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Tests for a vestibular diagnosis

Imagine seeking answers for persistent dizziness, only to find yourself shuttled between neurologists for MRI or CT scans, ENT specialists for auditory and balance testing, and even cardiology to rule out heart-related issues—all to no avail. You’re left bewildered, feeling anything but normal, despite test results consistently coming back within normal ranges. This frustrating journey is all too familiar for many individuals grappling with vestibular disorders. However, the key lies not in the conventional diagnostic avenues, but rather in understanding the intricacies of vestibular diagnosis.

Vestibular system background

The vestibular system, alongside proprioception and vision, plays a crucial role in maintaining balance and spatial orientation. Situated within the inner ear, the vestibular apparatus comprises semicircular canals and otolith organs, which detect rotational and linear movements, respectively. When this system malfunctions, individuals often experience a myriad of symptoms, including vertigo, dizziness, imbalance, nausea, and visual disturbances. These symptoms can significantly impair daily life, affecting mobility, productivity, and overall well-being.

Tests for a Vestibular diagnosis

Vestibular information is used in two ways. One is for balance, and the other is to keep our eyes focused and steady on a target, even while moving. For this to happen, information needs to be sent from the vestibular system to the brain. Certain systems and reflexes are designed to take this information and perform the necessary movements of the head, neck, trunk and eyes to do this seamlessly.

There is also an additional pathway that connects the vestibular system to the autonomic nervous system called the vestibulo-auntomic pathway. Knowing the different pathways the vestibular system is used in can help explain a lot about symptoms. Unsteadiness, bouncing vision, anxiousness etc. This also helps explain tests performed to help determine a vestibular diagnosis.

Testing to determine vestibular involvement

To unravel the mysteries of vestibular disorders, a range of specialized tests and examinations are utilized. The tests below are something that can be expected during a clinical examination at a physiotherapist or physical therapists office. If interested in learning more about specific diagnoses, check out the list of more detailed posts here.

Nystagmus, characterized by involuntary eye movements, can provide valuable insights into vestibular function. The vestibular system helps in keeping vision stable, so involuntary eyes movements that act a certain way can give insight into what signals are being sent by the vestibular system and vestibular nerves.

Positional testing, particularly for benign paroxysmal positional vertigo (BPPV), involves maneuvering the head to provoke characteristic symptoms and identify the affected canal. Involuntary eye movement (nystagmus) is helpful in combination with positional testing to determine the involved side (left or right) and canal to perform the proper corrective maneuvers.

Dynamic Visual Acuity (DVA) testing assesses the ability to maintain clear vision during head movements, offering further clues to vestibular dysfunction. If there is inaccurate signaling or information, this test will yield abnormal results. Retesting can help determine progress being made.

Standing balance assessments, such as Computerized Dynamic Posturography (CDP) or modified Clinical Test of Sensory Integration of Balance (mCSTIB), evaluate postural stability under various conditions while manipulating the different sensory inputs used for balance. This gives insight into what conditions are challenging, and what sensory systems are involved.

Functional balance assessments like the Functional Gait Assessment (FGA) gauge the individual’s ability to perform everyday tasks requiring dynamic balance control. This ties the functional movement aspect that is so impactful with vestibular conditions. To include movements such as turns, stepping over objects, narrow walking, walking eyes closed, or walking with head turns helps determine troublesome movements for each individual. These types of test can also help build a rehab program and act as a retest to track progress.

Testing from other providers

Videonystagmography (VNG) and Vestibular Evoked Myogenic Potentials (VEMP), we delve deep into the function of the vestibular nerve branches, shedding light on the superior and inferior pathways. By assessing the integrity of these neural pathways, we gain invaluable insights into vestibular function. However, it’s essential to acknowledge the limitations—while VNG and VEMP offer vital information, they can’t capture every nuance of vestibular nerve activity. Consequently, normal test results don’t always rule out vestibular involvement, especially in conditions like vestibular migraine. This type of testing does include a hearing test, which can help determine conditions such as Meniere’s Disease.  More on this type of testing here and here.

MRI: this can rule out central causes of dizziness such as MS, stroke, Parkinsons, cerebellar disorders, acoustic neuroma. This cannot diagnose a concussion or vestibular migraine, which can be a vestibular condition resulting in dizziness, but a normal test result. This type of test is important to rule out other possible causes, but can feel discouraging as a normal test result when you’re not feeling normal.

Cardiology workup, tilt table testing. This is an area that can result in dizziness with conditions such as atrial fibrillation. Screening for other areas such as orthostatic hypotension, or Postural Orthostatic Tachycardia Syndrome (POTS) should be considered with a cardiologist (sometimes this is neurology as well) to diagnose and assist with management.

In conclusion

Navigating the labyrinth of vestibular diagnosis demands a holistic approach, recognizing the unique challenges posed by vestibular disorders. While conventional testing may yield normal results, it is imperative to delve deeper into the vestibular system to uncover underlying dysfunction. By harnessing specialized tests and examinations tailored to assess vestibular function, individuals can finally find clarity amidst the dizzying array of symptoms. So, if you find yourself trapped in the cycle of unexplained dizziness, remember—it’s not just about normal test results; it’s about deciphering the vestibular puzzle to reclaim your equilibrium and quality of life.

Want to learn more about testing, diagnoses, and other vestibular tools from the experts and be a part of a supportive community to get back to your daily life?  Find out more at this link: https://tvd.flywheelstaging.com/about-group/

Disclaimer:

Remember: this post is for informational purposes only and may not be the best fit for you and your personal situation. It shall not be construed as medical advice. The information and education provided here is not intended or implied to supplement or replace professional medical treatment, advice, and/or diagnosis. Always check with your own physician or medical professional before trying or implementing any information read here.

Renga V. Clinical Evaluation of Patients with Vestibular Dysfunction. Neurol Res Int. 2019 Feb 3;2019:3931548. doi: 10.1155/2019/3931548. PMID: 30863640; PMCID: PMC6377969.

