Balance System Disorders

Management of balance and vestibular disorders is often a multidisciplinary endeavor. Management may include medical, surgical, rehabilitative, or a combination of these approaches.

Medical Management

Depending on the etiology of the patient's vestibular disorder and/or underlying cause(s) of balance symptoms, a variety of medical and surgical options may be recommended by appropriate medical professional(s). Medications may be provided to suppress the vestibular symptoms or to treat the underlying pathology (e.g., migraine, multiple sclerosis). Dietary and/or lifestyle changes may be recommended. Surgical intervention may be considered in specific cases (e.g., excision of vestibular schwannoma, repair of superior semicircular canal dehiscence or perilymph fistula).

Vestibular Management and Rehabilitation

Vestibular and balance rehabilitation therapy involves activities specific to the diagnosis and individual needs of each patient. This therapy works to promote the central nervous system's natural compensation process to reduce or eliminate problematic symptoms that come with chronic balance disorders and/or dizziness.

Goals of vestibular rehabilitation include

  • promoting the compensation process of the central vestibular system,
  • reducing the patient's sensitivity to symptom-provoking movements or visual motion,
  • reducing fall risk by improving static/dynamic balance and gait, and
  • maintaining the compensation process.

Adaptation/Gaze Stabilization Exercises

Adaptation exercises target the VOR and involve the patient performing specific head movements while keeping a visual target in focus. The clinician carefully monitors the patient's performance for accuracy and for appropriateness of progression in difficulty. Variations are made to patient positioning, distances from target, and speed of movement. A typical adaptation exercise program may last between 6 and 8 weeks (Dye, 2008).

Habituation Exercises

The goal of habituation exercises is long-term reduction of negative responses (e.g., dizziness) to particular stimuli (e.g., motion) by repeated exposure to those stimuli. The patient will be guided to perform specific symptom-inducing movements repeatedly. Monitored progression of habituation exercises may be appropriate for a patient who has dizziness or other vestibular symptoms caused by motion or visual field sensitivity.

Substitution Exercises

The patient learns to substitute and actively control eye movements during head movement to reduce vestibular symptoms. For example, smooth pursuit and/or corrective saccades may be used to reduce dizziness. Substitution skills can be mastered with repetitive exercises using visual targets.

Balance, Strength, And Conditioning Exercises

Balance exercises challenge the patient by removing or disturbing visual input or using uneven surfaces. These exercises can focus on static and/or dynamic balance. An exercise program focusing on balance may be appropriate for a person experiencing symptoms from a general vestibular hypofunction.

In some cases, muscle weakness may be found to be a contributing factor to a patient's balance difficulties. These patients may benefit from traditional strength and conditioning exercises. This aspect of vestibular rehabilitation will require input and collaboration with a physical and/or occupational therapist.

Functional Activities

In addition to exercise programs, the balance management team also considers the patient's functional performance. For example, an occupational therapist may do a home assessment to ensure that fall risk is reduced, a physical therapist may recommend gait activities, or an audiologist may provide education on how specific vestibular and balance disorders can impact a person's daily activities.

Canalith Repositioning Procedures (CRP)

Canalith repositioning maneuvers/procedures are used in the management of BPPV. This type of vertigo is caused by otoconia detaching from the utricle and/or saccule and collecting in the semicircular canals. Typical symptoms of BPPV include dizziness, vertigo, imbalance, and nausea. The goal of repositioning maneuvers is to move otoconia out of the semicircular canals and reduce dizziness and/or other vestibular symptoms. CRP involve specific sequences of head/body movements guided by a trained professional. Eye movements are monitored during each guided head/body movement. A number of canalith repositioning maneuvers are commonly used to manage BPPV.

Patients may be instructed to follow limitations and restrictions (e.g., posture, head movements, activities) for a period of time after the maneuver. However, use of postmaneuver restrictions generally does not improve the efficacy of the procedure or the patient outcomes (Casqueiro, Ayala, & Monedero, 2008; Hunt, Zimmerman, & Hilton, 2012; McGinnis, Nebbia, Saez, & Rudolph, 2009; Roberts, Gans, DeBoodt, & Lister, 2005).

Posterior Semicircular Canal BPPV Management Maneuvers

One management option for posterior semicircular canal BPPV is the Epley maneuver, which assists in the migration of otoconia (Epley, 1992). Medication may be given to reduce nausea during the procedure.

The Semont maneuver, also called the Liberatory maneuver, manages BPPV in conditions with free-floating otoconia and with otoconia that are attached to the cupula in the posterior semicircular canal. Movements undertaken with this maneuver are done with more speed than required with the Epley maneuver.

Lateral Semicircular Canal BPPV Management Maneuvers

Techniques such as the "barbeque roll," Lempert maneuver, and Gufoni maneuver all target the lateral semicircular canal variant of BPPV. These techniques involve variations of rotating and tilting movements performed by the patient.

Anterior Semicircular Canal BPPV Management Maneuvers

Anterior semicircular canal BPPV is rare, and less information is available on effective management. In some cases, the Epley maneuver or Semont maneuver may be helpful. Another technique called prolonged forced position procedure (PFPP) has been described (Crevits, 2004).

Counseling and Patient Education

Each patient with dizziness and/or imbalance concerns will require education and counseling specific to the etiology, symptomology, and characteristics of their disorder. Ensuring a patient's health literacy regarding their diagnosis and management options will allow them to make informed decisions and to be an active participant in their care. The patient with chronic balance issues can use a variety of strategies to remain active, reduce fall risk, and cope with symptoms.

Outside Referrals/IPP

IPP is a vital part of the management process of balance and vestibular disorders. Coordination and communication between and among balance professionals will assist in providing the patient with the best outcomes. Involved professionals may include a trained audiologist, a physical or occupational therapist with balance expertise, primary care physicians, otolaryngologists, neurologists, and other medical professionals, as appropriate.

Management Considerations

Pediatrics

Untreated vestibular system impairments in children can lead to incoordination and delays in developmental milestones (Rine et al., 2004). Management techniques will vary depending on the etiology of the impairment. Once a child with dizziness has had a medical evaluation by a physician (e.g., pediatrician, neurologist, or otolaryngologist) and a thorough diagnostic assessment, an effective management plan can be developed. Determination of management success may include measures of dizziness-related quality of life and dizziness symptoms (McCaslin, Jacobson, Lambert, English, & Kemph, 2015).

Management Limitations

Factors that may limit vestibular rehabilitation success include

  • cerebellar dysfunction (e.g., stroke),
  • cognitive deficits,
  • excessive nausea,
  • patient compliance,
  • polypharmacy,
  • reduced proprioception,
  • reduced vision, and
  • fluctuating etiologies (e.g., Ménière's disease, perilymph fistula).

Contraindications for canalith repositioning maneuvers include

  • acute bone fractures,
  • history of back or neck problems,
  • medical conditions (e.g., unstable heart disease),
  • reduced mobility or flexibility, and
  • retinal detachment.

Service Delivery

The multidisciplinary management team will consider service delivery variables and how they may affect patient outcomes.

  • Format: In most cases, the patient will be seen individually for balance disorder management.
  • Provider: The person or persons providing services will vary per the management plan.
  • Dosage: The frequency, intensity, and duration of service will vary per the management plan.
  • Setting: The location of services provided will vary per the management plan.

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