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Acoustic Neuroma

Most acoustic neuromas and other tumours seen in NF (Neurofibromatosis) can be detected by an MRI (Magnetic Resonance Imaging), particularly if contrast is used.

Unfortunately, cases have been described in the literature of patients who did not have acoustic neuromas but reported dizziness. In these cases, dizziness was caused by tumours in other areas of the central nervous system and not on the VIII nerve (vestibulocochlear nerve).

Alternative Treatments

There isn’t enough evidence to support the diagnosis of cervical vertigo. Some argue that cervical vertigo can be related to compressed blood vessel and/or nerve endings. An MRI (magnetic resonance imaging) would not show this. MRIs are done to rule out growths such as tumours. People with motion sensitivity usually avoid moving their head and tend to move in a block without turning their neck.  Little by little, this leads to a stiff and sore neck; when you are forced to move your neck, you get dizzier.

Instead of using a firm pillow to keep your head immobile while sleeping, for example, consider doing some type of exercise, such as tai chi, involving gentle head movement; over time, you’ll be able to move your head more freely without feeling dizzy.

This is a grey area. Sometimes chiropractic treatments work, but sometimes the patient is much worse afterwards. There is much debate in the medical literature concerning whether it works; and, in cases where it seems to work, why. What is commonly observed in patients who suffer from dizziness is great neck and shoulder muscle tension and pain. This is often interpreted as a sign of a neck problem which is provoking dizziness. However in most instances the neck and shoulder tension is caused by the patient’s natural reaction of avoiding head movement. Since head movements often trigger dizziness, such movements are avoided. The result is neck and shoulder tension. Massage therapy combined with vestibular rehabilitation can be very helpful in these instances.

BPPV

The otoliths are a chandelier-like structure hanging from the ceiling of the inner ear. As we move, its canals bend from side to side and we sense these movements. Like a chandelier, this structure is weighted by crystals. These tiny rocks can come loose and fall into the canals causing BPPV (benign paroxysmal positional vertigo).

Every time someone with BPPV does a particular head movement, for example putting their head back to look for something on an upper shelf or rolling over in bed, they get dizzy.  This happens because the loose crystals overstimulate the movement sensors in the canal. There are canal-specific manoeuvres that can be performed by a doctor, audiologist or physiotherapist to shift the crystals back to where they belong.

Between 85 to 90% of BPPV affects the posterior canal; for most patients, it is easily fixed using the Epley manoeuvre. The Barbeque Roll (rotational) manoeuvre is used when the horizontal canal is affected.

Category: BPPV

You might have an underlying condition that behaves like BPPV. A second possibility is recurrent BPPV; it can be fixed by a manoeuvre but then comes back. It’s also possible that the source of your problem isn’t in the inner ear, but higher up in your brain; if the sensors in your brain that interpret the information sent by the ear aren’t working properly, these manoeuvres will be of no use.

Category: BPPV

Ménière's Disease

Complex vestibular disorders are challenging to treat. For example, it can be very difficult to tease out the symptoms that distinguish Ménière’s disease or migrainous vertigo: they have very similar symptoms, however are treated very differently. More complex cases are very individual and cannot always be pigeon-holed as Ménière’s or migrainous vertigo or some other particular disorder. Patients may have some but not all of the characteristics of Ménière’s disease, for example, and that is frustrating for doctors.

About a third of patients benefit from medications such as betahistine. Others benefit from a reduced salt diet and other dietary changes. When spells happen often and quality of life is reduced, intratympanic (within the middle ear) steroid injections may be used by the ear specialist (otologist). The objective of the injections is to prevent or reduce further attacks as each attack results in a further loss of hearing and balance.

Vestibular rehabilitation usually doesn’t help in the early stages of Ménière’s. Patients will have attacks that can neither be predicted nor be kept under control with exercises. Vestibular rehabilitation doesn’t work well when a patient’s condition fluctuates–that is, good hearing and balance between attacks and poor during attacks.