What causes vertigo?

The Causes of vertigo are vast, but we first need to remember that Vertigo is a symptom, and never ever ever a diagnosis. Vertigo is like saying ‘it hurts’. What hurts? What does it feel like? Where is the pain? Is it sharp or dull? Is it acute or chronic? What is the cause of the pain, just like we would ask ‘what is the cause of the vertigo?’

Knowing the pain is like knowing your vertigo. It’s only a symptom, and it is never a diagnosis. We need to determine the cause of the vertigo in order to accurately help you understand your body better and manage life with a vestibular disorder!

What causes a vestibular disorder?

A vestibular disorder is an inner ear disorder that can cause many symptoms, including but not limited to, dizziness, vertigo, nausea, vomiting, lightheadedness, and more. Vestibular Disorders are largely split into central and peripheral vestibular disorders. A central disorder happens in your brain; like vestibular migraine, concussion, persistent postural perceptual dizziness, or a stroke. A peripheral vestibular disorder happens in the vestibular system itself, like vestibular neuritis, BPPV, or Meniere’s Disease.

In order to understand a vestibular disorder, we also need to understand the vestibular system itself.

What causes vertigo? Many things, but typically vestibular disorders are what causes vertigo.

What is the vestibular system?

Your vestibular system lives in your skull, deep in your inner ear. It is attached to your hearing organ, AKA your cochlea, and the vestibular system itself. It’s made up of bone, cartilage, and two types of fluid. If you want to learn more about the vestibular system and it’s inner workings, read more here.

5 causes of vestibular dysfunction

What causes vertigo? Vestibular disorders are very common causes of vertigo!

  1. Illness
  2. Injury
  3. Medication ototoxicity
  4. Mechanical issues and calcium debris
  5. Migraine disorders

Illnesses and infections of vestibular disorders

There are many illnesses that are associated with vestibular disorders, which cause vertigo symptoms.

Inner ear infections, like a vestibular neuritis, will leave you with a vestibular hypofunction, which is a peripheral vestibular disorder. IF you want to learn more about peripheral disorders, listen to this free podcast episode. This kind of inner ear infection can also cause labyrinthitis, which is the same as neuritis but includes hearing loss.

Long COVID is another infection that can cause dizziness. COVID infections can infect the vestibular system, also leaving you with a hypofunction, or can cut off the blood circulation to the inner ear, causing damage to the vestibular system itself. This can cause chronic or acute dizziness, both of which are treated in Vestibular Group Fit! You can read more about Long-COVID and dizziness in this article here.

Injuries and vestibular disorders

Your vestibular system can be injured, specifically with head and neck trauma, in a Traumatic Brain Injury. TBI, mTBI, or concussion can cause a vestibular hypofunction. In some cases, if the person is impacted in the side of their head it can cause a hypofunction in the vestibular system itself. These disorders, just like all disorders, are manageable and rewiring your brain with vestibular rehab is possible to do to get back to a place where dizziness is not 24/7.

Medication ototoxicity

Ototoxic medications are some NSAIDs, Chemotherapy drugs, Gentimicin, antimalarials, loop diuretics, and salicylates (1). Sometimes, these medications are absolutely necessary, especially chemotherapy medications. Because these medications can cause injury to the vestibular system(s), they can be what causes vertigo.

However, when they’re taken they can be toxic to your inner ear and cause a decrease in function, hypofunction, in one or both ears. This can cause intermittent or permanent symptoms in one or both ears. For example, after chemotherapy treatment, bilateral vestibular hypofunction can be common, as well as

Sometimes, there are intentional ototoxic doses of Gentamicin, like for the treatment of Meniere’s Disease.

Mechanical disorders and debris

Benign Paroxysmal Positional Vertigo, Superior Canal Dehiscence Syndrome, and Perilymph Fistula are all mechanical disorders.

BPPV is a mechanical disorder because calcium carbonate crystals are misplaces from the otolith organs into the semicircular canals, causing episodic vertigo. If you want to learn more about BPPV, click here.

Superior canal dehiscence and perilymph fistula are both mechanical disorders as they are physical holes in your inner ear causing specific symptoms. A surgical or other medical intervention is usually recommended.

Migraine disorders (Vestibular Migriane)

Migraine is more than just a headache. Migraine is a full body neurological disorder that occurs in your brain 24/7 but presents itself in attacks. Vestibular migraine is the most common cause of neurological dizziness and vertigo! Vestibular Migraine is so treatable, but can feel so difficult to get there. We will help you with this, as you need a comprehensive treatment program with a comprehensive outlook, from everything from medical treatment to lifestyle adjustments and being educated about your disorder.

Dizziness gets better, you just need the right tools!

The right tools exist and they’re all in 1 place in Vestibular Group Fit! You can learn more about Group, and why we use this method here.

Sources:

(1) Joo Y, Cruickshanks KJ, Klein BEK, Klein R, Hong O, Wallhagen M. Prevalence of ototoxic medication use among older adults in Beaver Dam, Wisconsin. J Am Assoc Nurse Pract. 2018 Jan;30(1):27-34. doi: 10.1097/JXX.0000000000000011. PMID: 29757919; PMCID: PMC6044447.

Bilateral vestibular dysfunction

Learn about what bilateral vestibular dysfunction is and what treatment options are available. This vestibular condition requires a different approach due to the nature of the condition. Learn more about this lesser known vestibular condition below.

What is bilateral vestibular dysfunction

Bilateral vestibular dysfunction (BVD) is also known and bilateral vestibular loss (BVL) or bilateral vestibular hypofunction (BVH). This is when both our left and right vestibular systems are affected by an event that results in reduced function. This impacts about 4% of individuals that have a vestibular disorder.

Bilateral vestibular dysfunction can be a result of:

Typically with bilateral vestibular loss, dizziness is not a main symptom. Balance tends to be the main concern that brings someone to the doctor. Those with bilateral vestibular loss tend to experience:

I have bilateral vestibular dysfunction, what type of progress can I expect?

