- Brian Sass
Vestibular Rehabilitation: Insights and Recommendations
Updated: Mar 19
The human vestibular system is made up of three components; a peripheral sensory apparatus, a central processor, and a neuronal mechanism of motor output. The vestibular system, or inner ear, has two main functions; to sense motion of your head/body and to sense shifts in gravity/translational movement. Humans have two vestibular systems; one on the right side and one on the left. When working appropriately, the vestibular system as a whole works in tandem with other brain areas to constantly update the cortex regarding spatial orientation, postural control, and reflexes of the head and body relative to motion and gravity signals. When the vestibular system becomes weak, imbalanced, injured, skewed, overstressed, or overfatigued, numerous symptoms can occur.
Imagine your vestibular system as an automobile; as more sensory information is received, the gas pedal is activated and you have an output of movement. For the purposes of this example, remember that you have two individual vestibular systems (one of the left and one on the right). Dysfunction and symptoms can occur when one of the systems (or vehicles) is sensing more information than the other side, resulting in a mismatch or imbalance in output (one vehicle is sensing movement and “moves” at 25 mph while the other side sensing a different movement signal and “moves” at 50 mph). This imbalance is output is very confusing to the brain, which can create significant problems. Sometimes, other areas of the brain like the cerebellum can compensate (or adapt) for vestibular imbalance for a period of time with relatively low symptoms. However, when vestibular imbalance remains unchecked, debilitating symptoms with significant alterations in your daily lifestyle can occur as a result.
Symptoms of vestibular imbalance commonly include general dizziness, vertigo, lightheadedness, motion sickness, disequilibrium, nausea, “rocking on a boat” feelings, positional dizziness, brain fog, and/or unsteadiness on your feet/balance problems. However, vestibular imbalance can also cause less commonly known symptoms such as headaches, blurriness in vision, problems with concentration and focus, memory issues, changes in emotion/personality, musculoskeletal pain, sensory neuropathy, numbness/tingling in the body, “floating” sensations, anxiety, heart palpitations, panic attacks, depression, and other neurological symptoms. Vestibular imbalance or dysfunction in the vestibular system has a variety of causes; ranging from viral infections to mild traumatic brain injuries and concussion. Many times, people have no idea that their vestibular system is dysfunctional until after a neurological evaluation (if you don’t experience vertigo, many doctors and patients commonly assume their vestibular system is fine). If you are experiencing symptoms that could indicate dysfunction in your vestibular system, or if you already know that there is dysfunction in that system, what do you do for treatment? How do you “re-balance” or heal the vestibular injury?
Rehabilitation of the vestibular system involves both training exercises and therapeutic interventions specifically designed and targeted for the vestibular system. Both of these interventions are non-invasive and do not include medication (there are medications that are given for vestibular symptoms). There are two main categories of vestibular rehabilitation; repositioning maneuvers and vestibular re-training. Repositioning maneuvers are utilized when a “crystal” is thought to be the mechanism of vertigo or other symptoms (sometimes, a calcium crystal gets dislodged and falls into one of the canals of the vestibular system, causing symptoms with your head in certain positions). The most common repositioning maneuver is called an Epley maneuver. There are other repositioning maneuvers as well, each designed to “reposition” a crystal out of a specific vestibular canal. Repositioning maneuvers usually entail a doctor or therapist having you lie down and rotate your head and body in certain motions/directions to reposition the crystal effectively (the doctor will usually support your head during the maneuver). Most times, this maneuver lasts a few minutes to several minutes and can be very effective in significantly reducing or stopping your symptoms after the maneuver is completed.
If you are experiencing symptoms from a vestibular injury that does not involve a displaced crystal, then chances are the best therapy to heal and recover this injury would be vestibular training exercises and rehabilitation. Vestibular re-training is a diverse treatment paradigm; there are many exercises that can be utilized ranging from head movements, visual eye movements, body movements, coordination exercises, positional therapies, eye-head movements, balance therapies, neck therapies, and dynamic movements of the body and head (like athletic training exercises). Additionally, some clinics and rehabilitation centers offer manual vestibular therapy (all of the exercises that they offer involve using their hands to coordinate movement or they will have you perform the movements yourself) while other clinics offer equipment-assisted or “passive” rehabilitation (the vestibular rehabilitation is performed with computerized rotational chairs that perform the movements/rotations/ inversions to the patient). There are pros and cons of each type of vestibular rehabilitation technique. Manual vestibular rehabilitation is more widely offered and available but it has obvious limitations. Equipment-assisted vestibular rehabilitation can offer a far more targeted and dynamic approach to vestibular training, as well as speed/velocity training that manual training cannot. Inversion therapies and dynamic movement (combinations of vertical and horizontal stimuli) can also be achieved with equipment-assisted rehabilitation. Unfortunately, equipment assisted vestibular rehabilitation can be less available (most clinics do not offer this kind of rehabilitation) and at times hard to find. If you are experiencing symptoms that you think may have vestibular component, or if you are searching for vestibular therapy, looking into manual vestibular rehabilitation or equipment-assisted vestibular training is a good first step.
1. Herdman, Susan J. Vestibular Rehabilitation: 3rd Edition. Published by F.A. Davis Company and Jaypee Brothers Medical Publishers Ltd in 2007.
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