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There are many ways to train your balance, but to truly focus on your vestibular system you need two big factors. The first factor is decreased or eliminated vision, and the second is an uneven surface. Your vestibular system processes your spatial orientation and balance constantly; it works with your proprioception and vision to keep you upright. If you have tested your balance and you have difficulty depending on your vestibular system, it’s time to do some vestibular balance training.

To do this, you’re going to need a balance pad. There are many options to choose from when you’re searching for the perfect surface to do balance training. The most important factor is that you are standing on an unstable surface.

Personally, my favorite balance pad is the Airex balance pad. It’s one of those staples in any good PT clinic and it’s a consistently good product. It has just enough stability that it doesn’t break with overuse, and unstable enough that you won’t be able to feel the floor when you use it. Not being able to feel the floor when practicing balance training is incredibly important.In my opinion, the Airex a fantastic option, however it is pricier than other balance pad options that are pretty comparable.

This balance pad, the Yes4All has different sizes and colors to choose from, and I have used it in my practice many times. This balance pad has a little less give to it, it feels a little more like the floor. For those who are looking for more give and a greater challenge that you would find in the clinic, the Airex is right for you! However, if you have a much harder time balancing, or you’re worried your balance on uneven surfaces, it may actually be a better choice for you!

If you are going to be testing your balance and practicing your balance in the future, it’s a great idea to invest in a balance pad like the ones above! Challenging your balance in a variety of ways, especially with uneven surfaces, helps your overall balance, increases confidence in your ability to get around, and will decrease your risk for falling!

Your inner ear talks to your brain to control your spatial awareness, balance, and hearing through your vestibulocochlear nerve. In a normal vestibular system, your nerves send signals to your brain at the same rate when you’re looking forward to tell your brain, if your eyes are open or closed, you’re looking forwards. When you look to the right, your right vestibulocochlear nerve fires more than the left, and when you look left the opposite happens. This is why, when your eyes are open or closed, you always know where your head is facing. However, if you have a vestibular neuritis, you have swelling, typically caused by a viral infection, in your vestibulocochlear nerve.

A vestibular neuritis in your right vestibulocochlear nerve causes a decreased firing response at baseline in your right side, which makes it seem like you have an increased firing rate in your left ear. This makes your brain think you’re looking, or spinning, to the left. But, you know that you are not doing that; you can override this system and realize “no, I’m looking straight.” This ability to discriminate between what your brain thinks is happening and what is actually happening is really important. But, if you have a vestibular neuritis, your brain is struggling to pair these two things together. This internal confusion can last weeks to months when untreated, although it slowly improves a little bit, until you plateau at baseline lightheadedness, over time. Vestibular Rehabilitation Therapy is the best way to care for yourself post-virus, and will help get you over the plateau of your symptom improvement.

Symptoms & Diagnosis

Neuritis symptoms can vary in severity and presentation. The types can be split into two groups: acute and chronic. Acute symptoms last for the first 1-3 days, and are often so severe it can limit your ability to sit or stand upright, and to walk around. Chronic symptoms remain after the acute symptoms dissipate but can cause general nausea, fatigue, and confusion. The symptoms that are related to acute vestibular neuritis are: (1)

These symptoms will peak within 24 hours and then slowly begin to dissipate over the next few days. When your symptoms relax, you are left with a new set of symptoms: (1)

The remaining symptoms from your neuritis will slowly improve, but improvements often plateau at one point, leaving you feeling lightheaded and off balance constantly. These symptoms can be difficult to describe to friends, family, and providers, and may cause frustration because although you look healthy, you don’t feel like yourself. These confusing and hard-to-describe symptoms can help your provider get to the diagnosis of vestibular neuritis. There are no specific diagnostic criteria for vestibular neuritis, but there are a few diagnostic tests that can help your provider come to a conclusion. 

There are a few diagnostic tests for vestibular neuritis. These include:

These tests should all be considered and evaluated carefully when making a diagnosis of vestibular neuritis. Your clinician should be able to perform all of these in the clinic easily without access to any high tech equipment, with the exception of the VNG and VEMP tests. When your physical therapist or other practitioner takes a thorough subjective history and carefully considers the objective test results, he or she will be able to conclusively diagnose you with signs and symptoms consistent with vestibular neuritis.

Treatment

Proper treatment for vestibular neuritis completely depends on what stage of the neuritis you are currently in. An acute neuritis is treated completely differently than lingering and chronic symptoms of vestibular neuritis. 

If it is caught early, within the first 24 hours, your physician can prescribe a steroid. A steroid prescribed and taken within this time period significantly impacts your long term outcome positively (2). Unfortunately, after 24 hours, the use of the steroid is not the same as the immediate effect that it can have. Additionally, your physician may prescribe an antibiotic of an antiviral if a middle or inner ear infection is suspected. 

To treat the feeling of spinning and lightheadedness, your physician may also prescribe you Meclizine, which is a vestibular suppressant. Taking Meclizine short term may be necessary, but because it suppresses your vestibular system it is usually recommended you stop taking this after a few days. 

Chronic symptoms of vestibular neuritis are the lingering symptoms that seem to not disappear no matter what you do. These symptoms can be treated with physical therapy. Your brain is having a difficult time pairing what is, and is not, moving. Because one nerve had an infection, it is now sending a lesser signal than it would previously have at baseline. Your nerve will be like this forever, but because of neuroplasticity, the ability for your brain to adapt and change, your brain will adjust to its new normal. The most efficient way to adapt your brain this way is Vestibular Rehabilitation Therapy, or VRT. VRT is performed by a physical therapist and will focus on relearning how to adjust and adapt to the stimuli in the world. 