The difference in bilateral vestibular loss is that both vestibular systems are impacted. This makes progress variable. With both systems impacted, it’s difficult to get the benefits of adaptation and habituation that is utilized in vestibular rehabilitation therapy (VRT) when only 1 vestibular system is involved.

VRT can still be beneficial. The goal is to promote the maximum amount of habituation and adaptation as possible while also working on ways to compensate for BVL. This helps many return to functional daily activities, but it most likely doesn’t look exactly how someone performed the activity prior to BVL. [2]

Bilateral vestibular dysfunction treatment options

As mentioned above, treatment will look different for those with BVL. Vestibular therapy will trial various VRT exercises to promote as much adaptation as possible. Finding ways to substitute and compensate movements will be a major focus of treatment. The goal of these compenstations is to get people back to their daily routines and activities, just in a slightly different way.

This might include using motion sensor night lights in the home to promote safe walking at night, or use of a hiking pole for safe walking on uneven surfaces. A popular hiking pole brand that physical therapists have recommended to me are linked here.

Bilateral Vestibular Loss Treatment Options

Part of treatment will be finding exercises to promote overall health and activity. Exercising and movement has many benefits to our overall health and well being. An animal study looking animals with BVL showed that animals who exercised on a regular basis were able to return to normal movement and ability. This might not happen exactly in the same way in humans, but movement is important! [3]

Another area of treatment undergoing development is surgical implants. These surgical implants act as vestibular prosthesis. There’s been great results and improvement in mobility, reduced falls, and overall quality of life at 6 months and 1 year out from surgery. There are a few clinical trials going on with the goal of making this an available treatment option for the public.

All you need to know on Bilateral Vestibular Dysfunction

Disclaimer

Want to learn more about bilateral vestibular dysfunction and other vestibular tools from the experts and be a part of a supportive community to get back to your daily life?  Find out more at this link: https://tvd.flywheelstaging.com/about-group/

Disclaimer:

Remember: this post is for informational purposes only and may not be the best fit for you and your personal situation. It shall not be construed as medical advice. The information and education provided here is not intended or implied to supplement or replace professional medical treatment, advice, and/or diagnosis. Always check with your own physician or medical professional before trying or implementing any information read here.

Sources:

(1) Lee SU, Kim HJ, Kim JS. Bilateral Vestibular Dysfunction. Semin Neurol. 2020 Feb;40(1):40-48. doi: 10.1055/s0039-3402066. Epub 2020 Jan 14. PMID: 31935769.

(2) McCall AA, Yates BJ. Compensation following bilateral vestibular damage. Front Neurol. 2011 Dec 27;2:88. doi: 10.3389/fneur.2011.00088. PMID: 22207864; PMCID: PMC3246292.

(3) Igarashi M, Ishikawa K, Ishii M, Yamane H. Physical exercise and balance compensation after total ablation of vestibular organs. Prog Brain Res. 1988;76:395-401. doi: 10.1016/s0079-6123(08)64526-4. PMID: 3217529.

(4) Chow MR, Ayiotis AI, Schoo DP, Gimmon Y, Lane KE, Morris BJ, Rahman MA, Valentin NS, Boutros PJ, Bowditch SP, Ward BK, Sun DQ, Treviño Guajardo C, Schubert MC, Carey JP, Della Santina CC. Posture, Gait, Quality of Life, and Hearing with a Vestibular Implant. N Engl J Med. 2021 Feb 11;384(6):521-532. doi: 10.1056/NEJMoa2020457. PMID: 33567192; PMCID: PMC8477665

Concussion treatment in 5 buckets

Learn about what concussion is, common symptoms, recovery timeline and the 5 main areas of concussion treatment. Dr. Madison talks with concussion expert Dr. Heisig in Vestibular Group Fit to go over the different areas of concussion and important treatment areas to consider. check out some of the great information below!

What is a concussion

A concussion is classified as a mild traumatic brain injury. Traumatic brain injuries are classified  on a spectrum from mild to severe, we are only looking at concussion in this post.

A concussion occurs from hitting your head, or a sudden speed change that impacts the brain. You don’t have to hit your head for this rapid speed change, but is a common way concussions occur.

Imaging will not show a concussion. imaging can show blood clots, bleeding, or broken bones and other structures, but it cannot show a doctor that there is a concussion. This is determine by the method of injury and reported symptoms.

Concussion metabolic cascade

What happens to our body during an acute concussive event happens at the cellular level. The sudden change in speed creates stretching and shearing of the brain cells and neurons.

Sudden stretching and shearing of our neurons changes the balance of our electrolytes. These electrolytes are important for brain function and how our neurons fire. This sudden change in electrolyte balance results in random neuron firing and neural toxicity.

Getting our brain’s electrolytes back in proper balance takes a lot of energy and time. Typically around 3-4 weeks. During this time our brain is functioning in a metabolic energy deficit.  Our brain has difficulty carrying out typical functions due to the metabolic energy deficit. This energy deficit leads to many symptoms people experience such a disorientation, fatigue, brain fog, headaches etc.

One way to think of this is with a circle or pie analogy. A full circle is the total amount of energy we have to perform daily functions. The electrolyte rebalancing is taking up a large part of this energy pie. This leaves a smaller amount of energy pie to do the typical activities our brain does. This leaves to picking and choosing certain activities, or having to take additional time between tasks to restore energy.

Concussion treatment: 5 areas to focus concussion treatment

Rest or not rest? What research says about best concussion treatment

New guidelines in concussion have changed the way concussion treatment is performed. Typically in concussion treatment, someone might be told to rest for weeks, this should no longer be the case. Research shows that resting after a concussion for 24-48 hours and then gradually getting back into typical activities yields the best results.

Rest doesn’t mean sleeping all day. It means taking things a little slower than you normally would. This might look like a short walk instead of a high intensity workout, or limiting screen time with more breaks in between screen use. This can vary by the person depending on their concussion treatment buckets we’ll talk about next.