With continued attacks, patients lose much of their hearing and balance. Once the balance function is greatly diminished and doesn’t change a lot when in or between attacks, the patient is a candidate for vestibular rehabilitation. If a patient has lost balance function on one side, the brain can be trained to compensate for the loss; however, it takes practice.

Migrainous Vertigo

Complex vestibular disorders are challenging to treat. For example, it can be very difficult to tease out the symptoms that distinguish Ménière’s disease or migrainous vertigo: they have very similar symptoms, however are treated very differently. More complex cases are very individual and cannot always be pigeon-holed as Ménière’s or migrainous vertigo or some other particular disorder. Patients may have some but not all of the characteristics of Ménière’s disease, for example, and that is frustrating for doctors.

Motion sickness and an overall reduced tolerance to movement is often reported in patients who suffer from migraines. The recommendation is to treat the migraine first. When migrainous episodes are under control, patients benefit greatly from vestibular rehabilitation aimed at increasing motion tolerance. Identifying and avoiding triggers is one way to keep migraines under control as well reduce the number of episodes. Triggers include stress, foods (e.g., cheese), alcohol (e.g., red wine), smells. Preventative medications can also be used to avoid migraine episodes from happening.

Motion Sensitivity

We’re still not sure of the process by which motion sickness happens. Drugs for this condition have not changed for 60 years. The believed mechanism is a conflict of information between the inner balance sensors, visual, and proprioceptive systems. Those who suffer from motion sickness tend to rely predominantly on their visual system for balance. If you can’t see where you are going, for example while seated in the back seat of a moving car, your motion sickness gets triggered. If you drive, you see where you’re going and feel fine.

For similar reasons, watching things move can also be a major trigger. The brain wants stable vision. Watching moving objects causes problems for some. Examples include crowded situations, action movies, and scrolling computer screens. In these circumstances, the brain has no stable frame of reference. It becomes confused, resulting in nausea and/or dizziness.

We can help the brain by fixing our eyes on a stable object. In a crowd, try to focus on something that isn’t moving. If in a moving car, try to concentrate on a distant stationary object. Nearby objects that are rapidly moving will confuse the brain. Flashes of light or a pattern of light and shadow also trigger motion sickness.

If your problem is “central positional nystagmus,” the approach is through habituation. Instead of having Epley or other manoeuvres performed, you can try Brandt-Daroff or other vestibular rehabilitation exercises. These habituation exercises retrain the brain and are beneficial for most patients. They are helpful for both peripheral and central types of dizziness.

If you are motion sensitive, you can start by doing tiny doses of movements that make you feel nauseated. For example, move your head back and forth for just 30 seconds. Then push yourself for one or two seconds longer and give your brain a chance to overcome the feeling of nausea. Gradually, your brain will get habituated to more motion.

If done properly and routinely, those with motion sensitivity, BPPV or central positional nystagmus should start to feel some benefit from habituation exercises in three to four weeks and feel a lot better in about five to six weeks. If you are unsure how to do these exercises, have back or neck problems, or can’t do them quickly enough on your own, have a physiotherapist, audiologist or ENT do them.

Vestibular Disorders

Complex vestibular disorders are challenging to treat. For example, it can be very difficult to tease out the symptoms that distinguish Ménière’s disease or migrainous vertigo: they have very similar symptoms, however are treated very differently. More complex cases are very individual and cannot always be pigeon-holed as Ménière’s or migrainous vertigo or some other particular disorder. Patients may have some but not all of the characteristics of Ménière’s disease, for example, and that is frustrating for doctors.

We’re still not sure of the process by which motion sickness happens. Drugs for this condition have not changed for 60 years. The believed mechanism is a conflict of information between the inner balance sensors, visual, and proprioceptive systems. Those who suffer from motion sickness tend to rely predominantly on their visual system for balance. If you can’t see where you are going, for example while seated in the back seat of a moving car, your motion sickness gets triggered. If you drive, you see where you’re going and feel fine.

