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Vestibular Rehab - A Patient Perspective

Posted by Cynthia Ryan

Ruth Goldberg shares her experiences with Vestibular Physical Therapy (VPT) and other exercises.

I have had Meniere's for over 35 years and have discovered that Meniere's and other vestibular illnesses are ongoing chronic conditions that continually send us messages that less moving = less symptoms.  It is important to move, especially when the condition continues for many years, we need to deal with it!

What stops patients from VPT and exercises

  1. VPT exercises cause the person to get dizzy, and who wants to get dizzy on a good day

  2. Because of the dizziness, one gets subconsciously afraid, especially newly symptomatic patients.

  3. If the therapy environment of the clinic is noisy, crowded, hot, cold, difficult to get to, or doesn’t have a place to rest after the therapy, it becomes difficult to recover from the effect dizziness caused by the therapy.

  4. It is difficult to understand the need to continue the therapy when the medical support system is inconsistent.

I believe that the brain is smart. Even If we don’t continuously retrain our brain to compensate correctly, it will produce solutions that may work for the short term but not for the long term.  It may, for example, cause a tilt of the head bringing about additional dizziness related to the muscles, tension etc.  As Meniere is a chronic illness that follows us for most of our lives it is important to prevent these long-term complications.

Why isn't Vestibular Physical Therapy more popular?

At the moment research on vestibular exercises lacks significant scientific background because of the numerous amounts of variables

Patient variables

  • Date of initial onset
  • Date of diagnosis
  • Frequency of attacks, their duration, and intensity
  • Symptoms of tinnitus, hyperacusis, loss of hearing, or from migraines
  • Unilateral or bilateral dysfunction
  • Medication
  • Pain
  • Other illnesses
  • Age
  • General strength
  • Living conditions; family, friend, or living in a facility
  • Level of standardized daily living
  • Safety of the daily exercise environment

 VPT variables

  • Where is the therapy held? Is it at a clinic or at home? Is it training or retraining?
  • What did the person do just before starting the training? Did he warm up his muscles and relax his eyes or just got off a busy and noisy subway?
  • How difficult is it for the person to get to the PT clinic, and how does a person return home?
  • How and to what level does the patient bring himself back to his baseline after therapy, before returning to daily activities.
  • Is the therapist in a hurry to get as much done as possible, because of external limitations, causing less than optimal results?
  • Concerns of patient’s other conditions such as fibromyalgia, cancer, migraines, visual symptoms etc.
  • In chronic conditions, situations change within the many years since onset; environment, general health, mood, family life, age etc.
  • Everyday changes that the patient goes through, may result in terrible dizziness in one day and pass uneventfully in another.

 

It should be explained to the patient beforehand that dizziness could result from the therapy because it is part of training the brain to function better. Some of the responses I get from my support group seem close to hysteria: “I am never ever going again… He made me dizzy... She made my situation worse.” We then run a statistical analysis: Did the therapy help you? and the results are negative because of unrealistic expectations or giving up prematurely.

Setting a baseline for comparison

Because so many variables are involved, it is important to build a baseline for VPT for each patient.

A preparation set* of exercises that include self-massage, stretching specific for the central nervous system, Tai chi warm up exercises including neck and shoulders, and palming eyes.  This means that when I start the vestibular retraining I have relaxed muscles including neck and shoulders, relaxed eyes and a relaxed mind.

Relaxation just before VPT makes an enormous difference to my individual VPT outcome and so does relaxation after the training where I return to my daily activities only after returning to my baseline.

Holistic, Full Body Response – Some Theoretical Suggestions

The classic vestibular physiotherapy takes each element that effects the vestibular system and isolates them. It is based on the idea that in order to change the threshold of our dizziness we need to work at close to 90-95% of our threshold. This method helps us understand what the triggers are, and provides the trainee with automatic, and at times even a reflexive response which is the goal. It also increases awareness.

On the other hand, because these exercises are isolated from other elements, they do not take enough into account the complexity of movement. An example is the saccadic exercise where one moves the eyes between two targets. One usually starts with two stationary dots. In the real world, the two targets are not stationary, new objects are introduced that compete for attention, the speed of the movement of the targets and objects change, etc. We reach an unlimited number of variables, that are difficult to control, measure or understand their outcome.