The goal with concussion is to gradually increase the intensity of activity to get back to your baseline. Again this can take up to 3-4 weeks. Listen to your body as guidance, new or worsening symptoms is your body saying that you’re taking on more than your body can tolerate. Take a note from your body to rest and recover and adjust the activity.

What are the 5 main buckets of concussion treatment

Recent concussion treatment and management has taken on a new way to help classify concussion to better include the many different presentations and symptoms someone with a concussion can have. A questionnaire tool called the CP Screen gives a series of questions that help determine the main categories of symptoms someone is experiencing. This screen has 5 main subtypes and 2 modifiers to help capture the main symptom areas to address on a person to person basis.

The five concussion treatment buckets are:

  1. Autonomic and Exercise Intolerance
  2. Visual Vestibular
  3. Neck and Cervical
  4. Hormonal and Metabolic
  5. Psychological (Mental and Emotional)

In the next section, we’ll go into more detail on each of these 5 areas of concussion treatment. More than one can apply to someone with a concussion but breaking down into these categories can help determine how to prioritize treatment to address the major concerns being experienced.

5 buckets of concussion treatment cont.

1.Autonomic and Exercise Intolerance

Concussion can impact blood flow. This can lead to autonomic dysfunction such as lightheadedness, dizziness, tunnel vision or elevated heart rate when standing up. In other cases, symptoms might be gone at rest, and reappear during exercise or increased exertion. Graded movement, and testing such as the Nasa lean test or buffalo concussion testing performed by a medical provider can assist in working with you in exercise progression and treatment.

2. Visual Vestibular

A concussion can impact our visual and vestibular system making us feel dizzy, off balance, or even difficulty with reading, screens or eye strain. BPPV prevalence increases after concussion and should be screened as part of a  comprehensive concussion assessment. VRT or vision therapy can further determine areas to work on to address these symptoms.

3. Neck and Cervical

Neck pain, stiffness, limited range of motion are common after a concussion. This again can vary based on the mechanism of injury and individual presentation. Focused treatment on the neck can assist with headaches, muscle pain, reduced range of motion and more.

4. Hormonal and Metabolic

Keeping the full picture in mind includes looking at lifestyle and other medical conditions someone has. Nutrition and hydration is key for overall health and recovery. Avoiding any allergies or food sensitivities is important to reduce stress and inflammation while healing from a concussion. Pre existing metabolic conditions such as a thyroid condition can also contribute to concussion symptoms and should be evaluated and ensure it is being properly managed.

5. Psychological (Mental and Emotional)

A concussion can create a major shift in how you’re feeling, your usual routine, or maybe even result in trauma from the event that the concussion came from. Those with a concussion will report feeling more irritable, anxious, depressed, or just not like their typical self. for concussion treatment, having a skilled professional to assist with mental health can be extremely helpful as part of concussion treatment. There are ways to see someone over telehealth or over the phone to make this essential healthcare more accessible and provide the privacy some may want. Check out some options here or here or here, yup that important!

Learn more with Vestibular Group Fit

Want to learn more about concussion  and other vestibular tools from the experts and be a part of a supportive community to get back to your daily life?  Find out more at this link: https://tvd.flywheelstaging.com/about-group/

Disclaimer:

Remember: this post is for informational purposes only and may not be the best fit for you and your personal situation. It shall not be construed as medical advice. The information and education provided here is not intended or implied to supplement or replace professional medical treatment, advice, and/or diagnosis. Always check with your own physician or medical professional before trying or implementing any information read here.

Best steps to Treat MDDS (Mal de Debarquement Syndrome)

Learn about what MDDS is, how it can be treated, and other resources to learn more about MDDS management.

Diagnosis criteria for Mal de Debarquement Syndrome

Criteria for the diagnosis of Mal de Débarquement syndrome

  1. Non-spinning vertigo characterized by an oscillatory perception (rocking, bobbing, or
    swaying) present continuously or for most of the day.
  2. Onset occurs within 48 hours after the end of exposure to passive motion.
  3. Symptoms temporarily reduce with exposure to passive motion.
  4. Symptoms continue for >48 hours. (More on this in the next section)
  5. Symptoms not better accounted for by another disease or disorder.

MDDS diagnostic criteria has changed slightly to include a spectrum of time someone has been experiencing symptoms. This has been designed to help those get a diagnosis and begin treatment sooner which is a great addition. Here they are:

3PD vs MDDS: what are the differences?

When searching for answers and finding a diagnosis, it can be tough to know which description fits best. You can also have more than one vestibular condition to make diagnosis more challenging. Dr. Madison talks with Vestibular Group fit Members the differences between Vestibular Migraine, PPPD, and MDDS as well as treatment considerations if you have a combination of diagnoses.

In this blog we’ll briefly talk about some differences between 3PD (persistent postural perceptual disorder) and MDDS

3PD

MDDS

Non-motion triggered Mal de Debarquement Syndrome

If you’re searching for answers, you might come across non-motion triggered MDDS. This area of vestibular research and classification is still up for debate. Some think this is a different form of chronic dizziness, or vestibular migraine, or something else. Time will tell where this ends up!

MDDS treatment: Dai protocol

A very popular protocol for MDDS treatment is the Dai protocol. A 2018 research study by Dai et al show that 75% of those undergoing treatment had significant improvement when followed for 1 year. This protocol involves a few important tests and equipment to follow and is best to be done with a provider knowledgeable in this protocol. If you’re in a place where a provider isn’t familiar, they can read research and implement the protocol with you.

More information on the Dai protocol can be found here.

A great treatment tool for MDDS or other visual vertigo can be found here through 360 Neuro Health. Talk to your provider before using to find the best dosage and progressions.

Mal de Debarquement Syndrome treatment continued

There are more treatment considerations than the Dai protocol. Medications such as SNRIs/SSRIs and benzodiazepines have been shown to be a beneficial part of treatment for some.