For similar reasons, watching things move can also be a major trigger. The brain wants stable vision. Watching moving objects causes problems for some. Examples include crowded situations, action movies, and scrolling computer screens. In these circumstances, the brain has no stable frame of reference. It becomes confused, resulting in nausea and/or dizziness.

We can help the brain by fixing our eyes on a stable object. In a crowd, try to focus on something that isn’t moving. If in a moving car, try to concentrate on a distant stationary object. Nearby objects that are rapidly moving will confuse the brain. Flashes of light or a pattern of light and shadow also trigger motion sickness.

Motion sickness and an overall reduced tolerance to movement is often reported in patients who suffer from migraines. The recommendation is to treat the migraine first. When migrainous episodes are under control, patients benefit greatly from vestibular rehabilitation aimed at increasing motion tolerance. Identifying and avoiding triggers is one way to keep migraines under control as well reduce the number of episodes. Triggers include stress, foods (e.g., cheese), alcohol (e.g., red wine), smells. Preventative medications can also be used to avoid migraine episodes from happening.

If your problem is “central positional nystagmus,” the approach is through habituation. Instead of having Epley or other manoeuvres performed, you can try Brandt-Daroff or other vestibular rehabilitation exercises. These habituation exercises retrain the brain and are beneficial for most patients. They are helpful for both peripheral and central types of dizziness.

If you are motion sensitive, you can start by doing tiny doses of movements that make you feel nauseated. For example, move your head back and forth for just 30 seconds. Then push yourself for one or two seconds longer and give your brain a chance to overcome the feeling of nausea. Gradually, your brain will get habituated to more motion.

If done properly and routinely, those with motion sensitivity, BPPV or central positional nystagmus should start to feel some benefit from habituation exercises in three to four weeks and feel a lot better in about five to six weeks. If you are unsure how to do these exercises, have back or neck problems, or can’t do them quickly enough on your own, have a physiotherapist, audiologist or ENT do them.

It is very common to have dizziness triggered by watching things move, as opposed to moving oneself. Many people feel dizzy in busy visual environments, such as browsing in a crowded grocery store, at busy intersections, or even seeing someone carrying a boldly striped bag. This problem, referred to by British researchers as visual vertigo, is caused by your brain not being able to match up the information coming from your eyes, your inner ear and the proprioception sensors on your joints. When you watch a 3-D movie, your eyes follow things around as if you were actually moving. If your brain is hard-wired to believe your eyes more than your inner ear or body, the message from your eyes will dominate and you’ll feel dizzy.

A treatment for visually-stimulated vertigo consists of watching things in motion. Audiologist Erica Zaia suggests repeatedly watching full-screen versions of the NED Leader (right and left) video clips on YouTube. When you get the feeling that you want to look away, watch for three to five seconds longer. Becoming accustomed to doing the tai chi “cloud hands” movement follows the same principle; it habituates your brain to the movement of your hands.

Below are two simple optokinetic videos. Once you are used to these, try the more complex one here.

Category: Visual Vertigo

About a third of patients benefit from medications such as betahistine. Others benefit from a reduced salt diet and other dietary changes. When spells happen often and quality of life is reduced, intratympanic (within the middle ear) steroid injections may be used by the ear specialist (otologist). The objective of the injections is to prevent or reduce further attacks as each attack results in a further loss of hearing and balance.

The otoliths are a chandelier-like structure hanging from the ceiling of the inner ear. As we move, its canals bend from side to side and we sense these movements. Like a chandelier, this structure is weighted by crystals. These tiny rocks can come loose and fall into the canals causing BPPV (benign paroxysmal positional vertigo).

Every time someone with BPPV does a particular head movement, for example putting their head back to look for something on an upper shelf or rolling over in bed, they get dizzy.  This happens because the loose crystals overstimulate the movement sensors in the canal. There are canal-specific manoeuvres that can be performed by a doctor, audiologist or physiotherapist to shift the crystals back to where they belong.

