This content was updated for accuracy and relevance on Oct 10, 2023

Do you experience dizziness, vertigo a sense of spinning, or an unsteady feeling? You may be suffering from a problem in your vestibular system. These vestibular dizziness conditions are often very responsive to treatment by a physical therapist.

Let’s examine common symptoms associated with vestibular dysfunction:

• Lightheadedness
• Vertigo (room spinning or spinning in your head)
• Blurred vision when you are in motion
• Unsteadiness when walking and turning your head or body
• Veering while walking
• Difficulty orienting yourself in the dark or the shower
• Difficulty concentrating especially at the end of the day
• The sensation of movement of self or your surroundings
• Decreased hearing, fluctuating hearing loss, or ringing in your ears
• Dizziness when lying down or getting up quickly
• Dizziness when walking in crowded areas such as the grocery store or mall
• Objects moving or jumping when walking (oscillopsia)

What is the Vestibular System?

The vestibular system is located in the inner ear behind the eardrum. It cannot be seen when a doctor checks one’s ears with a scope. The vestibular organ is about the size of a dime, and it is a complex system of 3 interlocking tubes, called the semicircular canals, tucked deep inside the ear, protected by the skull. The vestibular system is neighbor to the main organ of hearing (the cochlea).

The vestibular system is filled with a fluid in each of the 3 tubes which are angled in different directions. Every time your head is moved, the fluid moves to cause a signal to the brain that tells you what position your head is in – even without you thinking about it. Consider this system to be like an internal GPS system constantly sending these messages about head orientation to your brain. The movement of this fluid also controls reflexes between your eyes and head movement to keep you balanced and able to adapt to change in body position. This automatic body and balance reflex are also aided by tiny little crystals (called otoconia) that sit on top of tiny sensors (called hair cells) that send automatic signals to the brain to correct posture and body position.

Important Reflexes

Two reflexes are important to be working perfectly for us to keeping the world in focus and our bodies in upright balance. The Vestibular-Ocular Reflex (often called the VOR) coordinates our vision with our head movements. When this reflex isn’t working quite right, blurry vision or dizziness with head-turning might be experienced. The Vestibular-Spinal Reflex is another automatic reaction to self-correct our posture when the balance is challenged.

Balance is automatically controlled by 3 systems:

1. Our eyes – These control what we see.
2. Our inner ears (the vestibular system) – This senses where we are in space.
3. Our sensors in our joints and tissues – These send messages about how fast we are moving and our posture and body position.

So why don’t we fall over when our eyes are closed? Our vestibular system and other body sensors send us as much feedback as they can to keep us balanced. As we age, we become more visually dependent to maintain balance, so it’s a part of balance therapy to sharpen all 3 systems to maximize our balance and prevent falls.

So what happens when the vestibular system is not working quite right?

Common Types of Vestibular Disorders

Vestibular Labyrinthitis and Neuritis

This vestibular balance disorder is caused by viral or bacterial infections entering the inner ear and causing inflammation or damage to the vestibular nerve in one or both ears. When this damage occurs, the vestibular nerves send messages to the brain which are no longer balanced between the right and left ear, and people experience a sudden onset of vertigo and imbalance which may be accompanied by nausea and vomiting. Symptoms of this inner ear disorder are severe and can last days with residual symptoms causing vestibular dizziness and imbalance which can be present for longer periods after the acute phase of vertigo has stopped. In cases of vestibular labyrinthitis patients may experience loss of hearing or tinnitus (ringing in the ears).

Benign paroxysmal Positional Vertigo (BPPV)

This vestibular balance disorder is the most common cause of vertigo and it is the number one reason people over the age of 65 visit their doctor. It is characterized by room spinning vertigo based on head position, sometimes just for a few seconds, but this symptom is enough to be very disruptive to life. The vestibular disorder is also referred to as “top-shelf vertigo” because patients report vertigo when looking up or tipping their heads back. Spinning occurs when lying flat, getting up quickly from bed, rolling over in bed, or bending down to pick up an object from the floor. This condition occurs when the calcium crystals float into the semicircular canals where they don’t belong. Oftentimes, a simple repositioning of these crystals with a combination of head movements can get the crystals back where they belong and eliminate symptoms. Physical therapists are experts in this type of vertigo treatment.

