goal. Physical therapists can provide essential coping strategies that make recovery more tolerable. If specific activities or chores around the house or in the community cause dizziness, then learning ways to perform them differently may help to keep the dizziness to a minimum. Activities that were simple before the vestibular disorder may become difficult, causing fatigue and dizziness. A therapist can help you work through some of these issues right away and get you moving, and back to a productive life more quickly.

Therapy for vestibular disorders takes many forms. The type of exercise utilized depends upon the unique problems that the individual demonstrates during the evaluation. Some exercises are geared toward helping with balance, some with helping the brain resolve differences in the inner ear signals and some with improving the ability to visually focus. In addition, general exercise is often prescribed to improve overall physical health and well-being.

Regardless of the cause of your vestibular disorder, the sooner you start therapy the better. Research has shown that the brain and inner ears work best for compensation, or recovery, in the first few months after a vestibular deficit occurs. This time period is optimal for vestibular rehabilitation to promote the best chance for recovery.

What should I expect on my first visit?

VRT begins with a comprehensive clinical assessment that will include gathering a detailed history and how symptoms are affecting daily activities, medications, hearing or vision problems, other medical issues, fall history, previous and current activity level and living/work situation.

After the collection of a detailed history, your therapist will administer different tests to more objectively evaluate symptoms. The therapist will screen the visual and vestibular system, posture, balance, muscle strength, range of motion, sensation and coordination. At this point a customized plan is developed from the referring physician’s recommendations, findings of the clinical assessment, results from laboratory testing and input from the patient about their goals for rehabilitation.

Before leaving your first visit you can expect to be provided with a home exercise program. This is an important part of the VRT process. Compliance with the home exercise program is essential to help achieve both patient and rehabilitation goals. Along with exercise, patient and caregiver education is an integral part of VRT. Many patients find it useful to understand the science behind their vestibular problems, and how it relates to the difficulties that you may be experiencing in daily life. Your therapist can provide information about how to deal with these difficulties and what to be expected from VRT. Education is important because it can help take away much of the mystery of what you may be experiencing, which can help reduce anxiety that may occur as a result of your vestibular disorder.