Dr. Anirban Biswas
Vertigo and Deafness Clinic
BJ-252, Salt Lake, Kolkata-91
Physiotherapy or physical therapy is defined as the treatment of disease, deformity disability by physical methods such as massage, heat treatment, and exercise rather than by drugs i.e., medicines or surgery. Vestibular physiotherapy is physical therapy that helps in the correction of vestibular disorders and in the improvement of body’s balance mechanism.
Vestibular disorders are a pretty common cause of extreme morbidity and induce a severe impact on the quality of life of the patient suffering from it. Vestibular disorders are very incapacitating not only physically but also mentally. Patients with balance problems not only have physical limitations, but most such patients also harbour a deep sense of fear of an impending fall or a sudden onset of acute head spinning with nausea and vomiting which makes life miserable for them. A fall or an episode of severe head spinning is one of the most dreaded and traumatic experiences physically and mentally that a person can ever have. Only patients who have experienced it can appreciate the physical and mental trauma that a vestibular disorder can induce.
Unfortunately, however, the biological mechanism of maintenance of balance and how different diseases of the balance system change this normal functioning of the balance system was ill-understood till about a decade back. This was due to its inherent complexity. Hence, the common practice of treating balance disorders was by prescribing anti-vertigo drugs or vestibular sedatives (like betahistine/ cinnarizine/ meclizine/ prochlorperazine/ dimenhydrinate etc) that merely helped in partly and temporarily reducing the symptom of head spinning without correcting the underlying cause of the disorder. As for patients with the imbalance, the vestibular sedatives did not help at all. Rather, by sedating and reducing the sensitivity of the balance organs they actually aggravated the patient’s imbalance. Vestibular sedatives neither corrected the disease nor restored the balance function that had been deranged by the disease. The biggest fall out of a derangement of the balance organs by any disease is the imbalance / unsteadiness induced by the disease.
The balance organs are special sense organs where dead cells do not regenerate; yet then after the balance organs have been damaged by disease, most (but not all) patients slowly re-gain their normal or near normal balance function. This happens because we have an in-built system called the vestibular compensatory mechanism which brings about some functional changes in the brain by virtue of which a patient having a damaged balance organ at least partly if not wholly gets back normal balance function. This is a unique system of the human body and the best part of it is that it is a natural process. Medicines do not enhance this process of vestibular compensation. Rather, most if not all vestibular sedatives that are used for symptomatic relief in vertigo depresses this natural process of restoration of balance that is ingrained in our systems. But, physical therapy in different forms does enhance and expedite this natural mechanism in a very big way. Herein lies the importance of physical therapy in the management of balance disorders.
It is only in the last 10 years that a paradigm shift has taken place in the management of vestibular disorders. It is now known that most if not all of the vestibular sedatives that were used for treating vestibular disorders actually jeopardise the natural process of restoration of balance function and the use of such medicines is now universally denounced and long term use is abhorred. In fact, some of them are not even approved by the FDA of USA which is a regulatory body for use of medical products / devices respected and followed internationally, but are freely sold as over the counter products in our country. The current medical consensus is that if at all these anti-vertigo drugs are used then, the use must be restricted to just 3 to 5 days never beyond that.
Physical therapy has now been found to be extremely beneficial for the restoration of balance function after the balance organs have been damaged by disease. Advancements in our understanding of the mechanism of balance in normal persons and also when affected by disease have established the efficacy of physical therapy in the management of balance disorders. Physical therapy is beneficial in augmenting the physical stability of any individual not only balance disorder patients but also in normal persons who do not have a balance disorder. It is used in fall prevention too and is hence immensely useful in improving quality of life of aged patients. Some special forms of physical therapies like those employing virtual reality systems also help patients overcome the fear of fall by adapting them to different types of challenging situations. In patients with disorders of the vestibular system, physical therapy restores the balance function by enhancing and expediting the vestibular compensatory mechanism and by specifically and individually stimulating the defective sensors in the vestibular labyrinth in the ears after the defect has been identified by the advanced vestibular function tests.
Physical therapy is basically of two forms viz: –
1) non-specific physical therapy to improve the general balance function and expedite the process of vestibular compensation only. As these are non-specific exercises, they are not targeted to improve the function of any particular balance organ that has been damaged by disease. These are-
a) Cawthrone-Cooksey Exercises
b) Yogic asanas
c) Tai Chi exercises
Of these three, though the Cawthrone-Cooksey Exercises are more widely practised and have stood the test of time, yet the other modalities of non-specific balance enhancing exercises i.e., Yogic asanas and Taichi have been found to be more efficacious. These exercises, including the Cawthrone-Cooksey Excersises need to be taught and demonstrated by trained and qualified physical therapists and experts in yoga and tai chi. Not all physical therapists can do this job with the required finesse that this special form of physical therapy demands. Practical experience shows that therapists who are not adequately trained in physical therapy for balance disorders and have not been exposed to neurotology or has not worked in neurotology clinics under the guidance of a neurotologist, actually mess up the therapy and the end result is very often undesirable. The common practice of doctors giving some tear-away sheets of the Cawthrone-Cooksey Excersises to patients (circulated by some pharmaceutical companies with the names of some anti-vertigo products advertised there) is farcical and defeats, if not makes a joke of the purpose of these exercises. These exercises are beneficial only if properly done and for this specialised first hand training from trained experts is mandatory. Now modern technology like virtual reality is also being used to restore stability in balance disorder patients and is instrumental in improving the plight of balance challenged patients.
2) specific organ-targeted physical therapy. Modern research has unravelled many of the mysteries of the functioning of the balance system and has advanced our understanding of the mechanism of balance enormously. We now know the exact function of each part of the balance system. The balance organs in the ear have different and very specific and specialised sensors for identifying different types of body movement. Today we know that the saccule senses up-down movement in the vertical axis, the utricle senses linear movement in the horizontal axis i.e., side to side and front-back movement and the three semi-circular canals sense angular movement in three different planes. In diseases of the balance system, one or more of these sensors are often damaged. Advancements in diagnostic neurotology have sharpened the diagnostic techniques to such an extent that the modern vestibular function tests like videonystagmography (VNG), cervical and ocular VEMP, subjective visual vertical tests (SVV), video head impulse test (VHIT), the subjective visual vertical test (SVV)etc. can accurately and very precisely identify the exact part of the balance system that has been damaged and specify which type of body movement is not being adequately sensed by the balance organs. Vestibulometry today can so very precisely localise and quantify the dysfunction in the defective organ that a modern neurotologist using the advanced vestibulometric tests available today can specify that the saccule of one side is 56.2% defective or that the posterior semi-circular canal of one side is 39.62% defective or that there is a in a specific defect in the oculomotor function. In keeping with the advancements in diagnostic neurotology, therapeutic neurotology especially physical therapy has also undergone great sophistication. Specific physical therapy to stimulate the functional status of the defective sense-organ is now possible. A huge lot of electro-mechanical gadgetry is now available for this some of which has been developed by the author. We can now specifically and individually stimulate the utricle, the saccule and/or one or more of the three semi-circular canals by organ targeted physical therapy. The results of such physical therapy is extremely promising.
Experts in physical therapy for balance disorder patients and specialists in neuro rehabilitation work in coordination with neurotologists to provide a much better quality of life to most if not all balance disorder patients. This form of physical therapy is very scientific and logical and stimulates the residual function of any dysfunctional sense-organ in the vestibular system. Advancements in physical therapy have been able to enhance the quality of life of balance disorder patients tremendously.
Click on the link below to view the article on VESTIBULAR PHYSIOTHERAPY by Dr Anirban Biswas published as in invited article in the December2017 issue of the INDIAN JOURNAL OF OTOLARYNGOLOGY AND HEAD NECK SURGERY