Written by Brigit Lim, MPT
Dizziness and vertigo are two common reasons people’s functional mobility and confidence with doing activities may change over time. Sometimes the reason for the dizziness and vertigo may be clear, such immediately following a car accident, fall or head injury. Other times, people have episodes of dizziness and vertigo which start out as infrequent, and with time become almost constant. Dizziness and vertiginous symptoms can be vague and hard to describe in terms of pattern and/or distinct triggers; can result from side effects of medications, cardiovascular system, or endocrine system issues; also heightened states of anxiety and stress can produce feelings of imbalance/swaying.
Regrettably, people may deal with issues for months or years because they are trying to figure out where to get help in the medical system when medications do not help, tests come back clearing the cardiovascular or neurologic regions of involvements, or it may take months to get into see specialties to get answers.
When starting vestibular rehabilitation with a patient who has had chronic sensitivity to dizziness and imbalance, the therapist attempts to determine how much of the issue is due to the peripheral vestibular system, dysfunctions in the proprioceptive and visual system, and/ or central processing. These assessments help determine pace of treatment, customization of exercises, and if other specialties involvement would help progress.
The peripheral vestibular system consists of the semicircular canals and otolith organs which sends information to the brainstem and cerebellum. The otolith organs detect linear acceleration such as walking quickly then stopping, ascending or descending on a ladder or elevator, or tilt of head/body on uneven surfaces. The semicircular canals are stimulated whenever the head and/or body rotates or flexes/extends to help maintain balance, and helps maintain gaze stability so the visual system can fixate on a point when the head is moving. The input from the semicircular canals also helps maintain autonomic control of the cardiovascular system and other gravity-sensitive structures. Deficits found on a vestibular evaluation help indicate if all parts of the vestibular system are affected or if certain areas are more challenged, and therefore which exercises would be indicated for rehabilitated.
There are various diagnoses which affect only the peripheral vestibular system, but not the other sensory inputs or brain, making vestibular/balance rehabilitation somewhat more straightforward. All things being considered, if one has a mild/moderate impairment and no other co-morbidities, they can recover by continuing to move and do their normal day to day activities. Research has shown specific vestibular exercises tailored to patients helps expedite the healing process for peripheral vestibular disorders, but because there are individuals who recover without medical intervention, quite often more complex vestibular cases get told to keep moving and their bodies will adjust. Unfortunately, this can lead to mal adaptive behaviors which then persist into more chronic states, or the lack of screening of other systems prolong healing.
Besides the peripheral vestibular system, the ocular system and proprioceptive systems must also be considered with chronic dizziness and vertigo cases. Research has shown 50-90% 1 of those who suffered a mild traumatic brain injury/ concussion complain of vestibularoculomotor dysfunction producing dizziness, nausea, fatigue, brain fog, and neuro cognitive impairments. This is because 70% of the brain is used for visual and sensory processing; visual network requires efficient communication from the frontal, parietal, temporal and occipital lobes, midbrain, cerebellum, cranial nerves and axonal connections. Besides concussion patients, those with chronic vestibular disorders, like PPPD or vestibular migraine, may also complain of visual issues. Often in these populations may have mild/moderate visual deficits their brain learned to compensate for without formal treatment, but now overloaded with having to support a struggling vestibular system, which potentially includes not just the peripheral vestibular system detailed above but all of its interconnections to the cerebellum, midbrain, and visual system, the suppressed visual impairment emerges. Routine eye exams may say a patient has “perfect vision” but the patient can still complain of double vision, photosensitivity, motion sensitivity and nausea, or phobias being in visually complex environments like busy restaurants or stores, or just say “it does not feel like their eyes work right”. Many patients, and doctors, are unaware of a field called neuro-optometry which does a far more in-depth ocular exam to evaluate oculomotor, accommodative, visuomotor, binocular, and perceptual/visual information2. The examination is not to answer can one see, but how well is their brain integrating visual information. Working with a neuro-optometrist allows the patient and therapist to better understand how aggressively to push visual and vestibular/visual exercises based on how fatigued the brain becomes due to visual deficits.
The proprioceptive system is how our bodies process knowing where they are in space based on information the brain gets from the joints in our spine and lower extremities. If one can stand fairly comfortably on a firm surface with their eyes open, but feels insecure when the eyes are closed, they are relying more on visual cues to give a sense of where they are versus automatically using their proprioceptive system. Sometimes this is due to lack of input (neuropathy), disuse (the less active one is, the less they train the system), or due to lack of stability in the leg or potentially stiffness/pain in neck that decreases the body’s ability to trust the input coming in from these areas. The treating therapist must discern why a proprioceptive insufficiency exists, and then develop a treatment plan to uptrain this system to be more effective in providing balance input.
