When the vestibular organs of balance are damaged with disease or injury, there is conflict of information to the brain about the equilibrium and motion often resulting in dizziness, vertigo, and imbalance.Brain has tremendous plasticity so it usually adapts to the situation (An amazing process called Nature’s mechanism of vestibular compensation) and many people recover from these symptoms on their own after a few weeks.
Nature’s compensation process for imbalance can be accelerated by Vestibular Rehabilitation Therapy.
In next post — See How our Balance system works?
What is Vestibular rehabilitation Therapy (VRT)?
Vestibular rehabilitation therapy (VRT) is a form of physical therapy that uses specialized exercise to enhance nature’s compensatory mechanism for imbalance due to inner ear disorder (Peripheral Vestibular System) which helps in retraining of brain to recognize and process signals from inner ear in coordination with Eye (Vision) and Muscle and joints (Proprioception). It also helps to desensitize the balance system to movements that provoke the symptoms.
VRT is effective in a variety of vestibular problems, including benign paroxysmal positional vertigo (BPPV), Ménière’s disease, labyrinthitis, and vestibular neuritis.
What are the Benefits Of VRT
– Reduce fall risk level
– Decrease feelings of dizziness and unsteadiness
– Improve mobility
– Increase safety and independence
– Accelarating mechanism of central adaptation and compensation
How Vestibular Rehabilitation Therapy works?
Most VRT works at three ways— Adaptation, Compensation and Habituation
Adaptation — Head-eye coordination exercises which stimulate brain help the eye-ear reflex work in a coordinated manner. It also stimulates the balance portion of the ear. It is critical that the head turn separately from the rest of your body in order for the ear to receive proper inputs.
Compensation— Balance retraining exercises which help to reduce unsteadiness by utilizing vision, sensory system and postural system more effectively to keep the balance.
Habituation– continually repeating the actions that bring on the symptoms of dizziness or vertigo will eventually accustom the body to those actions.
Exercise Protocols for Individual Patients
On the Basis of symptoms of individual patient Specific Vestibular Program is designed tailored to fit need of the patient.
Extent and location of damage of vestibular system, state of visual and proprioceptive systems, General physical health, motor skills, cognitive abilities, anxiety states and integrity of the cerebellum are taken into consideration.
These custom-designed exercises are to be done at home several times a day which begins at the minimal skill level and complexity is increased as compensation and habituation occur.
Patients have regular follow-up visits with the therapist until compensation and habituation are complete and optimal balance is attained.
Caution-Someone should be there by the side of the patient to support in the case of imbalance as often people experience increased dizziness shortly after starting a vestibular therapy program. Caution should be used while doing these exercises, especially standing and walking exercises.
Vestibular rehabilitation exercises focus on gaze stability and gait stability. Gait stability includes both static and dynamic balance exercises.
I. Adaptation exercises Vestibulo-Ocular Reflex (VOR) stimulation exercises—
(Vestibule –means balance organ of Inner Ear & Ocular- means Related to eye)
When some object is moving towards one side, the eyes must also move along with it to keep it in focus, this stable gaze and visual focus (to stabilize the image of the surroundings in the retina) during active and passive head movement is maintained by Vestibulo-Ocular reflex.
When one side vestibular labyrinth is damaged this system does not work. So person will not be able to keep the image of the moving object in the visual focus (on retina) and this retinal slips cause vertigo.
Eye movements are controlled by extra ocular muscle activity, under the control of an image stabilization. Adaptation exercises are basically retraining of the extra ocular muscles to stabilize the gaze while focusing on a stationary object and follow a moving object by moving head.
Ia. Gaze stability and ocular control exercise
1. Focusing with Head Turns (Head Eye Coordination exercise))
This exercise helps in stabilizing the gaze with quick, short head movements.
- Sit in a comfortable chair and hold a card with a 1 inch letter written on it at arms length in front of you.
- While keeping eyes focused on the letter move your head from side to side approx. 30 degrees. .
- Increase speed of head movement with each progression.
- As function improves, move the card opposite to the head movement while keeping the eyes focused on the letters.
- Move the head to the left and the card to the right keeping the eyes focused on the letters.
- Begins slowly and increase the speed as the test progresses. Progress from sitting to standing to a sharpened stance.
- Post the card on the wall with a plain background and progress to posting on a wall with a busy patterned background.
2. Horizontal and Diagonal Head Movements)-This exercise helps to keep the vision stable with head movements.
- Sit in a comfortable chair with feet flat on the floor and hands on thighs.
- Have a target situated to your right and to your left as well as in the center.
- Quickly turn only your head and eyes to the right target pause for 2-3 seconds and then return to the middle target and pause for 2-3 seconds.
- Repeat 15-20 times
- Repeat the sequence to the left and center.
II. Compensation exercises Ocular motor exercises
In a normal person fullest utilization of all the 3 inputs for balance (Eyes, Inner Ear, Proprioception) is usually not required. But when one of these input systems is defective the brain uses remaining senses more effectively to compensate for the partial loss of function.
When the patient’s vestibular labyrinth is damaged, and to compensate for it we try to train the patient to use inputs from other component of balance system more effectively (eyes and the proprioceptors)
See components of Balance system
IIa Sensory substitution exercises—
To sensitize and enhance sensory proprioceptive inputs patient is advised to exercise and walk on uneven surfaces.