Other factors to consider as part of treatment include:

Dr. Shin Beh goes into detail on MDDS and treatment in his book Disembark, check it out here as well as other great books Dr. Beh has written.

Disclaimer

Interested in learning more? Check out this other blog post on Mal de Debarquement Syndrome

here.

Want to learn more about MDDS,  and other vestibular tools from the experts and be a part of a supportive community to get back to your daily life?  Find out more at this link: https://tvd.flywheelstaging.com/about-group/

Disclaimer:

Remember: this post is for informational purposes only and may not be the best fit for you and your personal situation. It shall not be construed as medical advice. The information and education provided here is not intended or implied to supplement or replace professional medical treatment, advice, and/or diagnosis. Always check with your own physician or medical professional before trying or implementing any information read here.

In Vestibular Group Fit, Dr Madison Oak and Vestibular PT Cheryl Wylie, MPT talk all things BPPV and vestibular migraine. They discuss what BPPV is, what assessment and treatment look like, and Cheryl’s amazing app Healing Vertigo (check it out here). There’s great conversation too revolving around a very common yet difficult task, am I dizzy with a vestibular migraine flare, or BPPV? Read on for some background, or jump to the differences between BPPV and VM at the of this post. 

Cheryl Wylie has been working in vestibular rehabilation for 13 years. Throughout her time traveling, she realized how common BPPV is, yet how difficult it can be to get it treated for those outside of big cities and specialized therapists. The app Cheryl created, Healing Vertigo, is designed for patients to learn how to address BPPV themselves. 

What is BPPV?

BPPV stands for “Benign Paroxysmal Positional Vertigo”. This is a common vestibular condition, and gets its name from its own characteristics. 

Benign: Not harmful (Don’t worry, we know firsthand how disruptive, scary and down right uncomfortable BPPV is…we have had it! They used the term benign in naming BPPV due to the fact it is not considered life threatening.)  

Paroxysmal: sudden onset

Positional: certain head/body positions bring on symptoms

Vertigo: sensation of motion or spinning

BPPV and the Vestibular System

We’ll keep this review brief, but feel free to check out this previous post that dives deep into all things BPPV here. 

Our vestibular system has 3 semicircular canals. These canals are filled with fluid and sit at different angles. Their job is to detect angular motion (are we moving sideways, up, down diagonal). 

In the otolith of the inner ear, tiny (but heavy for their size) crystals that help detect gravity and motion. 

If a crystal breaks away from the otolith and finds it’s way into a semicircular canal, this is the start of BPPV. When this crystal moves through the semicircular canal, the crystal pushes the fluid of the canal at a different rate. Our inner ear is now sending two very different signals of movement to our brain to try and understand. This results in a specific eye movement called a nystagmus (more on this here). This is why testing involves certain head positions, and looking at your eyes to assess any nystagmus present. Nystagmus is important information in addition to head position to know the next course of action, treatment! Here’s a chart of the different nystagmus here. 

NOT EVERYONE GETS DIZZY WITH BPPV. Some may not feel dizzy with BPPV, but off balance. This is why it’s important to screen for BPPV in those that are dizzy and those with balance concerns to rule out BPPV. 

Vestibular Migraine

Vestibular migraine is a neurological condition that can result in a variety of unpleasant symptoms. Common symptoms of vestibular migraine include: brain fog, light/sound sensitivity, neck pain, tingling, vision changes, and dizziness and/or vertigo. For more background check out our beginners guide to vestibular migraine. 

Those with vestibular migraine have most likely been treated for BPPV. The kicker here though, is not all  had BPPV. Unfortunately, this results in people getting treated for BPPV over and over, with no change in symptoms or feeling worse than before. This is because vestibular migraine can result in positional dizziness, but is not due to BPPV. This is why it’s important to understand the mechanism and nystagmus of BPPV to determine if treatment is warranted, or if it is due to a vestibular migraine attack. 

BPPV and Vestibular Migraine, which is it?

BPPV charactersistics:

Vestibular migraine characteristics:

It’s hard to know the difference between BPPV and vestibluar migraine. Hopefully this list helps point you in the right direction. BPPV needs to be treated with a repositioning maneuver to improve. A vestibular migraine needs to be treated during a flare, and then work on managing symptoms and increasing your migraine threshold. If you’re unsure, schedule with your vestibular PT for an assessment for BPPV or check out Cheryl’s Healing Vertigo App (website here, video presentation here)

Disclaimer

Want to learn more about what to expect with BPPV assessment and treatment,  debu7nking BPPV myths, reducing BPPV risk and other vestibular tools from the experts and be a part of a supportive community to get back to your daily life?  Find out more at this link: https://tvd.flywheelstaging.com/about-group/

Disclaimer:

Remember: this post is for informational purposes only and may not be the best fit for you and your personal situation. It shall not be construed as medical advice. The information and education provided here is not intended or implied to supplement or replace professional medical treatment, advice, and/or diagnosis. Always check with your own physician or medical professional before trying or implementing any information read here. 

Neck pain, dizziness, and what to do about it

Neck pain and dizziness is a common symptom that can have a significant impact on an individual’s daily life. It can also involve migraines, making it challenging to know where to start in finding relief.  It’s  important to address the root cause of the pain for long term relief and management. In this blog post, we will explore the connection between neck pain, migraines, and dizziness, and neck pain exercises.

How neck pain impacts migraines

The neck is made up of several small vertebrae, muscles, and ligaments that support the weight of the head. When these structures become injured or strained, it can cause pain that radiates to other areas of the body, including the head. Neck pain can be associated with migraine, either as a prodrome or interictal symptom. This can result in neck pain and dizziness, especially if you have vestibular migraine.

Some report feeling like their headaches start at their neck, or neck massages or stretching will set off a migraine. This lets us know that the neck is involved, and  we want to continue with neck treatment BUT we need to be careful how much neck work is done at any given time to avoid setting off a migraine or headache.