It also becomes difficult to build a program as the specific needs are different from patient to patient.  Therefore, setting guidelines for, and training, VPT are complicated. This calls for inclusion of other approaches:

  • A good approach is to recommend trainees to get on with their life as normally as possible. It often   works, but a trainee like myself who has a complex condition, would find herself with extended and heightened symptoms.
  • A middle ground approach that lately has become more accepted and encouraged, is to do regular routines of movements such as Tai chi, chi-gong, and easy yoga. These exercises provide a routine of wellbeing for people like me that otherwise would avoid movement. They are based on balancing one’s body and mind, provide bring deep relaxation, and their repetition provides assurance.
  • The cause for Meniere is not clear.  For many there seems to be a correlation with the electrolyte and fluid balance. When I had breast cancer I discovered that lymph therapy cleared my head and reduced the fogginess that I had had also prior to cancer. It can be argued that there is no direct connection between the perilymph and lymph except for the name, but if a leakage exists in the inner ear to the blood then it could also be increased fluid of the lymph. Has any research been done in this area?

Routine exercises such as Tai chi as part of VPT

Our body tries to find ways to compensate, often causing imbalance of muscles in the rest of the body. Although I have no scientific research to demonstrate this. The emphasis of the oriental approach on balance, helps our body to realign and prevents the effects of the short term inappropriate compensation to take over.  I propose this hypothesis for a number of reasons:

  • Our imbalance is an abnormal condition where the brain may be interpreting it as an emergency fight and flight situation, and therefore finds the quickest solution -- usually a short-term solution -- that carries a long-term price like the chronic tilt of the head.
  • Although we practice classic VPT with the intention of finding long term solutions, in most of our awakening and sleeping hours our brain may compensate for the imbalance on a short term basis.
  • Smooth movements allow facia, muscles and tendons to make minute changes that slowly provide a long-term change. They usually do not cause dizziness because they do not push the limit, but they probably improve the threshold.
  • When we move with our whole body we provide support for the various parameters of the vestibular system. This probably provides a closer-to-real-life situation, which may offer an easier way for the body to train its responses.
  • It is important that the program for our home routine does not only push the limit  beyond the 90% threshold and cause us dizziness, but also provides us with an easier routine, keeping to the rule of 70% threshold thus allowing the body to relax.

Empowerment

Expanded vestibular training that combines Chi gong, Tai-chi or Yoga with the classical approach encourages movement, induces relaxation and can even be fun. This can also empower us. For many of us the situation is chronic and our life has changed significantly, we can still have some control in our daily lives. This is very important as years go by and no significant solutions are available.

Once I have learnt some exercises should I see my VPT again?

I believe one should get repeated feedback depending on one’s condition.

It is important to receive feedback to avoid long term complications for the way we stand, walk, hold our head, and respond to various stimuli and not only to avoid severe dizziness and imbalance. As patients, we cannot always perceive what is happening. This is true even if we are trained and do our exercises for years. For instance, I didn’t know how bad my tilted head was until I went to buy new glasses. I actually sat in the park next door to the optometrist and photographed myself a few times in order to comprehend my situation. Did I know I should keep my head straight?  Of course, I did, but I couldn’t do it myself without feedback.

Another reason is the shifting baseline of our dizziness. How do we decide if we can do something or not? I can go to a psychologist and discuss the pros and cons until I end up with my childhood saga, and my lost dreams, but a VPT can provide me with updated clues and cues to understand my current condition.

In cases, such as tearing a tendon, breaking a leg, having cancer or any other disease, we are sent to specialists who don’t know specifics about Vestibular issues and we end up ignoring our VPT needs. A yearly or half yearly visit to VPT will ensure optimum care of our vestibular symptoms and continue to improve our lives and live it to its fullest.

Do I exercise every single day?

Not really. Some days I am not well. Some days are very busy, some days I just can't bring myself to do exercises, but I do clearly plan to do them every day! I imagine myself doing them routinely and it helps returning to the exercises after a break. I end up doing some of them most days. Examples of the exercises I do are included below.  I plan to include more with time.  In days that I do not exercise because of an attack I force myself to move, even if it is only my toes. This attitude has really helped me.  

I always recommend that you check with your vestibular physical therapist before you try new exercises. Each of us has his or her own experiences and physical needs and you will be a good judge of what is helpful for you.  Even a few minutes a day are better than none!  I wish you success and hope you will feel well and empowered.

About Ruth Goldberg

Recently she has built a website in Hebrew with the support of VeDA.

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