Treating dizziness with vestibular rehabilitation

Each year five people out of every 1000 consult their general practitioner because of symptoms that are classified as vertigo; a further 10 in 1000 are seen for dizziness or giddiness.1 As many as one in four people aged 50 to 65 suffer from dizziness, which is even more common in elderly people.2 Despite the prevalence of and morbidity associated with balance disorders the value of vestibular rehabilitation is not widely recognised, and the availability of trained personnel and appropriate facilities is very limited both within and outside the health service.

Once the obvious and sinister causes for the symptom have been excluded patients are commonly reassured and advised to “learn to live with it.” Yet more serious investigation and active management is indicated as persistent dizziness or vertigo can result in chronic invalidism, with a severely circumscribed lifestyle, occupational disability, and a degradation in fitness, mobility, and balance that can have damaging repercussions in later life.3 Moreover, the drugs that are often prescribed for symptomatic relief, such as vestibular sedatives and tranquillisers, may retard recovery.4

In a substantial proportion of cases of dizziness a specific cause cannot be identified with certainty, even though evidence of vestibular dysfunction may exist. Diagnosis is further complicated by the close and complex relation between dizziness and anxiety. Dizziness is one of the key symptoms of panic, and more than four out of five people with panic disorder report it.5

On the other hand, recent research indicates that panic and agoraphobia may often be triggered by an underlying dysfunction of balance.^6,7 After specific general medical or otological conditions have been excluded there therefore exists a group of patients who pose a particularly intractable problem of differential diagnosis - is panic or balance disorder the primary cause of their dizziness? Fortunately, provided that investigation has excluded treatable disease, both the physical and the psychological causes and consequences of dizziness can be simultaneously addressed by a form of treatment known as “vestibular rehabilitation” or “balance retraining.”^8,9

First used to speed habituation after surgically induced unilateral vestibular dysfunction,10 vestibular rehabilitation is now applied to a wide range of balance disorders. Patients perform slow then more rapid head movements to stimulate the vestibular system and enhance the central compensation for the asymmetry in the peripheral vestibular input. At the same time exercises entailing eye movement and changes in posture are instituted to promote the recovery of normal vestibulo-ocular and vestibulospinal reflexes. At first the exercises induce symptoms of dysequilibrium, but with continued practice patients habituate to the positions and movements that originally provoked dizziness.

In addition to the improvement in symptoms achieved by means of habituation, vestibular rehabilitation offers psychological benefits - by supplying patients with an understanding of their dizziness and by encouraging them to cope actively with their problem. Basic education about the functioning of the balance system allows the patient to distinguish the symptoms induced by movement or disorienting environments from the onset of an acute spontaneous attack, thus rendering the dizziness more understandable and predictable. A rational physical explanation for their symptoms relieves patients of anxieties relating to underlying disease (most commonly, fear of an undiscovered brain tumour) and allays concern that their complaints may be interpreted as a sign of emotional weakness. The diagnosis also ends the potentially damaging introspective search for defects of personality or lifestyle to account for their otherwise inexplicable symptoms. But whereas physical explanations for ambiguous symptoms can sometimes foster inappropriate illness behaviour, the rationale for vestibular rehabilitation encourages the gradual resumption of normal activity and emphasises that control over recovery resides with the patient.

The performance of graded exercises that provoke dizziness in a controlled manner and safe environment helps patients to discover that their symptoms are less terrifying than they previously believed and shows them that they are able to tolerate and cope with disorientation. In cases where the dizziness seems to be related to increased psychological arousal and hyperventilation, the vestibular exercises can be supplemented by training in relaxation and respiratory control.11 If the dizziness is associated with excessive anxiety and avoidance of particular activities and environments then cognitive and behavioural techniques used in the treatment of panic and agoraphobia may be useful.12

Clinical trials of the efficacy of exercise programmes typically report improvement in symptoms in over 80% of those participating but with complete elimination of vertigo and dizziness in less than a third.^3,9,13 Balance retraining is a rehabilitative rather than a curative technique and cannot therefore be expected to prevent the recurrence of active disease or to relieve symptoms without a vestibular origin or that are unaffected by position or movement. Nevertheless, the acceleration of habituation by means of exercises results in much less dizziness in most patients; its far reaching psychological benefits may be helpful even to those with recurrent vertigo or whose dizziness seems related to anxiety.