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“It really matters how you approach it” –  introduction to treatment of vestibular disorders.

In my practice, I often receive an order from physician to evaluate and treat patient with dizziness. The prescription often has listed specific diagnosis or ICD-10 code but sometimes it does not. It is always helpful to know ordering physician opinion and therefore diagnosis, so we can select proper approach for evaluation and treatment of this particular vestibular condition. Many times, diagnosis is not listed. I remember many years ago my mentors who introduced me to the field of vestibular rehabilitation said “it is better to not have a diagnosis listed so you can then choose your own opinion and make your own determination of what is causing patient’s symptoms”. I did not understand it at the beginning. I was thinking ”what if I make a wrong decision regarding a treatment and patients will not make benefits from therapy?”

Well, the treatment we select should be based purely on diagnosis and we are the ones who spend sufficient amount of time with patient to make this determination. It is because of having this freedom of making my own diagnosis, I can take over patients care and for next several visits it is only up to me and my approach if patient gets better with his/her symptoms.

Vestibular treatment should be based on established diagnosis by us – Vestibular Rehabilitation Specialists. We have enough of knowledge to make the use of manual skills to determine what kind of treatment we should select. In fact, we do not need almost any equipment to do this. Our own hands and proper ruling in or out techniques often can be sufficient to establish diagnosis that is similar to the one that referring physician lists or not.

With peripheral vestibular disorders we have to establish if the issue is purely mechanical or actually neurological. With Benign Paroxysmal Positional Vertigo vestibular apparatus works very strong, so there is no need to strengthen it. Often canalith repositioning techniques will completely eliminate symptoms in one visit, so there is no need to keep patient on program if vertigo is abolished. Patients who suffer from Unilateral Vestibular Weakness, which is usually caused by viral inflammation, will benefit from vestibular adaptation exercises and gait and balance retraining as their vestibular apparatus is affected on one side but on the other side strength is normal. Central compensation occurs when we stimulate vestibular reflexes. Many times patients are afraid of these exercises as they make them more symptomatic. That is why we have to explain the need of these exercises and refer them to a “scale of dizziness”. It is important to explain to a patient that they should not make themselves symptomatic more that 3 out of 5 (in a 0 to 5 scale, where 0 is no dizziness and 5 is the strongest dizziness that patient ever had) when they perform the exercises as it can trigger unnecessary nausea and it can set them back so they wouldn’t tolerate more therapy. In the other hand, exercise that will not cause symptoms, may not give patient sufficient stimulation and should be progressed to address the issue. Patients with bilateral vestibular hypofunction can also benefit from adaptation exercises as long as there is sufficient function left, otherwise, when there is a complete vestibular loss present – compensatory strategies should be introduced.  Compensatory exercises will address other systems to assist the lost of the vestibular system so the patient can improve in balance reactions and manage their symptoms as vestibular apparatus is often not sufficiently strong to respond to adaptation exercises.

Patients who suffer from central vestibular disorders often present with severe imbalance and oculomotor dysfunctions. It is important to teach a patient to activate these systems to often suppress the increased activity of vestibular system as a result of concussion or stroke.

As we can see it is important to choose appropriate treatment when we address patients with vestibular disorders and carefully select right intervention.

In my next blog, I will write about appropriate treatment approach to Benign Paroxysmal Positional Vertigo – BPPV, vestibular condition that affects 3% of the population and often can be treated very quickly with Vestibular Rehabilitation Therapy.

Dr. Bart Roman, PT DPT
Certified Vestibular Rehabilitation Therapist

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