Physical Therapy

Finding a vestibular physical therapist will be vital to your healing process. A vestibular physical therapist will provide you with exercises in the clinic and at home that help your brain learn its new normal. Your PT can also help you work through anxiety related to your dizziness and help you return to other exercise and activities you did prior to your vestibular neuritis. 

Sources:

(1) Shupert, C., & Kulick, B. (2020, May 06). Labyrinthitis and Vestibular Neuritis. Retrieved September 24, 2020, from https://vestibular.org/article/diagnosis-treatment/types-of-vestibular-disorders/labyrinthitis-and-vestibular-neuritis/

(2) Sjögren, J., Magnusson, M., Tjernström, F., & Karlberg, M. (2019, March). Steroids for Acute Vestibular Neuronitis-the Earlier the… : Otology & Neurotology. Retrieved September 15, 2020, from https://journals.lww.com/otology-neurotology/fulltext/2019/03000/steroids_for_acute_vestibular_neuronitis_the.21.aspx

Superior Semicircular Canal Dehiscence (SSCD) is the result of a hole in the bony portion of your vestibular system. Your inner ear system is deep inside your ear and consists of two parts. The first is your cochlea, your hearing organ. And the second is your vestibular system, which consists of three semicircular canals, the utricle, and the saccule; you can find them pictured here. These canals detect angular motion and help with spatial awareness; this is how we know where our head is in space. If you have SSCD, you may have a thinner wall on your superior semicircular canal, or even a hole. This hole or thinned wall causes vestibular symptoms due to pressure fluctuations and/or changes in loud sounds. 

There are supposed to be two holes in your inner ear, the oval window (for sound transmission), and the round window (where sound exits) (1). These two windows allow pressure fluctuations and sounds to transmit functionally through our vestibular system (1). However, the addition of a third hole, a dehiscence, allows for improper signals to be sent and causes your dizziness symptoms. It is unlikely there there is anything you did to make this happen – research shows that Semicircular Canal Dehiscence is usually caused by a developmental abnormality. If you have an already thinned superior canal bone, head trauma or pressure caused by the temporal lobe of your brain can cause it to wear down, which forms the dehiscence. The dehiscence causes uncomfortable symptoms that can be either intermittent or chronic.

Symptoms & Diagnosis

Symptoms of Superior Semicircular Canal Dehiscence can vary from hearing to imbalance issues. Because there is a hole in the system, many people present with different symptoms. These symptoms include, but are not limited to: (1, 2, 3)

Many of these symptoms of spontaneous vertigo and lightheadedness have similar symptoms to other vestibular diagnoses such as:

To diagnose your symptoms, there are a few tests that your healthcare team will likely recommend. These diagnostic tests will begin with a thorough history of your symptoms to rule out other vestibular diagnostic possibilities. Then, if SCD is predicted you will be placed through one or more of the following tests:

Once you receive a diagnosis, your providers will devise a treatment plan that suits your specific needs.

Treatment

Most patients with Superior Semicircular Canal Dehiscence can manage their symptoms by avoiding stimuli like sudden loud noises. However, for those who cannot manage their symptoms with avoidance, there are other treatment options. These options are tinnitus retraining therapy, using a hearing aid, treating migraines if you have them, and surgical correction (2). If your symptoms are mild and not debilitating, the surgical option is not recommended as the risks often outweigh the benefits. 

Surgical correction is for those deeply affected by SSCD. The hole in the canal is plugged with fascia, which is thick connective tissue, to eliminate fluid movement (3). There are many risks to this procedure such as hearing loss, BPPV, high frequency sensorineural hearing loss, and general vestibular dysfunction. Luckily, most people who undergo this procedure have positive results. 

If you have any remaining symptoms from the surgery of imbalance, vestibular migraine, or other general vestibular dysfunction, physical therapy can help. 

Physical Therapy

Physical therapy for Superior Semicircular Canal Dehiscence will be treating the symptoms that affect you. Your physical therapist can help you with improving your balance, improving your lightheadedness or dizziness symptoms, and assisting with vestibular migraine. Vestibular Rehabilitation Therapy, or VRT, is very effective in improving vestibular dysfunction. Your PT will be able to find what stimuli are increasing your symptoms and slowly help your brain adapt to the stimuli in a more normal way. Having a PT as a part of your healthcare team will be vital to your recovery and management for SSCD. VRT will help you with imbalance, dizziness, and vertigo symptoms. 

Sources:

(1) Minor, L. (2020, June 26). Superior Semicircular Canal Dehiscence (SSCD). Retrieved September 10, 2020, from https://vestibular.org/article/diagnosis-treatment/types-of-vestibular-disorders/superior-semicircular-canal-dehiscence-sscd/

(2) BC Balance and Dizziness. (2019, September). Semicircular Canal Dehiscence. Retrieved September 10, 2020, from https://balanceanddizziness.org/disorders/vestibular-disorders/semicircular-canal-dehiscence/

(3) Carey, J. (n.d.). Superior Canal Dehiscence Syndrome (SCDS). Retrieved September 10, 2020, from https://www.hopkinsmedicine.org/health/conditions-and-diseases/superior-canal-dehiscence-syndrome-scds

Persistent Postural Perceptual Dizziness (PPPD) is chronic, long lasting, dizziness that is non-vertiginous and fluctuating in nature (1). PPPD is a relatively new diagnosis; the diagnostic criteria were created in 2014 and for that reason many providers don’t know about the condition or the criteria (1). PPPD has signs and symptoms that present like many other vestibular diagnoses including vestibular migraine, vestibular neuritis, or anxiety related dizziness making it even more difficult to diagnose. Prior to being titled Persistent Postural Perceptual Dizziness, PPPD was referred to names including: phobic postural vertigo (PPV), space-motion discomfort (SMD), visual vertigo (VV) and chronic subjective dizziness (CSD) (2). The criteria of these have now been combined to form Persistent Postural Perceptual Dizziness and has specific criteria designed to provide an exact diagnosis (3). 

