What Is Balance and Vestibular Rehabilitation Therapy? Timothy C. Hain, MD, American Hearing Research Foundation. This document discusses current ideas about physical therapy for dizziness and imbalance, also called vestibular rehabilitation, or more generally, balance rehabilitation. While there is some data regarding the efficacy vestibular rehabilitation (for example, Cowand et al, 1. Accordingly, this review is opinionated, based on 1. The main message is that therapy is often worthwhile, but selection of the best type depends on both the diagnosis and health care situation. This page is primarily intended to be a reference for patients who have been referred for therapy. What are the Indications for Therapy? There are three clear indications for vestibular rehabilitation referrals: Specific interventions for benign paroxysmal positional vertigo (BPPV). The Epley and Semont maneuvers The Brandt- Daroff exercises Log roll exercises (for lateral canal BPPV)General interventions for vestibular loss. Vestibular/Balance Program. Rehab 3 is helping people overcome dizziness/ vertigo and balance problems. We offer vestibular/ balance programs throughout our network. Vestibular Rehabilitation & Balance Program. Vestibular Rehabilitation. This is an exercise approach used to treat dizziness and desequilibrium caused by a. Vestibular rehabilitation exercises can help retrain the brain's ability to compensate for. Elements of the program Vestibular and balance rehabilitation can be an. Unilateral loss, such as for vestibular neuritis or acoustic neuroma. Bilateral loss, such as for gentamicin toxicity and related conditions. Empirical treatment for common situations where the diagnosis is unclear. Post- traumatic vertigo. Multifactorial disequilibrium of the elderly. Vestibular rehabilitation is an exercise approach to treating symptoms of dizziness associated with peripheral vestibular pathology. Vestibular Rehabilitation. Our primary specialty service is vestibular rehabilitation therapy (VRT) for patients that have been diagnosed with a vestibular deficit. The Vestibular Rehabilitation Program, provided in conjunction with the Division of Otolaryngology – Head and Neck Surgery, is dedicated to helping individuals with. Individuals not likely to benefit from vestibular therapy include: Persons without a vestibular problem, for example. T’ai Chi may be helpful for anxiety)migraine associated vertigo (although it has been reported to be helpful nonetheless)transient ischemic attacks (TIA)Persons with fluctuating vestibular problems. Meniere’s diseaseperilymphatic fistula. There are some conditions where it is not entirely clear whether rehabilitation is helpful, but it seems likely at this writing that it is not. Mal de debarquement (MDD)cerebellar degenerationsidiopathic motion intolerance. How Can the Success of Rehabilitation Be Measured? Measuring success is more difficult than it sounds. There are several fallacies: Tincture of time: Most disorders have a tendency to get better on their own, so one possible fallacy is to attribute improvement to physical therapy, without controlling for passage of time. What is important? Most people limit their activities by their overall risk. As they feel more stable, they move around more. Measurement of falls or trips is related to activity and objective risk. Given that people want to increase their activity, they may keep their number of falls constant, as they improve. Vestibular Rehabilitation Therapy (VRT) The American Academy of Otolaryngology has issued a position statement on the treatment of balance related disorders.What is balance? There presently is no method of measuring “balance.” There are numerous methods of measuring things that are associated with balance. How do you separate psychological aspects (that is, fear of falling) from objective aspects (that is, risk of falling)? Probably the most valid measures right now are subjective measures (questionnaires). Examples include the dizziness handicap inventory (DHI) and the activities- specific confidence scale (ABC). Nevertheless, these measures are greatly handicapped by their intrinsic variability, and tendency for people to scale their responses according to what they think they should be doing, rather than actual performance. Other measures of “balance” include posturography, rotatory chair testing, ENG testing; and mobility oriented scales, such as the timed “get up and go” test, and the Berg balance scale. A Medline search performed in February 2. A recent and very thourough review (Hillier, 2. The exception to this finding was in patients with BPPV, who benefited more from specific interventions (described below) than from general vestibular rehabilitation therapy. Several individual clinical trials also showed patients to benefit from vestibular rehabilitation, including both genetic and individualized interventions. Patients showed improvement both on subject questionnaires and on clinical vestibular testing (Enticott, 2. Badaracco, 2. 00. Venosa, 2. 00. 7; Meli, 2. Nishino, 2. 00. 5, Macias, 2. Bittar, 2. 00. 5, Badke, 2. Yardley, 2. 00. 4; Hansson, 2. Dannenbaum, 2. 00. Cohen, 2. 00. 4; Topuz, 2. Bittar, 2. 00. 