Vestibular Rehabilitation Therapy (VRT)

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Most dizzy patients avoid moving around too much as it simply makes them feel horrible.

 

This, in fact, can lead to further problems as the brain needs to be able to correct the faulty signals which are being passed from the inner ear. To do this, the dizzy person has to try and do things including different head positions, however difficult.

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This is the theory behind Vestibular Rehabilitation Therapy or VRT. VRT has been used for over 50 years and is widely gaining recognition for the treatment of chronic vestibular disorders.

 

 

 

 

 

 

 

 

 

 

 

It is important to note that the vestibular injury must be stable for VRT to work. For example, Menieres Disease is not a stable vestibular problem, it is progressive and fluctuating. BPPV is fluctuating as in the patient gets “attacks”.

 

If you have been diagnosed with Labyrinthitis, the most likely scenario is that you had a virus that attacked one or both sides of your vestibular system and you are left with the residual damage. This is said to be a stable problem. If you develop BPPV on top, this makes the situation unstable as the BPPV “attacks” upset the already damaged balance system. It is important to rule out any other things going on as these can hinder compensation. The two main ones we know of are: Migraine associated vertigo (MAV) and BPPV.

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Now, before we go into how VRT works, we feel it important to mention that VRT is not always easy to access. Over the past 20 years since we both fell ill, things have improved and the awareness of balance issues and the usefulness of VRT, has increased. But, you may need to do your own research about which hospitals near to you offer the therapy.

 

The longer you leave it, the longer VRT actually takes to work. It was about 1 and a half years before Emma got to VRT and about 3 years for Isla. Getting there earlier could have quickened both of our recoveries. The fact is VRT does work (we will give you some figures later) for most so stick to your guns and if you feel you need VRT – then demand it.

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Vestibular problems affect the VOR (Vestibulo-ocular reflex) which controls eye movement and gaze stabilization during head movement. They can also affect the VSR (Vestibulospinal reflex) which influences postural stability. Patients can have problems with one or both of these areas. VRT, as described later, focuses partly on these two areas.

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VRT focuses on the plasticity of the central nervous system. It does not repair the damaged inner ear. It instead works on getting the CNS and brain to adapt to the asymmetrical input from the VOR and VSR. A few theories exist as to how this occurs – perhaps it is the spontaneous rebalancing of tonic activity in the vestibular nuclei or the recovery of the VOR via adaption or the habituation effect – which lessens the response to the same stimuli over time.

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According to Gans, R (2003) “Theoretically, central compensation should occur within 90 days following dysfunction or loss of one of the vestibular systems. But many lesions, don’t benefit from this compensation phenomenon”.

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The reasons for the above can be down to patients taking vestibular suppressants (medication) which prevent the brain from re-learning what it should or it could be due to patients avoiding movement or certain head positions. As mentioned in the 'diagnosis' section, there are many GPs out there who very readily give out such drugs because they do not have the knowledge that these can in fact hinder the compensation process. All of the GPs we saw offered us them and mentioned nothing about VRT (this was some time ago and we hope things have now improved).

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Cawthorne and Cooksey developed the idea of VRT in the 1940s and you can do a search for these on the internet. Here they will give you some exercises. We are reluctant to do this as we are not health professionals – so it is important to get a referral and then follow the programme you are given. VRT also needs to be tailored to your issue and your needs - research shows that generic exercises such as the Cawthorne Cooksey ones, are much less effective.

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In brief, there are three approaches to VRT:

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ADAPTION – this will reset the VOR. The exercises will include things the patient has been avoiding – certain head positions etc. Many exercises will feature head movement with eye movement and often different surfaces – for example the patient could start doing the exercises standing on carpet and progress to foam. This gets the vestibular system to work harder.

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SUBSTITUTION – this will strengthen the vestibular system by reducing other inputs – for example, vision. Therefore, foam cushions are used or exercises are done with eyes closed.

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CANALITH REPOSITIONING – If you have BPPV on top of Labyrinthitis, then your specialist may want to perform this procedure which helps get the calcium crystals back into the correct inner ear canal. It is usually a one off treatment, but can take a few attempts.

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Ideally, you should have an assessment prior to starting the VRT to see if anything is hindering your recovery. Anxiety and depression have been found to - so some centres offer Cognitive Behaviour Therapy or counselling, which we think is a good thing. 

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As mentioned, research shows that customised VRT programmes (ones which are catered for each individual) appear to be more successful than generic (standard) ones. This is important to raise with your VRT specialist.

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Exercises are generally done for about 20 mins two times a day. Different programmes vary however - some feel that 5 mins 3 times a day works best.

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It is also believed that conditioning exercises (like walking briskly or going to gym) help recovery and when combined with VRT, can work well. Find something that is right for you but do not overdo it.

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Another important point is that VRT can take a long time. They say generally people first start seeing improvements at the 3 month mark. Many take longer. For chronic cases, they recommend doing VRT for 1 year. So do not become disheartened when you do not recover in a few weeks or a couple of months, it takes time and diligence is the key. Even if you have a bad day, you must still do the VRT. It is difficult to stick to but it won’t work if you don’t.

People often report an increase in symptoms when they first start VRT – Emma did with hers – this is normal and is a good sign that the brain is “getting it”! Do not be alarmed and keep going with the VRT, reducing it slightly if symptoms are very bad.

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Recovery from Uncompensated Labyrinthitis is not linear, in that it is very common to have "good" and "bad" periods. We have decided that for this reason this illness has to be one of the cruellest - as just as you think you are getting there - WHAM - a horrendous patch hits.

 

Mentally, this is very hard.

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Emma found that by writing in her diary how she felt each day - ie. "good", "ok" or "bad" helped to pinpoint progress which would otherwise most probably be missed.

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VRT has consistency been shown to be an important part of the management of vestibular patients. Research by UTMB (2000) shows that most studies state that patients improve by 70-80% but this does not always mean being symptom free. It is very much dependent on each individual and the amount and place of inner ear damage. If you do not feel you have improved enough after several months of VRT, get your specialist to re-evaluate you. They may find something stopping you compensating or may prescribe different/more challenging exercises.