It is not always possible to determine an exact cause of PPPD, however it rarely comes on slowly. Your balance system, which consists of three systems working together to keep you stable, is in a state of disequilibrium when you have PPPD. Instead of the three systems seamlessly working together for stability, your body has difficulty processing the information passed between them, making your brain feel like you may fall over at any moment. This feeling places your body on high falls risk alert, and the more you worry, the more anxious you may become. This anxiety causes an increase in dizziness, which then increases anxiety. This is a vicious anxiety cycle. All of this can be treated in vestibular physical therapy with your team of healthcare providers. 

Symptoms & Diagnosis

Symptoms of Persistent Postural Perceptual Dizziness vary widely from one individual to the next. The symptoms have an inciting event that caused the original onset of symptoms, and can be either vertiginous or non-vertiginous, even if you can’t remember when it occurred. This event can be any event that caused dizziness, either physical or psychological, and includes: (2)

Any of these, or other vestibular conditions, can be the cause of PPPD. There many symptoms related to Persistent Postural Perceptual Dizziness, including:

Symptoms are exacerbated with:

Other symptoms frequently reported are:

These symptoms are both directly and indirectly related to your experience with Persistent Postural Perceptual Dizziness. Your healthcare providers, especially your physical therapist, should be made aware of the symptoms you are experiencing. The more information that they have, the better your provider will be able to assist you in a diagnosis recovery. 

Because PPPD is such a new diagnosis, the criteria is widely unknown to many providers. However, we are all able to access them, and they can be found below. If you fit this criteria, vestibular therapy will be an avenue to help your recovery. The following are the official diagnostic criteria for Persistent Postural Perceptual Dizziness, all 5 must be met (A-E) to fit the diagnosis: (3)

Treatment

Vestibular Rehabilitation Therapy, or VRT, is effective in treating PPPD in conjunction with Cognitive Behavioral Therapy, education, and potentially some medications. Vestibular Rehabilitation Therapy is effective in habituating and adjusting your brain through neuroplasticity, or the ability for your brain to change and mold to its environment. Although there have been no randomized control trials at this point, clinical experience and reports show that 3-6 months of VRT is often very effective in treating your symptoms (1). 

Additionally, Cognitive Behavioral Therapy (CBT) can be effective for some individuals who have new PPPD symptoms, but is less effective for those who have had symptoms for a long time. If you begin Cognitive Behavioral Therapy within 8 weeks of symptom onset, the results from CBT are lasting and effective (1). 

Medications can also be effective in treating PPPD, some physicians prescribe SSRI’s and SRNI’s to help with symptoms of anxiety and dizziness. It has been found that symptoms were reduced by at least half in 60-70% of patients who were on one medication or the other for 8-12 weeks. Patients who had lasting effects were on the treatment for at least one year. Medications such as Benzodiazepines and vestibular suppressants, most commonly Meclizine, were found ineffective in treating PPPD symptoms (1).

There are many different treatments for PPPD, however treating the symptoms and the root cause simultaneously will have the longest lasting effect. Combining VRT, CBT, and medication will help you begin to feel like yourself as quickly as possible. 

Physical Therapy

The main and most effective form of treatment for PPPD is Vestibular Rehabilitation Therapy. VRT is prescribed by your physical therapist to slowly adjust your tolerance to stimuli that bother you. For some, a stimulus could be patterned carpets and for others it could be head motion.  Whatever the stimuli, VRT can help you. Your physical therapist will adjust the dosage of irritating stimuli to your symptoms using the 15 minute rule. In physical therapy your PT will grade the amount of a stimulus you can tolerate and dose your exercises accordingly. Do not attempt to dose PT yourself as I find patients often overstimulate themselves leading to a big flare up. 

Sources:

(1) VEDA. (2020, May 21). Persistent Postural-Perceptual Dizziness. Retrieved September 07, 2020, from https://vestibular.org/article/diagnosis-treatment/types-of-vestibular-disorders/persistent-postural-perceptual-dizziness/

(2) Balance and Dizziness. (2019, September). Persistent Postural-Perceptual Dizziness (PPPD). Retrieved September 08, 2020, from https://balanceanddizziness.org/disorders/vestibular-disorders/pppd/

(3) Staab, J. P., Eckhardt-Henn, A., Horii, A., Jacob, R., Strupp, M., Brandt, T., & Bronstein, A. (2017, January 01). Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): Consensus document of the committee for the Classification of Vestibular Disorders of the Bárány Society. Retrieved September 09, 2020, from https://content.iospress.com/articles/journal-of-vestibular-research/ves622

Balance is the system our body uses to keep us upright, helps us catch ourselves when we trip, and lets us walk, dance, and run without falling over. Our balance system is constantly being used, even when we are sitting down! There are three systems that make up our balance system. The first is proprioception, the second is vision, and the last is our vestibular system. All three are intricate and purposeful and they all help us with our daily activities. 

Proprioception

Proprioception is our internal awareness of where we are in space and how we are moving. Proprioception is used consciously and unconsciously so that we know the angles of our joints, how much force to produce with movement, to sense how and where we are moving, and to sense a change in our velocity. We use proprioception to help us balance constantly, it specifically is helpful when we are on uneven surfaces. Our brain uses constant input from our joints, especially our ankles, knees, and hips in order to keep us upright. When we are on an even surface, like a hardwood floor or smooth concrete, our brain has an easy time keeping us standing up. Our peripheral nervous system (nerves outside the brain and spinal cord) sends signals to our central nervous system (the spinal cord and brain) to tell us where our joints are, and if we need to make adjustments to our posture. When you are on an uneven surface, your joints and peripheral nervous system send signals to your central nervous system to make chronic adjustments so that you don’t trip on the surface. If your brain begins to process this information too slowly or if you receive poor signals for any reason you will have a harder time balancing. If you practice balancing on uneven surfaces your brain will relearn how to balance on all surfaces and you will have an easier time walking on surfaces like carpet, grass, and gravel.