Meniere’s Disease

This vestibular disorder is caused by an imbalance of fluid in the semicircular canals. Symptoms include episodic bouts of vertigo which may be accompanied by vomiting and a balance disorder. It is usually accompanied by fluctuating hearing loss and or ringing in the ears. These episodes can last hours to days and many people are symptom-free between episodes. The duration between these episodes vary from person to person and some individuals feel dizziness and or imbalance between episodes.

Vestibular Migraines

This condition is a common type of temporary dizziness that is triggered by the same mechanism causing vestibular migraine headaches. It is characterized by dizziness or vertigo which may be preceded by an aura and tends to be more common in patients who have a history of traditional migraines. It is believed that migraines can change presentation over the course of one’s life. A vestibular migraine headache can come on suddenly and can occur without head pain.

Concussions

Any trauma to the head can cause post-concussion symptoms. These symptoms can vary widely from patient to patient and can cause vertigo, dizziness, imbalance, and fatigue. The inner ear is vulnerable to sudden jolts or trauma to the head, and dizziness can be caused by either the neck or the inner ear. It is important to establish the source of the problem and see a physical therapist with special training in this area.

There are other causes of vestibular dysfunction, impacted by conditions of the nervous system such as a stroke, Parkinson’s disease, or multiple sclerosis. Dizziness can be tied to many causes – even dehydration or a reaction to medication – so it is important to seek help immediately.

Treatment for Vestibular Dysfunctions

Vestibular function therapy is proven to be the most effective way to treat dizziness, unsteadiness, and imbalance due to common vestibular deficits. Traditional vestibular therapy is done with a vestibular therapist in an outpatient setting and consists of first assuring what the problem is, and then checking to see that all of the crystals in the vestibular system are in the right place and sending accurate signals. Physical therapists have several tools to help them – moving the head, eyes, and body in different positions, and sometimes using special goggles that allow the therapists to see the movements of the eye (Frenzel glasses). The next step is to make corrections as needed, and then re-train the vestibular system to react in the correct, automatic way. If crystals are in the wrong place, physical therapists can move the head in specific patterns to encourage crystals to their original position. Patients usually feel better instantly, with over 80% of patients only requiring 1-2 treatments.

We shouldn’t need to think about our balance. Special adaptation and habituation vestibular rehabilitation exercises under the direction of a physical therapist may be very helpful in fully recovering functional balance. Treatments may include balance training in many different positions, progressing to balance in walking, vision exercises in different positions, and adaption and habituation exercises, retraining the brain to sense signals in the right way again.

Where can I go for a vestibular evaluation and treatment?

Vestibular rehabilitation therapy is a sub-specialty of physical therapy and requires additional training. Oftentimes, a physician will refer someone struggling with balance and dizziness to see a physical therapist, but it is important to note that people can advocate for themselves and refer themselves directly to a rehabilitation physical therapy medical professional. Be sure to ask for experienced vestibular rehabilitation therapy and follow their guidance. You will feel better in no time!

Ivy Rehab Physical Therapy offers quality care vestibular Evaluations and treatment plans performed by Doctors of Physical therapy specializing in vestibular pathology. Our vestibular expert clinicians have experience in evaluating and treating all of the above vestibular deficits and take pride in changing patients’ lives so they can live a dizzy free balanced life. You can see a vestibular specialist for evaluation with or without a Doctor’s prescription through Direct Access.

Article By: Robin Evans, DPT

Ivy Rehab Physical Therapy, Lynbrook, NY

Robin Evans been a PT for over 20 years. She received her Vestibular certification from Emory University in 2003 and has developed vestibular programs on Long Island incorporating state-of-the-art diagnostic equipment (Frenzel Video System) into her daily care. She currently treats patients in Ivy Rehab’sLynbrook, NY location. Ivy Vestibular therapists are available in 11 states.