One of the biggest setbacks for patients with decreased proprioceptive awareness in their trunk/legs is they are given balance exercises with instructions to use their upper extremities to help with balance. If one does not walk with an assistive device, and one is not indicated for any weakness or significant neuropathy issues, practicing balance exercises while holding onto an object only seeks to reinforce proprioception through the hands and upper extremities, not the legs and trunk. If the balance exercise is too advanced for the patient to do safely without the use of their hands, then the balance exercise must be simplified to do only with the use of their legs and trunk to help uptrain the proprioceptive system to react quicker and more accurately for real world scenarios.
Lastly, with long standing vestibular issues patients tend to limit head/neck motion to decrease dizziness/imbalance. If the neck muscles and joints are stiff, they can produce dizziness driven from the cervical spine when the patient tries to stretch the proprioceptors located in this area when practicing vestibular or visual exercises. By performing manual therapy and then practicing vestibular/visual exercises within an asymptomatic range the patient can retrain the cervical spine to provide correct proprioceptive input with functional activities3.
As mentioned above more complex vestibular cases can become chronic due to the problem being more “centralized.” Meaning the brain starts to create maladaptive behaviors in response to abnormal vestibular input and becomes more anxious in complex sensory settings and patients will often describe a feeling of “brain fog” or confusion with daily or work activities. The vestibular system does provide input via the cerebellum and midbrain to parts of the cerebral cortex involved with spatial memory and navigation. Spatial cognition is the ability to understand and organize information in two- and three-dimensional space and helps us recognize and memorize paths, locations and directions, as well as recognizing objects from different perspective4 . The pathologies of various vestibular illnesses remain poorly understood therefore the cognitive symptoms for each etiology may vary, but most pathways healthy vestibular pathways are thought to be subconscious in nature; allowing the brain the ability to focus on working memory to hold information temporarily, hold attention and concentration on specific tasks at hand, and executive decisions to solve problems/make decisions/plan/and self-regulate. In most chronic vestibular conditions (whether they be vestibular migraine, concussion, or PPPD) the brain cannot rely on clear input from the vestibular pathway and now is working overtime to solve daily skills thus creating “mental fog” or poor trust in postural perception of where the body is in space.
The other observation of chronic vestibular cases like PPPD or vestibular migraine, is the originating event may have been localized to the peripheral vestibular system, but became centralized due to underlying co-morbidities such as anxiety, depression, PTSD or OCD. In these populations the brain may rely more heavily on visual input, versus equally weighting input from somatosensory and vestibular system, so when vestibular input does become more abnormal the brain goes into overdrive using the visual system and becomes easily overwhelmed in visually complex environments or environments lacking clear visual input5 . Another observation of these co-morbidities is they often maintain a hypervigilant state and introspective self-monitoring; essentially the original vestibular event is no longer a threat but the brain believes the threat still exists and is on such high alert to analyze all sensory input, that the brain creates the perception of self-movement and vertigo6 .
So while some patients with a simple peripheral vestibular event will heal on their own without formal rehabilitation, potentially those with preexisting visual issues or psychological issues could develop more complex chronic vestibular patterns. For those with symptoms longer than 3 months, which are not positively progressing, it would be advisable for the patient to seek consultations in vestibular physical therapy, neuro-optometry, and neuropsychology/cognitive behavioral therapy for a thorough overview of what their brain might need to heal.
For further questions regarding vestibular physical therapy and manual therapy, please contact us at fpt@folsomphysicaltherapy.com or call 916-355-8500.
- Kaae et al. 2022 Vestibulo-ocular dysfunction in mTBI: Utility of VOMS for evaluation and management-A review.
Neurorehabilitation ↩︎ - Nouraeinejad, A. Review Paper: Neuro-Optometry, Neuro-Optometrist, and Neuro-Optometric Rehabilitative
Implications Journal of Modern Rehabilitation 2018. ↩︎ - Wong et al. Sequencing and Integration of Cervical Manual Therapy and Vestibulo-oculomotor Therapy for
Concussion Symptoms: Retrospective Analysis International Journal of Sports Physical Therapy. 2021. ↩︎ - Guo et al. Vestibular dysfunction leads to cognitive impairments: State of knowledge in the field and clinical
perspectives (Review) International Journal of Molecular Medicine. 2024. ↩︎ - Waterson et al. Persistent Postural-Perceptual Dizziness: Precipitating Conditions, Co-morbidities and Treatment
with Cognitive Behavioral Therapy Frontiers in Neurology. 2021. ↩︎ - Castro et al. Persistent Postural-Perceptual Dizziness (PPPD) from Brain Imaging to Behavior and Perception Brain
Sciences. 2022 ↩︎