Vision

Being able to see is another important variable in your balance. You may notice that when your eyes are closed or if it’s dark outside you have more trouble standing or walking around. Your visual system provides extra information to your vestibular and proprioception systems to process the information being provided to them. Something as simple as putting on your glasses or turning on the light can drastically improve your balance. Vision is the most relied upon system in our bodies; it is important that we can use vision if we have the option. Going to the optometrist or ophthalmologist is vital if you have visual dysfunction! However, over-relying on your vision can also be dangerous. When we are over-reliant on our vision we don’t utilize the other systems that are important for keeping us upright, our proprioceptive and vestibular systems.

Vestibular

Your vestibular system is an essential part of your balance. Your vestibular system is your inner ear system responsible for balance when you can’t see, can’t feel the floor well, or both! Your vestibular system has its biggest job if you’re walking on grass at night. This system will help your balance, and processing information from the other two systems to adjust your body in space. In practice, we often find that there are many people whose brains have unlearned this system. 

Impairment of any of these three systems can lead to poor balance, falls, and the feeling of general unsteadiness. Additionally, some patients with vestibular dysfunction report nausea, dizziness, and swaying when they are still. Many of my patients say that they assume that falling and balance dysfunction is “just a part of aging” and that they should “just get used to it”. On the contrary, balance dysfunction should NOT be a part of aging, and it should NOT be something you just get used to. There are so many ways you can work on your balance, independently or with a physical therapist. 

In the clinic there are numerous tests we can use to test your balance. However, in order to differentiate which of your balance systems are not functioning correctly we most often use the M-CTSIB, the Modified Clinical Test of Sensory Interaction in Balance (1). This test measures your balance on 2 surfaces with your eyes both open and closed. In the unmodified version (CTSIB), there is a dome used to provide a visual conflict; this shows whether or not you can intentionally override your vision and use your vestibular system intentionally. However, for most purposes, and ours here, using the modified version is great. Let’s go through how to test yourself if, and when, you find it necessary. Remember to always be as safe as possible when performing this test. I would recommend doing this test with another person nearby and to do it near your countertop or a sturdy chair. 

To perform this test you will need a solid surface to stand on, like hardwood or tile floor, and an uneven surface, like balance foam or a couch cushion. You must stand with your feet touching (as close as you can get them) and your arms at your sides, throughout the duration of the test periods.

There are 4 conditions:

  1. Firm, eyes open
  2. Firm, eyes closed
  3. Foam, eyes open
  4. Foam, eyes closed

For each of the four conditions, you may have three attempts. The time begins when you are set in position, and ends when you complete 30 consecutive seconds or make a mistake. Mistakes include: opening your eyes in a closed condition, taking a step, moving your arms from your sides, or needing assistance to prevent a fall (1). If you, the testee, are able to complete the first round without a mistake, move to the next condition and do not repeat all 3 attempts. 

Some sway at the ankles and/or hips, called ankle strategy or hip strategy, respectively, is normal. But, this test shows us which is most difficult for you; the condition that is most difficult is the condition you should work on most in PT. Let’s work through what your test results mean when you finish the test.

Condition 1) while standing in this position, all of your systems are available for balance, but your base of support (BOS) is significantly smaller than you would usually stand. BOS consists of the parts of your body touching the floor beneath you; when it is larger, it is easier to stand, and the smaller it is the more difficult it is to stand (2). 

Condition 2) you are able to use your proprioceptive and vestibular systems in this condition. However, you are unable to use your visual system. This tells us that you are very dependent on your vision, and without it you are at an increased risk for falling in situations when you have decreased light, or no vision at all.

Condition 3) in this condition, you are able to use vision and your vestibular system, but it challenges your proprioception significantly. If you have trouble here, it is a sign to work on proprioceptive and dynamic balance in physical therapy. 

Condition 4) here, you are mainly able to use your vestibular system to balance. Individuals have most difficulty in this position if they have vestibular dysfunction, and this is frequently something we treat in vestibular therapy. 

Fortunately, almost all of the reasons you are experiencing imbalance can be treated in physical therapy. Finding what is difficult for you, and then slowly working on it will improve your balance, reduce your risk of falling, and improve your confidence with your balance!

Sources:

(1) Wrisley, D. (n.d.). Clinical Test of Sensory Interaction on Balance. Retrieved September 07, 2020, from https://www.sralab.org/rehabilitation-measures/clinical-test-sensory-interaction-balance-vedge

(2) Physiopedia. (n.d.). Base of Support. Retrieved September 07, 2020, from https://www.physio-pedia.com/Base_of_Support

Migraine is a genetically induced hypersensitivity to internal or external stimuli within central nervous system neurons (1). When a neuron that is primed to a migraine, and is triggered by a stimulus either inside or outside of your body, the neuron reacts through a migraine (1). There are treatments for both acute and chronic migraines episodes as well as prevention methods an individual can use to reduce the number of migraines that occur. Migraine is generally considered a headache, however not everyone with migraines experience headaches. Some people get migraines in the form of vertigo, called Vestibular Migraine or Migraine Associated Vertigo. It is estimated that about 1% of the population has Vestibular Migraines (2). Vestibular Migraine often goes undiagnosed or misdiagnosed for a while before an individual receives a diagnosis of Vestibular Migraine. Some of the symptom and diagnosis criteria will be helpful to pinpoint exactly what’s going on for you specifically. Once you or a loved one is diagnosed with Vestibular Migraines, there are many ways that they can be treated. There is not a quick fix formula for Vestibular Migraine, and finding what works for you may be a process. 

