Diagnostic Error Survey
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During vestibular rehabilitation therapy (VRT), home exercises are a vital part of treatment. A physical therapist (PT) or occupational therapist (OT) specialist will design an individualized treatment plan with appropriate exercises to be performed at a prescribed pace.
While VeDA does not recommend doing vestibular exercises at home without a diagnosis and a personal treatment plan from vestibular specialists, if your doctor has told you that your dizziness is related to a vestibular deficit and that exercise is appropriate for you to try, ask yourself what makes you dizzy. Is your dizziness related to a particular movement of your head? Perhaps when you turn your head to look at something to one side or the other you feel dizzy.
Once you have identified dizziness-provoking movements, you can begin an exercise program to repeat those movements to help you to achieve vestibular compensation. It’s important to repeat them at least five times in a row and twice a day. If you find there are several different movements that make you dizzy, pick two to work on at a time. Once you no longer experience dizziness in response to these movements, add two more. Don’t try to do exercises for more than two movements at a time.
‘Balance retraining’ is a therapy which can speed recovery from any change in balance system function – including changes caused by chronic dizziness. But if you have chronic dizziness, you need to understand the difference between attacks of vertigo (which the exercises cannot help) and long-lasting dizziness and imbalance (which the exercises can help).
This is a strong sensation of spinning which happens suddenly, lasts several hours, and usually causes you to be sick, and to be unable to stand up, walk or drive. In chronic dizziness, attacks of vertigo are caused by changes in the inner ear. The exercises cannot prevent these attacks – but they cannot cause them either. If you are currently having these kinds of attacks very frequently (every six weeks, or more often) then the exercises cannot help you just now, as recovery takes at least six weeks even with the exercises.
The changes in the inner ear which cause an attack of vertigo result in a change in the signals given out by the faulty balance organ. Over time, your brain adjusts to these new signals (the booklet explains how this happens), and so you become less dizzy. Balance retraining exercises can speed this process of recovery.
Attacks of vertigo do not normally occur very often – usually there are many months or even years between attacks, although there are sometimes periods when the attacks occur frequently. But you may find that in between the attacks of vertigo you have long-lasting symptoms, such as dizziness, nausea, unsteadiness, tiredness, or a ‘hangover’ feeling. These symptoms often become worse when you are physically active, tired, stressed, or when you travel. The exercises can help you to clear up these symptoms during the period in between attacks of vertigo.
Of course, after you have cleared up the long-lasting symptoms, you may have another attack of vertigo. In this case, you will have to start all over again, using the exercises to speed recovery. But people with Chronic dizziness who have tried these exercises say that they give them confidence that they will be able to get over their next attack of vertigo more quickly, using the exercises to help to clear up symptoms.
The balance system relies on three different senses. Using your eyes you can see where you are and where you are going. Using the sensors in your body you can feel where you are and how you are moving. And the balance organ in your inner ear (which doctors sometimes refer to as the vestibular organ or labyrinth) senses whenever your head moves.
Your brain acts like a computer, combining signals from these three senses to give you a stable picture of the world and control your head, body and eye movements. If any part of this balance system is giving out unusual or faulty information then you may feel dizzy, disoriented or unsteady.
The balance system can be affected by many different medical problems, and so it is important to see your doctor and check which part of the balance system is not working normally. If your symptoms seem to be caused by your balance organ your doctor may tell you that you have vertigo, or vestibular imbalance. This can result from a mild virus or ear infection, or sometimes just wear and tear on the balance organ. Sometimes your doctor will not be able to discover why the dizziness started, but balance retraining can still help to speed recovery even when the cause for the dizziness is not known.
If your balance system is not working normally, then you may find that you become dizzy whenever you make quick or unusual movements, such as reaching up or looking behind you. You may also become dizzy when you are moved (e.g. in cars or lifts), or when you are in a situation with a lot of moving lights, objects or people (e.g. in busy traffic).
