Vestibular Therapy
Vestibular therapy is a type of therapy for patients experiencing dizziness, balance, and vision difficulties. Using a variety of methods similar to vision and physical therapy, vestibular therapy can help reduce vestibular issues, which can occur as a result of concussion. This page will cover:
What Happens to Your Brain During a Concussion?
Symptoms
Concussion symptoms that may indicate a disruption of the vestibular system include:
loss of balance
dizziness or spinning
eye strain
blurred vision
headaches
fatigue
The symptoms can occur right away or they can develop up to several weeks after the concussion. Patients will have different combinations of symptoms.
Definitions of the symptoms and how to recognize them
Dizziness
Dizziness when moving around, such as quick head movements, or changing positions such as bending over or looking up to reach above your head.
Dizziness in visually stimulating environments such as malls and stores, walking over shiny or patterned floors or watching action films or TV with a lot of visual action.
Gaze or Vision issues
The patient's "visual world appears to bounce or jump around, such as when reading or trying to identify objects in the environment, especially when the patient is moving about." (VeDA)
Balance Problems
A loss of balance that affects everyday life and may cause the patient to limit physical activity.
Thank you to VeDA for the information on vestibular symptoms.
What Happens to Your Brain During a Concussion?
The brain is made of very soft material, almost like jello, and is usually well protected by the skull and membrane, but it is not invincible. Human heads are not made to sustain sudden jolts and hard impacts, so when that happens, the brain will jostle and move within the skull, causing damage to the brain. When the brain impacts the skull, it causes the neurons to stretch and sometimes break. Neurons make the brain function properly, almost like wires for transferring electricity, and when one of the wires malfunctions, nothing works quite right. One of the functions that might be affected by damaged neurons is the vestibular system.
About Vestibular Therapy
Why You Should Consider Working with a Vestibular Therapist
Vestibular therapy is a subspecialty of physical therapy, therefore a physical therapist who specializes in vestibular treatment can help with vestibular rehabilitation. When looking for vestibular therapy, your provider may be a physical therapist. Other providers that may help with vestibular issues are otolaryngologists, also called Ear Nose and Throat physicians (ENT).
Vestibular therapists can play a significant role in concussion rehabilitation, helping to alleviate problems arising from vestibular disorders including vertigo, dizziness, gaze instability, and imbalance. Since the vestibular system is partially responsible for maintaining balance, patients most commonly present with dizziness or vertigo.
The vestibular therapist can determine which part of the vestibular system has been affected and develop an appropriate treatment plan. Most adults recover from concussions within two weeks, however, some may experience persisting symptoms outside this time frame, thus seeing a vestibular therapist may help manage the symptoms. Patients do not necessarily have to experience symptoms during the therapy session to benefit from vestibular therapy as vestibular therapists can help with fluctuations in vestibular problems.
It can be helpful to note down symptoms, their duration, and the triggers to help let the therapist know you better.
Benefits of Vestibular Therapy
Vestibular therapy has been shown to help alleviate symptoms in concussed individuals according to a review in the British Journal of Sports Medicine.
The brain is able to adapt through a process known as neural plasticity and so with proper treatment, the brain is able to adapt well to areas of poor function and reduce symptoms such as dizziness and lack of balance. Aside from physical benefits, therapy can also improve mental and emotional health, such as an increase in confidence in maintaining balance, and a decrease in anxiety and fatigue. A small study investigated the effects of the timing of when vestibular therapy is provided. The researchers found that vestibular therapy within 30 days of a sports-related concussion led to an earlier return to play and earlier resolution of symptoms.
What Does Vestibular Therapy Look Like?
Interview with Bara Alsalaheen, a Physical Therapist at NeuroSport, about recovery and rehabilitation following a sport-related concussion event.
When meeting with a vestibular therapist for the first time, patients may be asked about their medical history and the symptoms being experienced, as well as how they affect their daily life. Any previous falls and current activity levels will also be noted.
This initial discussion creates a foundation for a treatment plan and may also indicate whether you could be referred to another specialist. Patients experiencing red flag symptoms can be a reason for a referral.
Factors That Can Impact Recovery
Vestibular therapy cannot be placed under one umbrella diagnosis; there are multiple different issues that must be solved in different ways. If the proper treatment is not administered by a professional, it is not uncommon for the vestibular issues to worsen or exacerbate.
According to VeDA, a few of the extenuating factors that can hinder recovery include:
Sedentary lifestyle
Pain
Presence of other medical conditions
Certain medications or other medications
Emotional concerns
Decompensation; A return of vestibular symptoms following compensation. Can be caused by different emotional and/or physical stressors.
Virtual Reality (VR), a more recent vestibular therapy development, can be used on some patients. But as VeDA has found, some patients like those with progressive vestibular disorder Virtual reality therapy can have little to no effect, with possibly detrimental outcomes on the patient.
The importance of proper therapy can make or break a patient's recovery; this further clarifies the significance of finding the right vestibular therapist.
Finding a Specialist
Ask your medical provider for a referral to:
An otolaryngologist (ENT) who specializes in balance disorders
A physical therapist who specializes in vestibular rehabilitation therapy.
Review this guide on how to choose a vestibular specialist.
This guide to vestibular disorder specialists explains the different types of healthcare professionals in this field.
The "Find A Vestibular Specialist" search tool is courtesy of the Vestibular Disorders Association (VeDA.)
Vestibular Exams
A vestibular physical exam will be able to provide more information about what treatments would be most appropriate. A typical examination can include a thorough oculomotor exam, balance, and positional tests. The vestibular therapy will be based on each individual's tolerance of movement, symptoms, and mobility. Together with the therapist, you can create goals that can include improving balance, vision, and breathing.