Symptoms & Diagnosis

There are many symptoms of Vestibular Migraine and it can present differently in each individual. Using your symptom history and some objective tests to rule out other vestibular disorders, your clinician should be able to come to the diagnosis of Vestibular Migraine if it is right for you. It is important to recognize and remember that many vestibular disorders present similarly, and that migraine could present one way in you, and another in someone else. Logging your symptoms before and during your treatment is a good way to work with your healthcare team toward the right diagnosis. The symptoms include, but are not limited to:

The symptoms listed above are not the only symptoms patients experience, and you do not need to have headaches to be diagnosed with Vestibular Migraines. Because there are so many ways you can feel dizzy, and sometimes it can be hard to describe to the doctor, I recommend starting a list and showing it to your provider when you have your appointment. This can help you and your healthcare team decide if this is the diagnosis for you.

After a thorouogh history taking, likely from a few practitioners, you will undergo a series of tests. These will differ depending on the individual case, but are generally we are looking to distinguish between multiple vestibular diagnoses. Some combination of vestibulo-ocular, gaze stability, calorics, audiological, positional, functional balance, gait, VNG, and VEMP testing will be employed. A thorough review of all of these tests will tell your providers if you have another vestibular diagnosis that could better account for your symptoms. If no other diagnosis is the most logical, and you fit the International Classification of Headache Disorders criteria, you will receive the proper diagnosis of Vestibular Migraines. 

The International Classification of Headache Disorders criteria currently consist of: (4)

    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

All healthcare providers have access to this diagnostic criteria, and if they can’t find it on the internet, you can always come back and find it here! If you have gone through the diagnostic process and this is you, it’s time to start treating the cause of your symptoms. 

Treatment

Once you receive the Vestibular Migraine diagnosis, both prevention and acute treatments become important! Treating your migraines acutely means decreasing symptoms when you have a migrainous episode. Alternatively, treating your migraines preventatively is going to be a constant process and involves dedication from you and your healthcare team. There is no specific protocol for treating Vestibular Migraine, but both anecdotally and in research we have found effective tools for managing symptoms. The combination of acute and preventative treatments, as opposed to doing one or the other, is the most effective way we have found to treat Vestibular Migraines.

Acute treatments are what we call abortive — the concept is to get rid of the attack right as it is happening so it has a decreased impact on your life. These treatments are usually medications.  (2, 3, 5)

** please remember that medication overuse headache exists, and herefore meds like triptans, NSAIDS, and others in this list can cause rebound attacks!**

These acute treatments are used in response to the onset of a migraine or Vestibular Migraine symptoms. They all work differently, and you should treat your symptoms based on the treatment you find to be most effective with your healthcare team. You may use one, you may use more than one, but these are all tools that you should have around that you likely won’t be using daily. Daily treatments and prevention are going to be specific to you as well, and will become part of your daily routine.
Chronic prevention of your migraines, and treatment of symptoms that are left over from previous attacks, consist of diet modifications, physical activity, and vestibular therapy. Modifying your food and fluid intake is the most valuable and controllable tool you have to prevent migraines and avoid vertiginous symptoms. You can find out more about items to avoid on a migraine diet in a post I wrote here. However, the basics include decreasing sodium, eliminating caffeine, and eating fewer processed foods!
Other preventatives for migrainous symptoms are medications like beta-blockers, anticonvulsants, and SSRI’s (3). Combining diet changes, lifestyle modifications, some medications, and vestibular therapy will help you reduce symptoms and get back to the activities you love most!

Physical Therapy

Physical therapy for Vestibular Migraine is a gradual process of reintroducing irritating stimuli in a way that your brain can recover from quickly. Like most vestibular therapy, your PT will help determine what stimuli your brain has trouble processing and then help you relearn how to process the stimulus. I find that individuals with Vestibular Migraine frequently struggle with patterned carpets, fluorescent lightning, visual tracking, and quick head movements. All of these stimuli can be very irritating, and it’s your therapist’s job to slowly reintroduce them in a way your brain learns is safe and calm. Adhering to your home program is going to be imperative to your success in vestibular rehabilitation. Your brain  is very malleable, and you will heal from this given time and proper treatment!

Sources:

(1) Rothrock, J., MD. (2020). What is Migraine? Retrieved September 02, 2020, from https://americanmigrainefoundation.org/resource-library/what-is-migraine/

(2) Tepper, D. (2015, November 12). Migraine Associated Vertigo. Retrieved September 02, 2020, from https://americanmigrainefoundation.org/resource-library/migraine-associated-vertigo/

(3)Kramer, J. (2020, August 21). Vestibular Migraine. Retrieved September 03, 2020, from https://vestibular.org/article/diagnosis-treatment/types-of-vestibular-disorders/vestibular-migraine/

(4)Hilton, D. (2020, June 07). Migraine-Associated Vertigo (Vestibular Migraine). Retrieved September 03, 2020, from https://www.ncbi.nlm.nih.gov/books/NBK507859/

(5) Wolf, A. (2020, May 08). Acute Treatments for Vestibular Migraine. Retrieved September 03, 2020, from https://thedizzycook.com/acute-treatments-for-vestibular-migraine/

Secondary Endolymphatic Hydrops, SEH, is a vestibular system disorder caused by endolymphatic response to an underlying condition (1). In a normal ear, the fluid in your ear is maintained at a homeostatic level to help your balance, hearing, and spatial orientation. If you have Secondary Endolymphatic Hydrops, it is likely to be due to an underlying condition. These conditions include, but are not limited to, surgeries that affect the inner ear, inner ear infections, allergies, and head trauma (1, 2). The attacks are spaced weeks to months apart, and over time can destroy your balance and hearing organ slowly. These symptoms manifest in a few different ways depending on the individual. Regardless of your symptoms, we need to treat the symptoms and the root of the problem simultaneously to preserve your vestibular system and restore homeostasis in your body.