If your balance system is not working normally, it is very rare for this to be because of a dangerous medical condition. But although dizziness is not usually a sign of a dangerous illness, it is very unpleasant and frightening and can cause other symptoms and nausea, tiredness and difficulty concentrating. Often people who are dizzy avoid physical activity and quick movements, and this can lead to other health problems such as a stiff neck and headaches, and becoming unfit. Because of dizziness people sometimes end up avoiding even vital activities, such as working, travelling or going out alone. You need to have good balance as you get older, to reduce the risk of falling and hurting yourself. So even though dizziness is not usually due to serious illness, it is still important to speed recovery from it.
The bad news is that there is no medicine which can make the balance system work normally. Your doctor may be able to give you tablets to ease the dizziness and nausea, but these will not cure the problem. Sometimes the dizziness will clear up over a month or two, if you keep up your normal activities (see next section). If this has not happened, then the good news is that you can speed this natural recovery process using the exercises in this booklet.
Recovering from dizziness is exactly the same as getting your sea legs. At first being at sea makes people unsteady and sick, but if you stay at sea then gradually the brain learns to cope with the new balance signals from the eyes, body and balance organs, and the sickness disappears. In the same way, the brain can gradually overcome dizziness and imbalance due to a change in the way the balance system is working, following injury or illness. But your system can only learn to cope with the new balance signals if you practice the activities which cause dizziness. Balance retraining exercises give your balance system all the practice it needs, at a time and place where you will not be distracted or put at risk.
In scientific studies, 75%-80% (four out of five people) who were taught these exercises reported feeling better within a few months. A comparison group of people who were not taught the exercises did not get any improvement in their dizziness.
To find out whether these exercises are right for you, simply try out the exercises on the next pages. If they do not make you dizzy, even when you carry them out at top speed, then they will not help you. If they make you dizzy then this is a sign that your system needs practice with these activities. Until your system has learned to cope with these movements, you will become dizzy whenever you have to carry out these movements as part of your normal daily activities.
The exercises are based on normal head movements that you should be able to make during your daily life, and so they will be totally safe unless you have been told you should avoid these head movements. If you feel a bit more dizzy when you start the exercises this just means that they are working – they cannot cause any damage to the balance system – but you may want to practice them more slowly at first. If you have a stiff neck, you will also need to make the movements gently to start with, but the exercises should gradually help to ease the stiffness. If the exercises seem to bring on any of the symptoms listed below (which is very unlikely), or if you have these symptoms already, you should not carry on with the exercises until your doctor has said it is safe for you to do them.
Avoid doing the exercises if doing them seems to cause any of these symptoms: sharp, severe or prolonged pain in your neck, head or ear; a feeling of fullness in the ear; deafness or noises in the ear; fainting with loss of consciousness or blacking out; double vision; numbness, weakness or tingling in your arms and legs.
Everyone’s lifestyle is different, and different movements make different people dizzy. This page shows you how to design an exercise program which will suit you.
Use the scores on your exercises sheet to decide which exercises to do for the next week:
It helps to breathe slowly if you feel dizzy – no more than one breath every four to six seconds. To loosen up before starting, gently shrug your shoulders and circle them around a few times.
As well as these basic exercises, you should choose some special exercises and general activities.
When you first start carrying out the exercises they will make you a little dizzy. If the dizziness starts to interfere with your daily activities, then do the exercises a little more slowly at first, but do not skip them – it is only with regular practice that your balance system can recover.
Most people have good days and bad days at first. It is quite normal to find that the dizziness gets worse for a time when you are tired or stressed, or if you get a cold or flu. But after a few weeks of regular daily practice you will notice that the exercises are starting to make you less dizzy. Then you should gradually do the exercises more quickly, until you can do them at full speed.
After a while some exercises will no longer make you dizzy, and you will not need to practice them anymore. You need to check which exercises you need to do that the start of each week, by repeating the timed exercise scoring test. If you score 0 for any of the exercises (or if you score only 1 for several weeks), then you should make that exercise more difficult as follows.