Others feel like working on their neck helps improve their headache or relieves in entirely. This is great news and also tells us the neck is involved, but we can approach the neck in a different way, using neck pain exercises, stretches, manual work and other treatment options for symptom relief and long term management.

How neck pain impacts dizziness

Neck pain and dizziness are commonly paired together. When dizziness comes on, it’s natural for our body to tense up and try to limit head movements in attempts to reduce dizziness. Sometimes neck pain from an injury or tension adds to your body’s general stress and discomfort, amplifying overall discomfort and dizziness. There are also sensors in our neck that talk to our brain so we know where our head is in space. If these signals aren’t matching up with the other movement sensors in our body, or our brain is having a hard time integrating all this information, we can feel dizzy, bobble head like, spacey, and more.

Causes of neck pain

Neck pain can have many different causes, but some of the most common include:

  1. Poor Posture: Spending long periods sitting at a desk or slouching in a chair can cause tension in the neck muscles, leading to pain and stiffness. Poor posture doesn’t necessarily mean slouching, but just holding the same position for long periods of time. Poor posture for long periods can add additional strain on our muscles and make them work harder, potentially causing muscle strain and/or tension.
  2. Joint Laxity: Some of us are naturally more flexible than others. Sometimes this results in pain or discomfort from our joints because they don’t have as much support from our tendons and ligaments. Strengthening is important in these cases to build muscle tone and strength to help provide support. People with joint laxity feel may report the urge to pop or crack their joints for relief, or need to stretch. This relief is typically temporary.
  3. Movement Dysfunction: If the neck muscles and joints are not functioning properly, this can lead to pain and stiffness.
  4. Neck Injuries: Neck injuries, such as whiplash or sprains, can cause neck pain and dizziness. These injuries typically occur due to sudden movements or trauma to the neck, such as a car accident or a fall.
  5. Vestibular Disorders: a common statement I hear when working with those with vestibular conditions is head movements making symptoms worse. It’s natural for neck pain and tension to occur in those experiencing vestibular symptoms as your body tries to limit head movements.
  6. Arthritis: a natural part of aging and can result in neck stiffness and reduce mobility.
  7. Pinched Nerves: If a nerve is inflamed or crowded, it can cause pain, numbness, tingling.Neck pain can have many different causes, but some of the most common include:
    1. Poor Posture: Spending long periods sitting at a desk or slouching in a chair can cause tension in the neck muscles, leading to pain and stiffness. Poor posture doesn’t necessarily mean slouching, but just holding the same position for long periods of time. Poor posture for long periods can add additional strain on our muscles and make them work harder, potentially causing muscle strain and/or tension.
    2. Joint Laxity: Some of us are naturally more flexible than others. Sometimes this results in pain or discomfort from our joints because they don’t have as much support from our tendons and ligaments. Strengthening is important in these cases to build muscle tone and strength to help provide support. People with joint laxity feel may report the urge to pop or crack their joints for relief, or need to stretch. This relief is typically temporary.
    3. Movement Dysfunction: If the neck muscles and joints are not functioning properly, this can lead to pain and stiffness.
    4. Neck Injuries: Neck injuries, such as whiplash or sprains, can cause neck pain and dizziness. These injuries typically occur due to sudden movements or trauma to the neck, such as a car accident or a fall.
    5. Vestibular Disorders: a common statement I hear when working with those with vestibular conditions is head movements making symptoms worse. It’s natural for neck pain and tension to occur in those experiencing vestibular symptoms as your body tries to limit head movements.
    6. Arthritis: a natural part of aging and can result in neck stiffness and reduce mobility.
    7. Pinched Nerves: If a nerve is inflamed or crowded, it can cause pain, numbness, tingling.

Signs of possible neck involvement

The symptoms of neck pain can vary depending on the cause of the condition. Some common symptoms include:

  1. Neck Pain: The most obvious symptom of neck pain and dizziness is pain in the neck. The pain may be dull or sharp and can range from mild to severe.
  2. Headaches: Many people who experience neck pain and dizziness also suffer from headaches. The headaches may be located in the back of the head or around the temples.
  3. Dizziness:  Some report sensations of their head floating, or not being connected to their head and body. These feelings may increase with head movements or neck pain.
  4. Numbness and Tingling: Pinched nerves can cause numbness and tingling in the neck and shoulders. This can be a sign that the nerve is being compressed and may require medical attention.
  5. Limited Range of Motion: Neck pain and stiffness can make it difficult to turn your head or move your neck freely.

Neck treatment options

The treatment for neck pain and dizziness will depend on the underlying cause of the condition. In some cases, the symptoms may go away on their own with time and rest. In other cases, medical intervention may be necessary. Some common treatments include:

  1. Exercise: Gentle stretching and strengthening exercises can help to improve neck mobility and reduce pain. It is important to consult with a healthcare provider to ensure that the exercises are safe and appropriate for each individual.
  2. Mindset Work: Chronic pain can often be exacerbated by stress and anxiety. Learning to manage stress through mindfulness practices or cognitive-behavioral therapy may help to reduce pain and improve overall well-being. Check out these recent blog posts that cover this more here and here.
  3. Movement and Posture: moving every 45 minutes and checking in on your posture is important to reduce muscle tension and strain.
  4. Migraine Management: Keep in mind other factors of your migraine treatment pie to  reduce triggers and increase your threshold for symptom management.

Common neck exercises and stretches

Here are a variety of exercises and stretches that can help alleviate neck pain and improve mobility. Again, this can vary person to person based on the root cause of neck pain.  This may assist with neck pain and dizziness, or reducing headache/mgraine frequency and intensity, or a combination of things. Listed below are common exercises used in neck pain treatment. Consult your doctor or physical therapist to make sure you’re cleared to exercise and finding the exercises that are best for you.

  1. Chin Tucks
  2. Rows. Here’s a video for home set up.
  3. Thoracic mobility work such as cat cows, thread the needle, and open books (laying down or upright in kneeling)
  4. Neck Stretches: Gentle stretching can help stretch the muscles in the neck and relieve tension. Check out this blog post that dives more into specific stretches with videos.