The fluid in your ear, endolymph, contains sodium, potassium, and a fluid-like substance. This fluid maintains the correct pressure in your vestibular organ (the inner ear) and helps your balance and hearing function. Too much sodium causes the pressure in your endolymph to increase significantly, leading to an overall pressure change in your inner ear. This pressure fluctuation causes your dizziness and imbalance symptoms. This can be treated by limiting your sodium intake, or limiting other dietary factors that may increase symptoms. Remember, it is not the act of moving your head that causes the fluid to fluctuate; it is other factors like diet, fluid intake, and sodium intake that cause pressure and fluid fluctuations in your inner ear.

Symptoms & Diagnosis

A flareup of Secondary Endolymphatic Hydrops is secondary to another injury or dysfunction, and presents differently between each individual. Symptoms that I frequently hear are:

These symptoms tend to last for 8-36 hours. It may cause you nausea and force you to stay in bed during the duration of the episode. Over years of attacks, your hearing can slowly be lost, so it is important to treat it properly once you receive a diagnosis.

To diagnose Secondary Endolymphatic Hydrops, your physical therapist, or other healthcare provider, will need a thorough history of your symptoms, patterns, and observations. The patterns of your symptoms provide a clear diagnosis because there are usually triggers that affect the flare ups.

Triggers of Secondary Endolymphatic Hydrops usually include:

Knowing your triggers, the source of your symptoms, is important to treating SEH through conservative measures.
Another tool your healthcare team can use are a series of diagnostic tests. Electrocochleography, or EcoG, is a test for the vestibulocochlear nerve function, and if it is positive, supports the diagnosis of SEH. Audiometry can also support an SEH diagnosis; this is a hearing test to see if you have unilateral hearing loss. Lastly, new research has shown that an MRI with contrast shows definitively if you have either SEH or Ménière’s Disease, however it cannot differentiate between the two. Because a thorough history and clinical diagnosis is typically very accurate, diagnostic testing is not incredibly common or always necessary (1). Once you receive a diagnosis, it’s important to begin treating both your symptoms, and the root of the symptoms, in order to preserve your vestibular system and decrease your symptoms.

Treatment

Treating Secondary Endolymphatic Hydrops is very important in order to preserve your vestibular system and prevent future SEH episodes. This can be done through numerous conservative avenues. The first way to treat SEH is through dietary restrictions, the hydroptic diet (1). One of the biggest triggers, and the first thing we typically advise to limit, is sodium. Sodium shows up in our diets more than we think. It is more than just salting our meals, it is in sports drinks, dehydrated foods, ketchup, and sparkling water, just to name a few. Be wary of the presence of salt in your diet, and try your best to limit your intake significantly as too much can cause a large fluid fluctuation and induce an episode. Another common trigger is caffeine (1). Caffeine is the start to your day for many people — whether it is in tea or coffee, most people drink it daily. Caffeine can cause increased symptoms of tinnitus and is a diuretic, which causes fluid loss through urination, therefore disrupting our homeostasis. Following the diet recommended for those with Vestibular Migraines is incredibly effective as a treatment for Secondary Endolymphatic Hydrops.

Another, slightly less conservative option is prescribing a diuretic. Prescribing a diuretic is different from drinking caffeinated drinks, which are technically diuretics. A diuretic works to maintain fluid homeostasis in your body, specifically in your inner ear. This will help you excrete a sustained amount of water throughout the day, so it is important that you increase the amount of water you drink throughout the day in order to avoid dehydration. Some diuretics may cause you to excrete too much potassium, so be sure to discuss with your physician the kind of diuretic you are prescribed to see if you need to take a potassium supplement.

Treatment for Secondary Endolymphatic Hydrops is a process, and finding what helps your symptoms will be different from another person with a similar diagnosis. It is important that you maintain your quality of life by making this a part of your new routine and treating your symptoms effectively for you. Treating your symptoms doesn’t have to feel like it has taken control of your whole life; start small, and work your way into bigger changes if and when they’re necessary.

Physical Therapy

A physical therapist is one of the most qualified providers to help you treat your vestibular dysfunction, specifically Secondary Endolymphatic Hydrops, conservatively. Both your acute and chronic symptoms can be effectively managed with your physical therapist. First, getting a hold of your SEH symptoms by adhering to a hydroptic diet is something your vestibular PT will be able to assist you with. Then, your PT can help prescribe you exercises to improve your balance, decrease dizziness, and discuss any anxiety you may have surrounding your new diagnosis. I have found that those diagnosed with Secondary Endolymphatic Hydrops can be very fearful about their symptoms and sometimes end up secluding themselves from others and their normal activities. Instead of secluding yourself, work with a physical therapist and your healthcare team to get back to your favorite activities, and to continue living your life.

Sources:
(1) VEDA. (2020, August 07). Secondary Endolymphatic Hydrops (SEH). Retrieved September 01, 2020, from https://vestibular.org/article/diagnosis-treatment/types-of-vestibular-disorders/secondary-endolymphatic-hydrops-seh/

(2) BC Balance and Dizziness. (n.d.). Secondary Endolymphatic Hydrops. Retrieved September 01, 2020, from https://balanceanddizziness.org/disorders/vestibular-disorders/secondary-endolymphatic-hydrops/

Ménière’s Disease is a chronic, frustrating, and incurable inner ear disease thought to be caused by a buildup of endolymph in the membranous labyrinth of your cochlea and vestibular system (1). This buildup of endolymph causes swelling on the membranous divide between the endolymph and perilymph, the Reissner’s membrane. This imbalance in your vestibular system causes symptoms of vertigo, spinning, hearing loss, and tinnitus. The potassium-rich endolymph flows into the perilymph, causing your symptoms until the membrane heals and the balance is restored (2). Ménière’s Disease is also commonly called Primary Endolymphatic Hydrops. It is different from Secondary Endolymphatic Hydrops as it has a rupture of the Reissner’s membrane and causes intermittent and/or sustained hearing loss. Because the hypothesis of the Reissner’s membrane rupturing is solely theoretical, there is a lot of room for research and rethinking the potential mechanism for Ménière’s Disease. However, regardless of the theory, we can treat your symptoms with a good healthcare team.