Physical activity as part of your daily life also helps your balance system to recover. It is especially important to practice any activities you may have given up because of dizziness. Read through the tips for choosing physical activity below, and then write down an activity you will practice each week on the exercise sheet.
Catching a ball gives your balance system very good practice with quick eye, head and body movements. Get a soft ball, and practice throwing it above your head and then catching it. Like the basic exercises, you can start by doing this while sitting down, then standing up, and finally while walking.
If you have poor balance then simply walking for five to ten minutes a day will help it to improve. If you have no problems walking on a flat surface, you may still need to practice walking over rough ground, or up and down slopes or stairs.
If walking around a busy town center makes you dizzy, then practice in gradual stages. You could start by walking down to the end of your street and back for the first week. The following week, walk to the nearest busy road and watch the moving traffic until it does not make you dizzy. The next week walk along the busy road to the nearest shop and back – until eventually you are ready to practice walking in a place with lots of moving crowds and traffic.
Once your dizziness in nearly better, then sport, dance or exercise (e.g. yoga or keep fit) can help you balance system return to normal.
You may have found that you become dizzy when travelling by car, bus, train or boat, or in a lift or an escalator. The only way to get over this dizziness is with practice! Start by practising short trips as often as possible, e.g. travelling one or two stops on the bus, or a short car trip. Gradually practice longer trips as your dizziness gets less bad.
Since different movements make different people dizzy, there may be some activities which you already know make you dizzy. If so, write them down as special exercises on the exercise sheet, and practice them daily.
The special exercises listed below can help with the particular problem listed.
If you have problems walking in a straight line, or tend to lose balance and fall over, then you need extra practice with balancing. Once you can do the basic exercises while walking, you may find it helpful to carry them out while standing on one leg (stand by a sofa or bed, so you have something soft to lean on if you start to fall!). You could also practice them standing with your feet heel to toe – this is very difficult.
This is a very common problem which results from little particles floating into the wrong part of the balance organ. To help float the particles back out again, sit on the edge of the bed with your feet hanging down. Lie down as fast as you can on the side which makes you dizzy. Wait for 30 seconds, then sit up quickly and stay upright for 30 seconds. Now repeat this on the other side. If you do this exercise 10 times every day you will be very dizzy at first, but the dizziness should clear up in a few weeks.
If you find that reaching up or down or behind you makes you dizzy, sit in a chair and practice looking at and touching places on the floor, above you, and behind you. (Do not practice this exercise if it makes you feel faint or as if you will lose consciousness).
You may find you are made dizzy by vision – for example, when looking at stripes or scrolling computer screens, watching films, or looking at moving traffic or lights. If so, then stick a sheet of bright striped paper on the wall close to you, and practice carrying out the shake, nod, shake/stare and nod/stare exercises while facing this sheet of paper (sitting and then standing). Whenever possible, you should also practice the real-life situation which make you dizzy – for example, deliberately stare at moving traffic, or the scrolling computer screen.
Author: Professor Lucy Yardley, produced by the University of Southampton with funding provided by the Ménière’s Society. It is recommended for use only after a qualified medical doctor has confirmed that the exercises are safe and appropriate for the individual who will carry them out.
This booklet includes exercises that are suitable for people suffering from balance problems and dizziness. They are typical of the sort of exercises that are provided in physiotherapy rehabilitation programs. These exercises can be used for a range of balance problems and/or dizziness. However, they are not effective for all kinds of dizziness. It is important to check with your doctor to see if these exercises are suitable for you BEFORE you try any of the exercises on your own. If you have access to a vestibular rehabilitation center, it is preferable to explore treatment under the supervision of a trained physical or occupational therapist.
Exercises such as these take many weeks to start recalibrating the balance system and they are hard work. Initially they may make general balance and/or giddiness seem worse. If you are unsure whether to do them, discuss it with someone within your healthcare team who has an understanding of your symptoms.
In supplying this information the Vestibular Disorders Association accepts no responsibility for the response to, or outcome from, undertaking such exercises.