Between 85 to 90% of BPPV affects the posterior canal; for most patients, it is easily fixed using the Epley manoeuvre. The Barbeque Roll (rotational) manoeuvre is used when the horizontal canal is affected.

Category: BPPV

You might have an underlying condition that behaves like BPPV. A second possibility is recurrent BPPV; it can be fixed by a manoeuvre but then comes back. It’s also possible that the source of your problem isn’t in the inner ear, but higher up in your brain; if the sensors in your brain that interpret the information sent by the ear aren’t working properly, these manoeuvres will be of no use.

Category: BPPV

Vestibular rehabilitation usually doesn’t help in the early stages of Ménière’s. Patients will have attacks that can neither be predicted nor be kept under control with exercises. Vestibular rehabilitation doesn’t work well when a patient’s condition fluctuates–that is, good hearing and balance between attacks and poor during attacks.

With continued attacks, patients lose much of their hearing and balance. Once the balance function is greatly diminished and doesn’t change a lot when in or between attacks, the patient is a candidate for vestibular rehabilitation. If a patient has lost balance function on one side, the brain can be trained to compensate for the loss; however, it takes practice.

Most acoustic neuromas and other tumours seen in NF (Neurofibromatosis) can be detected by an MRI (Magnetic Resonance Imaging), particularly if contrast is used.

Unfortunately, cases have been described in the literature of patients who did not have acoustic neuromas but reported dizziness. In these cases, dizziness was caused by tumours in other areas of the central nervous system and not on the VIII nerve (vestibulocochlear nerve).

Vestibular Rehabilitation Exercises

Motion sickness and an overall reduced tolerance to movement is often reported in patients who suffer from migraines. The recommendation is to treat the migraine first. When migrainous episodes are under control, patients benefit greatly from vestibular rehabilitation aimed at increasing motion tolerance. Identifying and avoiding triggers is one way to keep migraines under control as well reduce the number of episodes. Triggers include stress, foods (e.g., cheese), alcohol (e.g., red wine), smells. Preventative medications can also be used to avoid migraine episodes from happening.

If your problem is “central positional nystagmus,” the approach is through habituation. Instead of having Epley or other manoeuvres performed, you can try Brandt-Daroff or other vestibular rehabilitation exercises. These habituation exercises retrain the brain and are beneficial for most patients. They are helpful for both peripheral and central types of dizziness.

If you are motion sensitive, you can start by doing tiny doses of movements that make you feel nauseated. For example, move your head back and forth for just 30 seconds. Then push yourself for one or two seconds longer and give your brain a chance to overcome the feeling of nausea. Gradually, your brain will get habituated to more motion.

If done properly and routinely, those with motion sensitivity, BPPV or central positional nystagmus should start to feel some benefit from habituation exercises in three to four weeks and feel a lot better in about five to six weeks. If you are unsure how to do these exercises, have back or neck problems, or can’t do them quickly enough on your own, have a physiotherapist, audiologist or ENT do them.

In a nutshell, vestibular rehabilitation gets our brains used to what makes us uncomfortable. The overall goal of vestibular rehabilitation is to increase quality of life by acclimatizing the body to the disorder. Vestibular rehabilitation is:

  • symptom-based
  • matched to the individual’s particular needs
  • appropriate for people with a vestibular disorder or a secondary complication

During vestibular rehabilitation, the vestibular symptoms are intentionally provoked in a safe and controlled manner to desensitize the brain. Clients are taught how to move their heads, for example, so their brains gradually become habituated to the movement and recognize that it isn’t a scary thing to be avoided.

The initial visit to a vestibular physiotherapist includes a full assessment that allows the physiotherapist to set up a rehabilitation program that allows the client to progress safely through sets of exercises.

Physiotherapists take a big picture approach, promoting overall health and exercise to prevent secondary complications as well as increased activity levels to guide clients towards full recovery. They emphasize the importance of stress and sleep management: anxiety and fatigue result in exaggerated symptoms. Keeping a log and rating your symptoms on a one (best) and ten (worst) scale is recommended. If your dizziness it ten out of ten on a really bad day, look back and see what happened – how was your sleep, did something stressful happen?