Symptoms & Diagnosis
Ménière’s Disease is associated with many signs and symptoms. It is important to recognize when they occur and differentiate between Ménière’s Disease and other causes of dizziness. The most common symptoms of Ménière’s Disease are: (1)

The above symptoms occur regularly with Ménière’s Disease, but there are other ways to present as well. The following are less common, but can be frequent: (1)

Some patients know when an attack is about to happen. These symptoms almost mimic pre-migraine symptoms, however this is not a migraine. These include:(1)

Knowing what your pre-Ménière’s symptoms are can help you move to a safer more comfortable space before the vertigo sets in. When you have a Ménière’s attack, try to keep tabs on these as a mental or physical list to be helpful to yourself.

Typically between Ménière’s attacks are asymptomatic, but for some there are symptoms that are lasting or sometimes occur between attacks. These kinds of symptoms tend to vary from person to person. Examples of symptoms are:(1)

The diagnosis of Ménière’s Disease can be complicated as symptoms come and go seemingly at random. There are specific diagnostic criteria in order to diagnose Ménière’s Disease. The following must be met in order to receive a diagnosis: (3)

Clinical tests also address and can help diagnose Ménière’s Disease. These tests are:(4)

The diagnosis of Ménière’s Disease is the first step ini direction to the beginning of your treatment. Although there is no treatment to cure Ménière’s Disease, treating your symptoms can be simple and effective.

Treatment
Treatment for Ménière’s Disease is all about symptom management and improvement of symptoms of dizziness and imbalance. Most of the time conservative care is effective to treat Ménière’s, and surgical intervention is unnecessary. These conservative treatments are most often provided by a physical therapist and your physician. These avenues are dietary considerations, medications, and Vestibular Rehabilitation Therapy (VRT).

The first step in treatment is the reduction of sodium in a person’s diet. Dietary restriction can be more strict than just reducing sodium, however sodium is usually the best place to start. Other dietary considerations include dairy, gluten, alcohol, and other common allergens and digestive irritants. Adhering to these new dietary restrictions is important in treatment as it will help reduce the risk of Ménière’s attacks recurring more frequently by reducing your overall inner ear pressure fluctuation risk. If this alone is ineffective for you, your physician may prescribe physical therapy and/or medications to help abate your symptoms and control your fluids.

The two most common medications in Ménière’s Disease are betahistine and diuretics. Betahistine is a vestibular suppressant used by those with Ménière’s Disease to suppress the vestibular system without interfering with vestibular habituation or compensation; this is different from Meclizine which both suppresses the vestibular system and interferes with compensation (5). Physical therapy is very effective in treating the vestibular system through CRT. It assists in compensation and habituation, and can treat imbalance; read more about PT below.

The non-conservative options are much less common and are a last resort for those who have frequent and recurring Ménière’s Disease episodes. The first option is an intratympanic gentamicin shot. This injection destroys some vestibular tissue in one ear, therefore decreasing or eliminating the change of a vertiginous episode. There is a risk of significant hearing loss with this option, so be sure to try and consider other things first (6). The other option is a surgical procedure to reduce pressure in the inner ear; this is done very infrequently and is often ineffective.

There are numerous treatments for Ménière’s Disease. Beginning with conservative treatments and working toward more intensive, invasive options is typically what I see in my patients. However, choosing with your healthcare team what is right for you is always the best option.

Physical Therapy

The goal of physical therapy in vestibular disorders is to treat symptoms of imbalance and lightheadedness, especially in those with Ménière’s Disease between attacks. After an episode, it is common for you to be tired, and laying down to recuperate for some time is normal and expected. However, when you begin to feel better it is important that you begin to move around to move your head when you’re feeling better. You just had an attack on your vestibular system, which now is unbalanced and is looking for input to help re-weight itself. By moving your head, you are assisting your vestibular system process and accommodate changing signals. Too much too soon can also be difficult, and you may want help grading your exercises. A physical therapist is the choice of a provider for help, he or she will be able to find exercises that help you rehabilitate your vestibular system in a way that will slowly improve your tolerance to activity and increase your balance. Often, your vestibular system will cause feelings of lightheadedness and nausea, and this can mean we’ve dont too much or not enough. Finding the fine line between the two is vital for a solid treatment plan.

Other Safety Considerations

When balance and mobility problems pop up, trips, and falls are more likely to occur. But many folks don’t realize the full spectrum of potential household hazards that can increase the likelihood of a stumble. With that in mind, NCOA created this guide, Home Safety for Older Adults: A Comprehensive Guide.This actionable PDF checklist that readers can use to ensure they or their loved ones remain safe at home.