IIb Visual inputs pursuit gain-
- While seated on a chair holds a card with lettering at arm’s length
- Move the card left and right across the visual field, tracking with eye movement and keeping the head still.
- Repeat the full cycle 20-30 times.
- Perform the procedure in the vertical and diagonal directions with increasing speed but being certain to keep the letters in focus.
- Progress from sitting to standing
IIc Saccade latency, velocity, and accuracy B. Visual-ocular control exercise
- Hold a card with lettering in each hand approximately 15 inches apart at arm’s length.
- Keep the head still and move the eyes back and forth from card to card with 1 second per card.
- Repeat 20-30 times for the complete cycle
- This test also can be performed in the vertical and diagonal planes. Progress from sitting to standing
III. Habituation exercises
Repeated head Movements to stimulate balancing system and exposing the patient to small periods of tolerable vertigo causes body to get accustomed and thus threshold of vertigo increases.
IIIa Balance exercises
1 Touching front wall
- Stand with the feet together and Maintain balance by touching the wall in front
- Take the hands off the wall for progressively longer periods. First begin by taking 1 hand off the wall and alternate hands.
- Stand with the feet shoulder-width apart looking at a target on the wall.
- Perform first with arms outstretched, then close to the body, and then folded across the chest.
Reach up as though for an object over the head and then bends over as though picking up an object from the floor.
The patient can then progress from sitting to standing to a sharpened stance. Exercises are performed in dim lighting and then with eyes closed. The difficulty level is raised by standing on foam or a pillow and then standing to one leg.
Stand approx. 4 inches in front of the kitchen counter.
- Stand approx 4 inches in front of the wall or kitchen counter with your feet shoulder width apart with equal weight on both feet and your arms relaxed at your side. Look straight ahead at a focal point.
- Slowly shift your weight forwards attempting to touch the counter with the front of your thighs as well as your shoulders coming forward. Return to midline position and repeat. All movement should be at ankles without bending at hips.
- Repeat 10 times, then perform with eyes closed.
3. Circle with a ball
Focus eyes on the ball and move it in a circular fashion in both directions with increasing speed. The head and body moves with the ball. Raise the difficulty level from sitting to standing to a narrowed stance.
4. Ball Diagonals
- Stand with your feet positioned shoulder width apart. Grip the ground with your toes. Hold a large ball or pillow with both hands and arms straight.
- Keeping your arms straight, move the ball in a diagonal pattern starting by your left knee and moving toward the right upper diagonal. Continue to keep eyes and head following the object as you return to the left lower diagonal. Hold the position until motion sensitivity is eliminated.
- Perform the activity 10 times and then repeat on the other diagonal pattern.
IIIb Gait exercises
1. Walking exercise —
a. Start walking next to a wall with the hand out for support. Then gradually increase the number of steps without support.
Difficulty is raised by narrowing the stance and by walking heel to toe.
b. Waling with head in motion-
Walk with the head in motion going left and right with increasing speed. The stance is narrowed and the patient can also move the head in the vertical plane.
c. Walking with Head turns
- Begin walking at regular speed, with eyes focused on a target straight ahead,
- After 3 steps turn head and eyes to the right 45 degrees, keeping eyes on a new target, (at eye level) while still walking straight ahead. Do this for 3 steps, then turn eyes and head back to the center finding a target.
- After three steps, turn your head and eyes to the left while walking straight ahead finding another target.
- After three more steps, turn your head back to the center while walking straight ahead.
- To increase the difficulty of this task, go from a solid floor to a carpeted floor, or walk outdoors on an uneven surface. Thick lawns usually are the most difficult surface.
2. Sit to stand —
- The patient walks from one chair to another chair positioned 10 feet away.
- Upon reaching the first chair, the patient sits without using the hands, waits for 5 seconds, and rises without using the hands.
- The patient goes to the second chair, touches it, and, with support, practices standing on 1 leg for 5 seconds.
- The entire cycle is repeated 10 times.
- The patient can add head movements as the exercise progresses, increase walking speeds, and decrease the width of gait.
3. Gait with a Focal Point–
- Have a focal point approximately 20 feet in front of you at eye level.
- As you begin walking keep eyes focused on target in front of you.
- Periodically briefly look down toward the floor (approx. 5 ft. in front of you) to check for obstacles and then return eyes to the target.
Combined category exercises(At a grocery store or mall)
Crowd can play a factor in the rehabilitation. Initially patient can go at a time of day when few people are shopping and then progress to a crowded time of the day. The patient should make an effort to look at items that are on the top and bottom shelves.
The patient can also walk at the mall by beginning with slow walks close to the wall and by going with the flow of the crowd. Then the patient can increase speed, move away from the walls, and go against traffic. Window shopping with purposeful head movements is helpful.
Patient can bend over, picking up objects, throwing and catching objects, bouncing them off walls, and walking on differing compliance surfaces.
Patient can also practice at the grocery store by pushing a cart. First the patient pushes with minimal support and then no support from the cart. Patient can begin with slow, small head movements, increasing speed and degrees of motion.
Vestibular compensation takes place from repeated exposure to sensory conflicts produced by movements of eyes, head and trunk and active Central Nervous System.
One thing should be extremely clear that no medicine and no surgery can regenerate the damaged sensory epithelium in the vestibular labyrinths. Nature’s mechanism to compensate the balance system should be enhanced by Vestibular Rehabilitation Therapy and anything which will jeopardize should be avoided like prescribing CNS sedatives to give symptomatic relief to the patient.