Calm, Cool, and Compensated

Posted by Kerrie Denner

by Julie Grove, MPT of Cascade Dizziness and Balance PT

(Presented to Seattle Dizzy Group 9/21/13)

This presentation discusses the role of vestibular rehabilitation for treating symptoms of dizziness, vertigo, disequilibrium, nausea, and anxiety. The tenets of vestibular rehabilitation and balance physical therapy are reviewed including evaluation, treatment, prognosis, barriers to treatment, and facilitators for recovery. Concepts of central compensation are explained including functional vs. physiological compensation, de-compensation, and failure to compensate related to inner ear dysfunction.


Brain compensation is the dynamic process of the central nervous system responding and “re-wiring” after a vestibular injury/trauma/onset. These phases are in acute and long term time frames.

Acute compensation refers to the cerebellum shutting down or inhibiting the severe neuronal asymmetrical inputs from a damaged vestibular system relative to a normally functioning one.

Long term compensation refers to the process of neurophysiological changes at the vestibular nuclei in the brainstem and how the labyrinthine inputs are recalibrated to reduce the asymmetry of responses (decrease mixed signals/sensory mismatch).

Vestibular rehabilitation therapy (VRT) is a specialized type of therapy which uses the active movements of head, eye, and body motion to help restore central compensation and optimize function.

There are two types of compensation used in VRT:

1. Vestibular Adaptation Exercises

- Used with an intact cerebellum/brain that learns with practice
- Used with stable, not progressive vestibular dysfunction
- Used for bilateral (both) vestibular dysfunction with some residual vestibular function
- Facilitated by exercises used to “force” the use of the remaining vestibular inputs and recalibrate the system through firing changes at the brainstem( vestibular nuclei):
• Eye-head coordination exercises
• Progressive balance re-training
• Dynamic gait activities
• Simple to complex tasks


MENTAL IMAGERY (visualize/imagine success)

ERROR SIGNAL GENERATION (make adjustments to compensate for errors)

INTERNALIZATION OF MOVEMENT (cognitive, intentional, self-correcting)

PRACTICE FUNCTIONAL TASKS (apply therapy to day-to-day tasks)


Stair-step gradual improvements

2. Substitution

- Used with vestibular problems which are permanent and not able to learn or change over time
- Used with progressive neurological dysfunction
- Used with complete loss of vestibular system bilaterally


Use of trekking poles, canes, walkers

Use of additional lighting, visual markers

Use of alternative sensory inputs: pressure, vibration, touch


Strengthen body systems capable of compensation and optimize environment by using balance aids and increasing awareness through visual cues and touch/sensor cues (proprioception).

De-compensation refers to the central nervous systems inability to maintain a compensated state when resources are inadequate to meet the demands of the systems when stressed/injured/deprived. (Regression after having improved from vestibular rehabilitation therapy).

Possible triggers/causes of de-compensation:

• Elevated life stressors
• Poor sleep, disrupted sleep
• Sickness, illness, new injury:
o Diagnosis of diabetes, poorly controlled
o Visual impairment
o One sided vestibular problem becomes a two sided problem
o Head injury o Neck/spinal whiplash
o Fluctuating vestibular or central disorders:
· Meniere’s disease
· Migraine related vertigo/dizziness
· Growing acoustic neuroma
· Perilymphatic fistula or canal dehiscence


Prevention Strategies:

Recognize the fragile state of compensation achieved by vestibular rehabilitation therapy and minimize the risk of de-compensation by modifying lifestyle, reducing stress, and managing fatigue.

Measuring Compensation is discussed in two ways:

1. Physiologic compensation = vestibular ocular responses (and central responses) measured on rotary chair

2. Functional compensation = the combined objective and subjective responses of the patient with a diagnosed vestibulopathy including changes in scores on:

• Dizziness handicap inventory
• Activities Balance Confidence Scale
• Vestibular ADL questionnaire
• Static balance measures
• Dynamic gait tests
• Dynamic visual acuity tests
• Gaze stabilization tests
• Quantitative analysis of nystagmus (involuntary eye movement) at rest and after headshake test in video infra-red goggles (IRV).



Heat and warmth can increase sensations of nausea.

When dizziness, vertigo, anxiety, or nausea/vomiting occur quickly apply cold towels to neck/head.

Move to a cool space, if safe, or feel the tactile (touch) receptors against a building wall.

Use cool/cold sensations to distract you (your brain) from the strong feelings of nausea.

Use natural anti-nausea foods: ginger and peppermint. 

Reduce your body’s autonomic nervous system reactionary fight/flight to nausea/dizziness.


Using diaphragmatic breathing as a first response to a “perceived threat” to the system. Belly breathing that does not induce exertional dizziness. (Breathe in through nose and out through mouth). Use to oxygenate the body and calm the central nervous system. Identify the fight/flight response and whether it is the brain anticipating vertigo or dizziness.

Identify the fight/flight response and whether it is a sensation of anxiety or panic.

Re-frame the sensation or response to identify the brain’s negativity bias.

Use positive coping strategies and affirming self-talk reiterating ideas of your resilience, strengths, independence, “mental toughness,” belief in oneself, or self efficacy. (For example, “l am a fighter”).

Use mental imagery or visualization to imagine yourself performing ANY task at your best performance and highest quality.

Reinforce to yourself that a positive outlook equates to a positive outcome.

Pace yourself to allow for optimal energy usage and conservation.

Reduce unneeded stressors.

Impact of Positive or Negative Thoughts/Outlook on Compensation:


Julie Grove, MPT of Cascade Dizziness and Balance PT

Julie graduated with her Masters in Physical Therapy from California State University Fresno in 1997. Since 1999, Julie has practiced in the specialized field of vestibular and balance rehabilitation, an area of physical therapy she is deeply passionate about. She has extensive training and experience in this field, exclusively treating patients with dizziness, vertigo, disequilibrium, and fall risk for over 14 years.

Julie completed the Herdman Vestibular Competency course in 2002, considered the “gold standard” of vestibular excellence in the balance community. In addition, she successfully completed the Vestibular Function Test Interpretation and Application to Rehabilitation in July 2004. She has continued her pursuit of understanding the neuroanatomy and neurophysiology of the central and vestibular systems by attending national conferences, regional case study rounds, and reviewing literature. Currently, Julie serves on the Vestibular Special Interest group committee for developing the “Clinical Practice Guidelines on Peripheral Vestibular Hypofunction.”

“When a trauma, virus, autoimmune disorder attacks the inner ear, your world will be turned upside down, literally, but treatment is available when a team approach is utilized for diagnostics, management, and rehabilitation.”

In addition to starting three regional balance programs, Julie also helped initiate a local support group for those suffering from dizziness. She has instructed students of physical therapy, audiology, and occupational therapy as well as various physician groups in the core aspects of vestibular rehabilitation. Julie enjoys “cutting edge” vestibular and balance research and recently participated in the BrainPort clinical trials as principal investigator.

“Patients need to understand that their seemingly unusual symptoms of blurred vision, fatigue, elevated fight/flight sensations, and dizziness are all part of the expected symptoms of the invisible problem that can be a vestibular or central dysfunction.”

In her spare time, Julie enjoys recreating outside be it kayaking in the San Juan Islands, jogging Seward Park, waterskiing, playing touch rugby, snow skiing, or walking. She has coached kids athletics as well as “Girls on the Run” and is a member of Feet First, a Seattle based pedestrian safety advocacy group. She would love to see more kids walking and biking outdoors safely!

Source: Seattle Dizzy Group


Accessed 10/21/2013

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