This piece includes a wide variety of practical tips and recommendations from senior safety experts, including:

Sources:
(1) VEDA. (2020, June 24). Ménière’s Disease. Retrieved September 01, 2020, from https://vestibular.org/article/diagnosis-treatment/types-of-vestibular-disorders/menieres-disease/
(2) Gibson, W. P. (2017, August 31). Revisiting the Cause of the Attacks of Vertigo During Meniere’s Disease. Retrieved August 30, 2020, from https://www.jscimedcentral.com/Otolaryngology/otolaryngology-4-1186.pdf
(3) Lopez-Escameza, J. A., Carey, J., Chung, W., Goebeld, J. A., Magnusson, M., & Mandalàf, M. (2015, February 10). Diagnostic criteria for Menière’s disease. Retrieved August 30, 2020, from https://content.iospress.com/download/journal-of-vestibular-research/ves00549?id=journal-of-vestibular-research/ves00549
(4) Martel, J. (2013, January 27). Meniere’s Disease: Symptoms, Causes, Treatments, and More. Retrieved September 01, 2020, from https://www.healthline.com/health/menieres-disease
(5) Lacour, M., Van de Heyning, P., Novotny, M., & Tighilet, B. (2007, August). Betahistine in the treatment of Ménière’s disease. Retrieved September 01, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2655085/
(6) NIDCD. (2020, July 15). Ménière’s Disease. Retrieved September 01, 2020, from https://www.nidcd.nih.gov/health/menieres-disease

Mal de Debarquement Syndrome, or MdDS, is a rare and complex syndrome that leaves you feeling like you have sea legs all the time — bobbing, swaying, and losing your balance. Typically when patients come in with this diagnosis they describe it as “I got off a boat, I walked onto dry land, but my legs and brain never feel like I stepped off of the boat”. There are two kinds of MdDS, classic and spontaneous. Classic develops after being in constant passive motion for a long period, and spontaneous MdDS develops without a movement trigger. MdDS is poorly understood, but what we do understand is that it occurs in healthy people who spend long durations with passive motion, such as being on a boat for days at a time, sleeping on a water bed, or being on a long plane flight (1). Those with Mal de Debarquement do not feel true vertiginous spinning, nor do they usually get motion sick. Physical therapy can be helpful for MdDS, but thorough treatment will be multidimensional and combine treatment from many practitioners.

MDDS Symptoms & Diagnosis

Symptoms of Mal de Debarquement are chronic consist of: (1)

The experience of feeling better when you are in motion is one of the keys to your diagnosis. There are no clinical tests for an MdDS diagnosis, but a thorough history and good clinical skills from your physical therapist will be able to help you toward a diagnosis.

The diagnostic criteria consist of: (2)

Your diagnosis of MdDS is often frustrating and can be anxiety-provoking. Individuals with MdDS are more likely to have pre-existing anxiety and/or depressive disorders (2). Additionally, migraines and headaches are associated with MdDS and generally increase with the onset of MdDS symptoms(2). Treating all of your symptoms, from rocking and swaying to anxiety is going to be vital to the holistic treatment of Mal de Debarquement Syndrome.

MDDS Treatment

Treating Mal de Debarquement Syndrome can be complex and requires significant commitment from both the patient and providers. According to research, patients treated for MdDS found that the most effective therapeutic for their symptoms was a medication, Benzodiazepines. Common Benzodiazepines are Xanax and Valium, they are used to sedate the central nervous system (brain and spinal cord) (2). Additionally, physical therapy and vestibular therapy were found to be somewhat helpful as well. In another study however, they used treatment of the vestibular ocular reflex (VOR) to treat the MdDS symptoms with significant decrease in symptom severity (3). The treatment cited in this article requires a large dome for full visual stimulus, then the patient is seated in a chair and the subject’s head is passively rolled at their rocking frequency while watching the stripes move to the opposite direction of the previously determined affected ear. This treatment was found to be effective immediately after in classic and spontaneous MdDS cases in 78% and 48% of patients respectively (3). In the study’s one-year-follow-up, over 50% of the patients reported that their improvements were lasting (3). A combination of treatments between medications and physical therapy will hopefully treat your Mal de Debarquement Syndrome symptoms.

Physical Therapy(5)

Physical therapy for Mal de Debarquement syndrome is going to be helpful for balance training, gait instability, and sometimes habituation of your vestibular system through Vestibular Rehabilitation Therapy (VRT). This reflex helps to stabilize your gaze and helps you know where your head is in space. VRT for MDDS is most effective in treating the functional deficits, not necessarily the actual rocking and swaying.

The gold standard for MDDS treatment is the Dai Method (3,4) for visual stimulation with head motion, this is especially helpful in those with classic MdDS. Your physical therapist should work closely with you and your other healthcare providers to assess and provide quality treatment for you specifically. If you have MDDS, this is worth a try as because we can easily access large TV screens or Virtual Reality goggles, this can be reproduced at home with a partner if you’d like to try.

Sources:

(1) National Organization for Rare Diseases. (2020, June 05). Mal de Debarquement. Retrieved August 29, 2020, from https://rarediseases.org/rare-diseases/mal-de-debarquement/

(2) Cha, Y., Cui, Y., & Baloh, R. (2018, May 7). Comprehensive Clinical Profile of Mal De Debarquement Syndrome. Retrieved August 29, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5950831/

(3) Dai, M., Cohen, B., Cho, C., Shin, S., & Yakushin, S. (2017, May 5). Treatment of the Mal de Debarquement Syndrome: A 1-Year Follow-up. Retrieved August 29, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5418223/

(4) Dai, M., Cohen, B., Smouha, E., & Cho, C. (2014, June 26). Readaptation of the Vestibulo-Ocular Reflex Relieves the Mal De Debarquement Syndrome. Retrieved August 29, 2020, from https://www.frontiersin.org/articles/10.3389/fneur.2014.00124/full

(5) Farrell, L., DPT. (2019, July). Mal de Debarquement Fact Sheet. Retrieved August 29, 2020, from https://www.neuropt.org/docs/default-source/vsig-english-pt-fact-sheets/mal-de-debarquementc0a035a5390366a68a96ff00001fc240.pdf?sfvrsn=7ca35343_0