Vestibular rehabilitation is not appropriate during the acute stage of a vestibular disorder. The best time to start is after the acute stage has passed or, for recurrent conditions such as Ménière’s disease, between bouts. Although it is not necessary to have a doctor’s referral to start vestibular rehabilitation, it is a good idea to see your doctor about dizziness problems and be cleared from any medical “red flags.” It is also important to get other medical tests done to rule out other reasons why you are feeling dizzy or light-headed. In addition to the vestibular system, problems with major body systems can cause dizziness.

Yes – though you don’t want to overdo it, you must make yourself dizzy in order to get better. Little by little, you will give your brain a chance to overcome the dizziness.

Though generalized sets of movements, such as the Cawthorne-Cooksey exercises, are helpful, they do not work as well as custom-tailored exercises. Based on your written vestibular test results, an audiologist or vestibular physiotherapist should be able to give you a personalized set of exercises to best address your particular symptoms.

Some of the vestibular rehabilitation activities done under supervision are taught to clients to practice at home in a safe and controlled manner. These activities include:

  • motion-sensitivity exercises such as rolling in bed, sitting to standing, and walking while turning the head
  • many different balance exercises
  • visual or gaze exercises
  • “target shooting,” that is keeping the head still while moving the eyes, or moving the head and keeping the eyes still
  • the Epley maneuver to reposition ear crystals

Vestibular rehabilitation usually doesn’t help in the early stages of Ménière’s. Patients will have attacks that can neither be predicted nor be kept under control with exercises. Vestibular rehabilitation doesn’t work well when a patient’s condition fluctuates–that is, good hearing and balance between attacks and poor during attacks.

With continued attacks, patients lose much of their hearing and balance. Once the balance function is greatly diminished and doesn’t change a lot when in or between attacks, the patient is a candidate for vestibular rehabilitation. If a patient has lost balance function on one side, the brain can be trained to compensate for the loss; however, it takes practice.

Vestibular rehabilitation exercises do not need to be continued when you are no longer experiencing symptoms. Once you’re back to moving quickly enough in your regular activities throughout the day, you no longer need to do them. Keep them in mind, however, should there be a recurrence of the symptoms.

Vestibular Testing

Complex vestibular disorders are challenging to treat. For example, it can be very difficult to tease out the symptoms that distinguish Ménière’s disease or migrainous vertigo: they have very similar symptoms, however are treated very differently. More complex cases are very individual and cannot always be pigeon-holed as Ménière’s or migrainous vertigo or some other particular disorder. Patients may have some but not all of the characteristics of Ménière’s disease, for example, and that is frustrating for doctors.

In BC, patients need a referral from an ENT (ear, nose and throat) specialist; this requires a referral from a family doctor. The process usually involves a waiting period of three to six months or more.

Visual Vertigo

It is very common to have dizziness triggered by watching things move, as opposed to moving oneself. Many people feel dizzy in busy visual environments, such as browsing in a crowded grocery store, at busy intersections, or even seeing someone carrying a boldly striped bag. This problem, referred to by British researchers as visual vertigo, is caused by your brain not being able to match up the information coming from your eyes, your inner ear and the proprioception sensors on your joints. When you watch a 3-D movie, your eyes follow things around as if you were actually moving. If your brain is hard-wired to believe your eyes more than your inner ear or body, the message from your eyes will dominate and you’ll feel dizzy.

A treatment for visually-stimulated vertigo consists of watching things in motion. Audiologist Erica Zaia suggests repeatedly watching full-screen versions of the NED Leader (right and left) video clips on YouTube. When you get the feeling that you want to look away, watch for three to five seconds longer. Becoming accustomed to doing the tai chi “cloud hands” movement follows the same principle; it habituates your brain to the movement of your hands.

Below are two simple optokinetic videos. Once you are used to these, try the more complex one here.

Category: Visual Vertigo