2; Murray, 2. Patients who experience anxiety or depression along with the vestibular symptoms may see improvement in their emotional state with vestibular rehabilitation (Meli, 2. Many patients, particularly older ones, have additional medical problems that contribute to the vestibular symptoms. Treatment of these other problems significantly affects their response to rehabilitation therapy (Moreira, 2. Children with peripheral vestibular disorders probably benefit from rehabilitation (Medeiros, 2. Specific Interventions. At this writing, only BPPV has specific rehabilitation interventions. This material is abstracted from our BPPV page. How is BPPV Treated? Office Treatment. Home Treatment (Brandt- Daroff Exercises)Office Treatment of BPPV: The Epley and Semont Maneuvers. There are two treatments of BPPV that are usually performed in the doctor’s office. Both treatments are very effective, with roughly an 8. Herdman and others (1. If your doctor is unfamiliar with these treatments, you can find a list of knowledgeable doctors from the Vestibular Disorders Association (VEDA). The maneuvers, named after their inventors, are both intended to move debris or “ear rocks” out of the sensitive part of the ear (posterior canal) to a less sensitive location. Each maneuver takes about 1. The Semont maneuver (also called the liberatory maneuver) involves a procedure whereby the patient is rapidly moved from lying on one side to lying on the other. It is a brisk maneuver that is not currently favored in the United States. The Epley maneuver is also called the particle repositioning, canalith repositioning procedure, and the modified liberatory maneuver. It involves sequential movement of the head into four positions, staying in each position for roughly 3. The recurrence rate for BPPV after these maneuvers is about 3. While some authors advocate use of vibration in the Epley maneuver, we have not found this useful in a study of our patients. After either of these maneuvers, you should be prepared to follow the instructions below, which are aimed at reducing the chance that debris might fall back into the sensitive back part of the ear. Instructions For Patients After Office Treatment (Epley or Semont Maneuvers)1. Wait for 1. 0 minutes after the maneuver is performed before going home. This is to avoid “quick spins,” or brief bursts of vertigo as debris repositions itself immediately after the maneuver. Don’t drive yourself home. Sleep semi- recumbent for the next two nights. This means sleep with your head halfway between being flat and upright (a 4. This is most easily done by using a recliner chair or by using pillows arranged on a couch. During the day, try to keep your head vertical. You must not go to the hairdresser or dentist, or engage in exercise that requires head movement. When men shave under their chins, they should bend their bodies forward in order to keep their head vertical. If eye drops are required, try to put them in without tilting the head back. Shampoo only under the shower. For at least one week, avoid provoking head positions that might bring BPPV on again: Use two pillows when you sleep. Avoid sleeping on the “bad” side. Don’t turn your head far up or far down. Be careful to avoid head- extended position, in which you are lying on your back, especially with your head turned towards the affected side. This means that you should be cautious at the beauty parlor, dentist’s office, and while undergoing minor surgery. Try to stay as upright as possible. Exercises for low- back pain should be stopped for a week. No sit- ups should be done for at least one week and no “crawl” swimming. Do not start doing the Brandt- Daroff exercises immediately or two days after the Epley or Semont maneuver, unless specifically instructed otherwise by your doctor. At one week after treatment, put yourself in the position that usually makes you dizzy. Position yourself cautiously and under conditions in which you can’t fall or hurt yourself. Let your doctor know how you did. Massoud and Ireland (1. While we respect these authors, at this writing (2. Epley. What if One Has Bilateral BPPV? There is some concern in this situation that treating one side followed by treating the other might “undo” the positive effects of the first. Therefore, a common approach is to treat one side, and move on to the other a week later. Nevertheless, some physicians treat both sides in the same session, with good results. In either case, a follow- up visit is usually needed at roughly a week from the initial attempt. What if the Maneuvers Don’t Work? These maneuvers are effective in about 8. BPPV (Herdman et al, 1. If you are among the other 2. Brandt- Daroff exercises, as described below. If a maneuver works but symptoms recur or the response is only partial (about 4. Smouha, 1. 99. 7), another trial of the maneuver might be advised. When all maneuvers have been tried and symptoms are still intolerable, then surgical management (posterior canal plugging) may be offered. BPPV often recurs. About 3. 3% of patients have a recurrence in the first year after treatment, and by five years, about half of all patients have a recurrence (Hain et al, 2. Nunez et al; 2. 00. If BPPV recurs in our practice, we usually retreat with one of the maneuvers above, and then follow this with a once a day set of the Brandt- Daroff exercises. In some persons, the positional vertigo can be eliminated, but imbalance persists. In these persons it may be reasonable to undertake a course of generic vestibular rehabilitation, as they may still need to accommodate to a changed utricular mass or a component of persistent vertigo caused by cupulolithiasis. Fujino et al (1. 99. Home Treatment Of BPPV: Brandt- Daroff Exercises. The Brandt- Daroff Exercises are a method of treating BPPV, usually used when the office treatment fails. They succeed in 9. These exercises are performed in three sets per day for two weeks.
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