Neck pain and dizziness are very common and can come hand in hand.  The exercises listed above can help relieve tension in the neck, shoulders, and upper back, which can reduce pain and improve mobility. It is important to consult with a healthcare professional before beginning any exercise program to ensure that the exercises are safe and appropriate for your specific condition. By incorporating these exercises into your daily routine, you can reduce neck pain and improve your overall quality of life

Want to learn more about neck pain, with example progression and exercise plans and other vestibular tools from the experts and be a part of a supportive community to get back to your daily life?  Find out more below:


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Disclaimer

Remember: this post is for informational purposes only and may not be the best fit for you and your personal situation. It shall not be construed as medical advice. The information and education provided here is not intended or implied to supplement or replace professional medical treatment, advice, and/or diagnosis. Always check with your own physician or medical professional before trying or implementing any information read here.

Conquer vestibular migraine: a beginners guide

Here is a beginners guide to vestibular migraine. We’ll cover the difference between migraine, vestibular migraine, management tips and tricks, and when to start vestibular rehabilitation (VRT).

What is migraine? How is vestibular migraine different?

In general, migraine is a neurological disorder and has various symptoms that can be present. Here is a list of some common symptoms associated with migraine:

Migraines act differently with each person. A common misconception is that a migraine is only a bad headache, or if you know someone with migraines and their symptoms are different than what you experience you think “oh well I don’t have migraines because they’re nothing like my friends”. If it’s impacting your life, it’s worth talking to a medical provider about!

Vestibular migraine

Vestibular migraine accounts for 3% of all migraines. This subtype of migraine has specific symptoms relating to the vestibular system (vertigo, imbalance, dizziness, brain fog, feeling “off”, lightheadedness etc).

The International Classification of Headache Disorders criteria for vestibular migraine are:

    1. Headache with at least 2 of the following characteristics
    2. One-sided location, pulsating quality, moderate or severe pain intensity; photophobia or phonophobia
    3. Visual aura

click here for the research article that outlines this criteria.

The big thing to remember here is that not all vestibular migraines have head pain/headaches. Headache can be present, as well as the other symptoms on the list above in addition to vestibular symptoms.

Phases of migraine

The 5 phases are:

When to start Vestibular Rehabiliation (VRT)

VRT is beneficial in addressing residual symptoms after migraine attacks, or the interictal symptoms experienced in day to day life. VRT is most effective when attacks are mostly under control. If you’re having multiple attacks in a month, or you’re having a hard time getting symptoms under control, VRT may not be appropriate at that time. A couple of sessions may be helpful for education to try various methods to get symptoms under control, or addressing neck pain through gentle stretching, manual work, postural and ergonomic education).

VRT is most beneficial when your migraine is under control. Using habituation principles to improve interictal symptoms is best done when your vestibular migraine is under control. If your migraine and symptoms aren’t well managed, trying to do VRT is like throwing gasoline on an already raging fire and hoping it burns out.  This is why VRT can make you feel worse. It’s important to have a therapist familiar with vestibular disorders and vestibular migraine to guide and dose your VRT appropriately.

What should I do when I have a vestibular migraine attack

If you begin to feel an attack coming on, you want to initiate your plan as soon as possible to try to stop th eattack or minimze the severity or time of symptoms. This may look like:

Vestibular migraine management

There’s a lot of great content on tis website for vesitbular migraine, I tried to include most of it here but might have missed some. Vestibular Group Fit is a great place to find all this information presented to you in one spot with excellent resources, with a community of others to provide their own experience, advice and guidance for symptom management, lifestyle changes, and support with movement.

Disclaimer

Want to learn more about vestibular migraine management  and be a part of a supportive community to get back to your daily life?  Find out more at this link: https://tvd.flywheelstaging.com/about-group/

Disclaimer:

Remember: this post is for informational purposes only and may not be the best fit for you and your personal situation. It shall not be construed as medical advice. The information and education provided here is not intended or implied to supplement or replace professional medical treatment, advice, and/or diagnosis. Always check with your own physician or medical professional before trying or implementing any information read here.

5 Main Audiology Tests for Vestibular Disorders
With vestibular audiologist Dr. Alexandra Smith, Au.D, CCC-A, F-AAA.

Dr. Alexandra Smith is based in Santa Fe, NM (you can find her clinic here) and works to identify, diagnose, treat and prevent various diseases, injuries or defects of the ear. Audiologists are also able to assist their clients with maintaining good hearing and can assist with hearing devices. Dr. Smith perform audiology testing for vestibular disorders and is going over them in more detail to help you better understand your test results and know what to expect. If you think you’d benefit from audiology testing for vestibular disorders, talk to your doctor about comprehensive audiology testing.

 

This blog post covers some content Dr. Smith covers with Dr. Madison Oak, vestibular physical therapist for our vestibular group fit members. These tests are common when evaluating for vestibular disorders but aren’t always well known or explained. Read below to learn more about audiology tests for vestibular disorders and what they can help tell you about your vestibular condition.

What is a vestibular audiologist?

A specialty within audiology which includes: 

  1. Hearing and tinnitus evaluations 
  2. Surgical implant care
  3. Vestibular evaluation
  4. Select vestibular treatments (like the epley maneuver for BPPV) 
  5. Diagnostic tests which we’ll go into more detail below! (ECOG, audiogram, VNG, brain wave testing, positional testing and more)

Using audiology tests for vestibular disorders can be another piece of information to consider with other testing (MRI, physical therapy, occupational therapy, ENT, Neurology etc) to best determine a plan of care to manage your vestibular condition. 

What is the role of a vestibular audiologist?

What does audiology testing and vestibular disorders have to do with each other? Anatomically, our inner ear has both a spatial awareness system (the vestibular system) AND hearing portions (the cochlea) that make up the inner ear. The nerve that connects our inner ear to the brain also branches from the same nerve to reach both of these sections. It is also common to have other ear symptoms or hearing changes with vestibular conditions, so it’s important to get  testing done by a specialist in the hearing portion of our inner ear, an audiologist! 