Visio-Vestibular Exams
The visio-vestibular exam is the primary exam done by a physical therapist. Most commonly, vestibular therapists will use a pen or their hand and some offices may have Frenzel lenses or goggles to measure and note down vision behavior. Things that the therapist will look for include, how well the patient’s eyes track, whether the eyes move from point A to B without interruptions, how well the eyes can stay fixated on things (saccades are eye movements that abruptly change their fixation point), and are there any involuntary jerky or jumpy eye movements (presence of nystagmus).
Example of nystagmus
Six key elements of the visio-vestibular examination are demonstrated by Dr. Daniel Corwin in the video.
Balance and Positional Examination
Balance and positional testing can also shed light on the presence of vertigo. The therapist will examine the patient tolerance and mobility and decide whether balance and positional testing will be conducted.
Benign paroxysmal positional vertigo (BPPV) is fairly common, ranging in prevalence between 10 and 57% according to a review by Gerard J. Gianoli in the Frontiers. BPPV can present in dizziness and is usually triggered by changes in head position, such as looking up and down, lying down, and turning over in bed. BPPV is often accompanied by nausea or vomiting. Its diagnosis can be confirmed by the presence of vertigo (the perception of motion when there is no motion).
Vestibular Therapy Devices
Although going through vestibular rehabilitation may seem somewhat similar to physical therapy, it is not something to be done without proper instruction. While some light physical therapy exercises can be done at home, it is highly recommended that there is professional supervision unless given permission by your therapist otherwise. Exercises must be done correctly; if they are done improperly, vestibular issues may not improve or, in some cases, become more severe.
The equipment used for vestibular therapy is similar to what might be found in physical therapy. Including basic balance and movement exercise equipment like:
Foam pads
Stairs/Aerobic step
Treadmill
Stationary Bike
Vestibular impairments are not just a physical issue but a visual, sensory, and balance issue. Physical therapists make use of specialized equipment when working with their patients. Some of the equipment used in vestibular rehabilitation therapy includes devices such as:
Brock String
A string of beads used to analyze the patient's convergence.
Marsden Ball
A simple rubber ball with colorful letters and numbers on it, the patient will be tasked with calling out what they can see on the ball while it is in motion.
Infrared Video Goggles
Goggles very similar in style to a VR Headset used to aid in the diagnosis of different dizziness and balance disorders
Simple games like Spot it, memory games, and bean bags
Binasal or prism occlusion
Marsden Ball, this one is made of foam
Vestibular First Infrared Video Goggles
Binasal Occlusion Glasses
Other Balance Exercises
Epley’s Maneuver for BBPV
“One type of rehabilitation therapy called the canalith repositioning procedure (also called the “Epley maneuver”), specifically addresses dizziness or vertigo (a spinning sensation) caused by dislodged gravity-sensing crystals in the ear. The crystals can end up in the wrong place from a blow to the head. Vestibular rehabilitation therapy addresses vertigo and dizziness caused by other injuries to the systems for equilibrium and balance that can occur after a concussion." Elizabeth Sandel, M.D.
This series of exercises was designed by Dr. John Epley to bring back the crystals out from the semicircular canals to the utricle. Your therapist may use the Epley maneuver exercises if you are diagnosed with BBPV, and may provide you with the exercises at the office. They may also provide you with a home version, especially if the symptoms persist or reappear in the future.
Gaze Stabilization
The vestibulo-ocular reflex affects gaze stabilization, allowing a person to stay focused on an object even if their head is moving. A concussion may damage this reflex, leading to vertigo and disorientation. Exercises that can help restore the reflex. The goals of the exercises can be improving focus while the head is kept angled or in motion, changing the distance between the patient and the object in focus as outlined by the UMMC.
Cawthorne-Cooksey Exercises
Vertigo often arises from the imbalance in the inner ear, BPPV, or arising from other parts of the brain. The Cawthorne-Cookey exercises involve moving the head and eyes with the purpose of decreasing dizziness that comes from motion sensitivity (due to vision and balance not being aligned) can be found outlined by St. George’s Hospital. From these exercises, a tolerance mechanism can be built in the brain to compensate for the imbalance. The therapist will determine how often these should be carried out, for as long as vertigo is experienced.
It is highly recommended that these exercises are done under supervision, and if any of the symptoms worsen, stop immediately and seek out help.
The Science Behind the Symptoms
What is the Vestibular System
The vestibular system is a structure in the inner ear that helps control balance and eye movements. Each part of the vestibular system detects different types of motion; for example, the semicircular canals detect rotation of the head and body, and the otoliths (utricle and saccule) detect forward and backward movements. The movement of endolymph, a fluid in the vestibular system, flows through the semicircular canals and is detected by miniature hair cells in the ampullae and the otoliths. In addition, there are little “crystals” called otoconia, that float within the endolymph, that can (but not always) become dislodged during a concussion.
When diagnosing a concussion, a doctor looks at which motions cause difficulty for the patient and can identify what type of therapy is needed in order to either reconnect the signals from the vestibular system to the brain or if the otoconia (“crystals”) need to be repositioned.
App for learning about the vestibular system: aVOR
An app called aVOR includes information about the shape and size of the vestibular system as well as its impact on your perception of motion depending on what part is damaged or experiencing dysfunction.
aVOR while it is an interesting and very helpful app it can also be very difficult to use, the Canadian Audiologist has created a helpful guide to walk users through the app and learn about the vestibular system.
Screenshot of the app from an iPhone. Currently, this app is only available on apple products.
Video about the Vestibular System
Simple anatomy of the vestibular system
Video About Balance Exercises & Patient Experiences
Please ALWAYS exercise caution when performing exercises outside of a medical setting!
Experiences with Vestibular Therapy
Listen to other concussion patients’ injury and recovery stories:
Read Testimonials from patients of a rehabilitation clinic: