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Balance the imbalance with vestibular rehabilitation

Balance the imbalance with vestibular rehabilitation

Prevalent among the elderly population, vestibular dysfunction could be treated with medication, manoeuvres and vestibular rehabilitation programmes


In the elderly population, falls are largely caused by imbalance in the vestibular system. As one ages, the health of the vestibular system can play a crucial role in determining a fall-free life.

Dr Prabha Adhikari, Professor and Head, Department of Geriatric Medicine, Yenepoya Medical College, Mangaluru, tells Happiest Health, “Vestibular disorders are common in the middle-aged and older population, more so in females.”

A 2019 research paper, ‘The Aging Vestibular System: Dizziness and Imbalance in the Elderly’, stated that 20 per cent of the elderly above 60, 30 per cent above 70 and nearly 50 per cent over the age of 80 experienced dizziness that affected their day-to-day chores.

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Dizziness, when left untreated, can eventually lead to fall or gait abnormalities too.

In this regard, Dr Steve Paul Manjaly, consultant geriatrician at Apollo Hospitals in Bengaluru, tells Happiest Health, “The risk of fall due to vestibular dysfunctions is high among elderly above 75. However, those who are in their sixties with multiple comorbidities – such as hypertension or diabetes – are more at risk of developing vestibular dysfunctions than those who are older than 75 (without any comorbidities),” says Dr Manjaly. 

All that you need to know about the vestibular system

Vestibular disorders are disorders of the vestibular system. This is an otoneurological system – which connects the inner ear with the neural pathways leading to the brain. It regulates the balance and spatial position (proprioception) of the head and body.

Specifically, the inner ear organs such as semicircular canals (that help to detect angular acceleration and balance head movements), otolith organs (which help to detect forward-backwards, left-right, and up-down movements), otoconia (multiple calcium carbonate crystals that help to bend the hair cells in linear acceleration) and vestibular nuclei (part of the inner ear which plays a role in reflex eye movements) determine vestibular balance or imbalance.

The vestibular system is functioning well, if a person can accomplish the following day-to-day tasks without the fear of fall or feeling dizzy:

  • nod/tilt your head up-down or left-right
  • walk up/down the stairs
  • drive a car or ride a bike
  • reach the top shelf in the cupboard and pick an object

A classic case of vestibular imbalance explained

Shanta Rao (name changed), 62, was leading a happy life after her retirement in Mangaluru. She suddenly developed dizziness. Due to the condition, Rao was unable to turn her head and respond to someone on her extreme right/left or bend down and pick a fallen object from the floor.

She assumed the dizziness was a temporary issue, caused by some food or changing weather conditions. She had to temporarily put a pause on her grocery shopping and evening walk with her friends, assuming that taking rest would subside the disorienting sensation in time.

But the dizziness continued to trouble her even after two weeks. Acting on her friends’ recommendations, Rao visited a neurologist, an ear, nose, and throat (ENT) surgeon, an orthopedic surgeon, and an endocrinologist.

“The dizziness episodes limited my movement for a while. I was apprehensive to move about on my own. Doctors told me I had vertigo. I was prescribed six tablets to manage the condition. I have been consuming these medicines since a month along with my diabetes medicines. I also make it a point to wear my neck collar whenever I walk,” Rao tells Happiest Health.

Vestibular dysfunction — according to ‘Clinical evaluation of elderly people with chronic vestibular disorder’, published in 2006 in Brazilian Journal of Otorhinolaryngology — causes “dizziness (in the form of vertigo), hearing loss, tinnitus (unreasonable ringing or other noises in one or both ears), changes in body balance, gait disturbances and occasional falls, among others.”

The warning signs of vestibular imbalance

Dr Adhikari enumerates the immediate warning signs for vestibular dysfunction as:

  • dizziness (that could lead to vertigo – sensation of rotation of the body or the environment)
  • giddiness

In severe or chronic cases, the above symptoms are supplemented with:

  • vomiting
  • inability to stand or walk

Physiology of vestibular dysfunction

A physiological examination indicates that degeneration of the components of the inner ear is one of the significant reasons for vestibular dysfunction.

The study – ‘The Aging Vestibular System: Dizziness and Imbalance in the Elderly’ – stated that with every decade, the vestibular hair cell counts decrease.

The hair cells in the semicircular canals of the inner ear degenerate earlier, followed by hair cells in the otolith organs.

Additionally, American Aging Association in 2012 confirmed that ageing brings about degeneration of otoconia, hair cells, loss of vestibular nerves, and cells in the vestibular nuclei.

Dr Adhikari explains that in adults and the elderly population, the degeneration could result in conditions such as “benign paroxysmal positional vertigo (BBPV) (which is caused by shift of debris in the semicircular canals in the inner ear), vestibular neuronitis (caused by infection or inflammation of vestibular nerve in the inner ear) or Meniere’s disease (impairment of membranous labyrinth of the inner ear).”

These conditions soar the chances of dizziness, fall and gait abnormalities.

“Other comorbid conditions that heighten the risk of developing vestibular disorders include sensory (hearing) or visual (seeing) impairments or memory-related issues or uncontrolled diabetes or hypertension or underlying heart disease, or blood pressure (BP),” informs Dr Manjaly.

Vestibular rehabilitation as the treatment

Rao finally visited a vestibular speciality clinic after about a month of experiencing continued dizziness. Confirming Rao’s vertigo, Dr Adhikari from Mangaluru, who was treating her, elaborates, “The first line of treatment for Rao was vestibular rehabilitation exercises along with a few medications. Her condition improved in about three weeks, and she is now moving around independently and with confidence.”

Dr Adhikari, who treats numerous people with vertigo and vestibular dysfunction, states, “Acute vertigo is generally treated with medications. Peripheral vertigo due to BPPV is usually cured with manoeuvres – (preferably Epley manoeuvre, which is a type of canalith repositioning exercise).

“However, other conditions need specific vestibular rehabilitation programme, and it should be conducted in a specialised vertigo clinic where tests such as videonystagmogram (VNG) – a test that measures the reflex-eye movements – aids the doctor in accurate diagnosis.”

Vestibular rehabilitation (VR) is an exercise-based therapy. Neurologists from Korean universities – Dr Byung In Han, Dr Hyun Seok Song and Dr Ji Soo Kim – explain the therapy involves:

  • Repeating head-eye movements with various body postures
  • Reestablishing balance with a reduced support base with various orientations of the head and trunk
  • Training on upper-extremity tasks
  • Repeating the movements that provoke dizziness

Thus, it aims at:

  • Gaze stability and postural stability
  • Improving vertigo and activities of daily living

Psychologically, VR therapy reinforces confidence and reduces anxiety among the elderly, experts opine.

“Adaptation, habituation, substitution, and vestibular compensation (the process of overcoming balance and gait through exercises)” is the rationale behind VR, according to ‘Effects of vestibular rehabilitation in the elderly’, published in Aging Clinical and Experimental Research (2015).

Dr Manjaly advises the elderly to regularly engage in “vestibular rehabilitation exercises” to prevent this condition. “The exercises, as outlined in the charts, will include focusing your gaze on an object as the object is moved to both sides or neck flexion exercises such as looking upwards and downwards,” recommends Dr Manjaly.

However, Dr Manjaly also cautions that these exercises should be based on physician’s guidance. “Those with cervical spondylosis or any other neck-related injury should avoid these exercises,” he reminds.

Commenting on the causes and prevention mechanisms, Dr Adhikari points out, “Strokes are one of the leading causes for eventual development of vestibular dysfunctions. Hence, controlling diabetes and hypertension, being physically active and avoiding smoking could help prevent the condition.”

She also advices, “BPPV, a common form of vertigo in the elderly, can be prevented by avoiding prolonged immobilisation of neck, rough bike rides and severe or rigorous aerobic exercises.”

Regarding diabetes, Dr Manjaly says that these conditions are related to atherosclerosis (inflammation of the arteries due to fatty deposits) or degeneration of nerves.

Controlling diabetes significantly reduces the chances of vestibular dysfunctions. Additionally, regular comprehensive geriatric assessments, which encompass ENT and eye exams, are recommended for elders after 60 years of age and for those with multiple comorbidities.

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