Audiology tests for vestibular disorders

What are the 5 main audiology tests for vestibular disorders?

Common audiology tests for vestibular disorders include: 

  1. VNG (Videonystagmography exam)
  2. Caloric testing 
  3. ECOG (Electrocochleography exam)
  4. VEMP (Vestibular evoked myogenic potential)
  5. Audiogram

Below, we’ll go into more detail on what these tests measure, what to expect, and how these tests can help with vestibular diagnostics. 

VNG (Videonystagmography exam)

Caloric testing

You are in control and can stop at anytime, it is NOT AN ATTACK.

ECOG (Electrocochleography exam)

VEMP (Vestibular evoked myogenic potential)

Audiogram

Can you have normal testing and still have a vestibular disorder?

YES! Certain vestibular conditions will not show up on this testing. Migraine will not show up on MRI, CT scans, ECOG VEMP or VNG or audiograms. These tests can still be helpful for these conditions that require a diagnosis of exclusion to rule out other conditions that these tests can reveal. Audiology tests for vestibular disorders can help lead us to identify specific diagnoses. If testing comes out normal, audiology tests for vestibular disorders can also help consider other diagnoses that would show normal testing. 

Audiology tests for vestibular disorders is one piece of testing to be considered with other providers testing and listening to what you’ve experienced. Listening to your experience and looking at all the test results can help get the right team of providers (OT, PT, Neuro, ENT) in your corner to start your healing journey. It’s natural for this team to change slightly, or change focus for periods of time with certain providers based on your needs. Keep your team in the loop so they can help adjust accordingly, they’re here to help YOU. 

 

Want to learn more about vestibular testing, ear pressure, tinnitus and other vestibular tools to get back to your daily life?  Find out more at this link: https://tvd.flywheelstaging.com/about-group/

 

Disclaimer:

Remember: this post is for informational purposes only and may not be the best fit for you and your personal situation. It shall not be construed as medical advice. The information and education provided here is not intended or implied to supplement or replace professional medical treatment, advice, and/or diagnosis. Always check with your own physician or medical professional before trying or implementing any information read here.

Holistic Management of Vestibular Migraine with Dr. Sheikh

Dr. Sheikh is very knowledgeable and has had extensive training to help address and manage headaches, and more specifically migraines. Dr. Sheikh got her MD and then completed her residency at MOntefiore Medical Center in Bronx NY. She then went on to complete two fellowships; a vascular fellowship and then a fellowship in “Headache and Facial Pain” Harvard Medical school and is now an adjunct professor at Ichan Medical school at Mt Sinai in New York City. Being in a clinic setting for over 6 years now, Dr. Sheikh has been treating and helping her patients manage complex headaches with a holistic approach. She’s very up to date on current medication options and other complementary treatments that she is sharing with us in Vestibular Group Fit!

Migraine is more than a Headache

“I like to think of migraine as a disease, and headache as a symptom…migraine is a genetic neurological disease and headache is a symptom of migraine”. Dr. Sheikh 

Migraine is more than just a headache! Migraine may have a headache (not in all cases) but also vertigo and dizziness, light or sound sensitivity, brain fog, or visual auras. Headache associated with migraine is most reported disabling symptom, but others may have dizziness or sound sensitivity as their most prominent symptom. For a more indepth look at vestibular migraine, here’s a helpful article to review, click here.

How do we treat migraine holistically?

How do we treat migraine holistically? 

  1. Your doctor should listen 
    1. Best management should be a discussion about your experience, your options, and creating a plan. Not just being given a prescription and nothing else. If a med is all you need and you’re interested in, great! Having the chance to discuss what you want and the options is key. 
  2. Remember, you have options 
    1. Don’t like the idea of medications? Meditation, diet, exercise, yoga, breathing, sleep and more can be a major part of your preventative plan. Sometimes medications are helpful in getting you feeling better to get a better foundation to manage holistically. You don’t need to be on meds forever but it can be a useful tool. Using medications is not a failure, just a tool that can be used daily, only during attacks, or never. This is why discussions are so important to address concerns and adjust your plan based on your responses for best results. 
  3. Reducing hypersensitivity (increasing your threshold) 
    1. Addressing your treatment holistically can reduce hypersensitivities and help increase your migraine threshold 
  4. Treat from all angles
    1. Holistic and natural options are wide ranging and finding the ones that work for you can be super helpful in migraine management. Medications can range from a daily preventative, botox injections that are months apart, or an abortive med that’s only used to reduce your symptoms during a migraine. 
  5. Stress management
    1. Stress can lower our migraine threshold and make you susceptible to an attack, the better we can use holistic approaches to manage stress, the better for not only your migraines but your overall well being! 
  6. Be prepared! 
    1. A common stressor for those with migraine is the unpredictability of when a migraine attack might occur. Having a plan in place (natural remedies, an abortive med, ice packs etc) can help reduce the stress about a possible attack, ultimately decreasing your attack frequency. Having a plan is key!

 

Treatment for vestibular migraines is overall similar to other migraine management, however Vestibular Rehab Therapy with a physical therapist can be helpful and neuromodulation devices (cepahly or gammacore for example) can be good options to consider when addressing vestibular migraine!  

Contact info for Dr. Huma Sheikh: 

Instagram: @headachesnyc

Website: Headachesnyc.com

Dr. Sheikh talks more about family planning, diet, and sleep in the premium content in Vestibular Group Fit.  Found out more at this link: https://tvd.flywheelstaging.com/about-group/

 

Disclaimer:

Remember: this post is for informational purposes only and may not be the best fit for you and your personal situation. It shall not be construed as medical advice. The information and education provided here is not intended or implied to supplement or replace professional medical treatment, advice, and/or diagnosis. Always check with your own physician or medical professional before trying or implementing any information read here.