An uncompensated vestibulopathy is a term used to describe your symptoms, rather than the exact cause of your problem. It is similar to describing shoulder pain as a subacromial impingement. This tells us that you have shoulder pain with overhead movements, but it doesn’t yet explain why you have shoulder pain.

With vestibulopathy, the symptoms include dizziness, difficulty moving through busy environments, challenges walking on uneven ground, or unsteadiness in the dark. Everyday activities—like looking side to side in supermarket aisles, watching a moving ball in sports, or reading road signs from a moving car—can all increase dizziness and make daily life harder.

The good news is that vestibular rehabilitation can help. With the right exercises, you can retrain your balance system, reduce dizziness, and learn new strategies to keep your vision and balance steady in everyday life.

Your vestibular apparatus is like your body’s gyroscope. You have one on each side that communicates with your brain to enable balanced, smooth, coordinated movement by interpreting head and body position in space and changes in velocity.  Your vestibular apparatus are snugly embedded in your temporal bones. Your temporal bones are part of your skull, in your hairline above and around your ear. You may have heard the phrase “temporal headache” to describe pain in this area. Deeper within the bone, tucked into its special compartment or vestibule, sits your vestibular apparatus.

The hard bony labyrinth protects the soft membranous labyrinth, in the same way as the skull protects the brain. The bony labyrinth is filled with perilymphatic fluid that has a similar composition to cerebrospinal fluid. In contrast, the membranous labyrinth is filled with endolymph, with a similar composition to intracellular fluid. These different recipes of fluid result in different viscosities, which is important for the functioning of your gyroscopes.

You have five organs that sense movement and body position on each side, three semicircular canals (SCC) and two otoliths. These organs communicate with your brain via your vestibulocochlear nerve, CN VIII.

Balance is dependent on your eyes, body and ears, like a tripod. How the brain interprets the sensory information it receives from sight, proprioception and the vestibular apparatus determines if you can pirouette, land steady from a back flip or navigate the supermarket aisles without bumping into other customers.

Your semicircular canals detect changes in velocity. These three canals are at right angles to one another and communicate with the opposing SCC of the opposite side. That means your right posterior SCC communicates with your left anterior SCC. They can be described as the x,y and z axes of a 3D graph.

The otoliths detect changes in linear acceleration and gravity. Your utricle relays the change of linear speed, like the movement in a car. While your saccule detects gravitational change in an elevator.

Nerve impulses are generated when hair cells, stereocilia, at the base of the semicircular canal or otolith, the ampulla, are deflected because of the movement of endolymph, almost like seaweed in a current. This movement of the endolymph bends or deflects the stereocilia. This movement causes mechano-sensitive ion channels to open in the hair cell membrane. Potassium, from the potassium-rich endolymph, flows through these channels and changes the electrical potential. When the membrane’s electric potential changes the firing rate of the nerve cells also changes. This means more or fewer messages are sent to your brain to interpret the change in orientation or velocity.

You have experienced this in the real world: once you have reached a steady speed, in a car, plane or elevator, the deflection of hair cells stops, therefor you are not aware of the movement anymore, only when the speed of travel changes again will you notice it again.

For you to maintain a steady, safe position, while still or moving, your brain in continuously interpreting information from these sensory organs to create a spatial map. Your vestibular nerve has a resting discharge rate of 90 action potentials per minute, all day everyday, just like your heart your vestibular system is never offline. When you move your vestibular system relays this information. If you are dancing and turn to your right, your right vestibular nerve will be stimulated, while your left vestibular nerve is inhibited. This information makes sense to your brain as your visual field changes.

If something happend to affect any part of your vestibular organs or nerves, the acute asymmetry in vestibulocochlear tone is interpreted by your brain as vertigo.

• Vestibular Neuritis
• Meniere’s Disease
• Vestibular Migraine
• Ramsay Hunt Syndrome
• Ototoxic medication (gentamicin)
• Neurogenerative conditions (cerebellar ataxia, CANVAS)
• Auto immune disease (Cogan’s syndrome, Lupus, Sarcoidosis)
• Vascualar Disease (hypertension, aterosclerosis, stroke)
• Trauma, through injury like Labyrinthine concussion, or ablative surgical treatment.

All uncompensated vestibulopathy is scary, frustrating and debilitating. People tend to be patient and sympathise with injuries they can see and understand. Because vertigo is poorly understood by anyone who hasn’t experienced it themselves, it will be difficult to explain to family and colleagues what you are going through. The fact that uncompensated vestibulopathy symptoms may fluctuate also confuses people who expect all recovery to be linear.

Chronic unilateral uncompensated vestibulopahty

If you have been living with your symptoms for three months, we expect some form of compensation to have occurred by means of neural plasticity. You may only be experiencing symptoms in really busy environments, places you don’t know or when you decompensate, like after a cold, poor night’s sleep or period of stress. This doesn’t mean that it is less scary to deal with, but you may be functioning better that someone who is experiencing new onset symptoms.

Acute unilateral uncompensated vestibulopathy

During the first few days to three months, the “new” difference in vestibular tone will cause a lot of confusion in your brain. Dizziness will be severe, you may feel nauseas every waking moment and vomit frequently. The slightest mismatch with movement will cause vertigo and you may opt to stop moving all together. It may feel better, but it won’t help you in the long run. Anti-emetic medication can help your nausea, but don’t fall in the trap of taking motion sickness medication all the time. This prevents your brain from figuring it out. Not knowing what is going on and feeling anxious can make this feel worse.

Bilateral vestibulopathy

If both vestibular apparatus are affected, because of ototoxic medication or injury, you will rely completely on other strategies, like your vision. So walking in the dark will feel impossible. Depending on the cause and extent of the damage to your vestibular apparatus, this will be the most debilitating and take the longest to make progress.

Our physiotherapists can identify if any central pathology is causing your symptoms, with visual and balance screening. Or is your vertigo caused by a different structure within the vestibular apparatus?

We make use of a bedside evaluation, which means all tests are done in the consultation room by your therapist or yourself. The experience of your physiotherapist is important to understand your history, vertigo type, duration of attacks, and what aggravates your vertigo.

We understand the physiological stages you’ll go through, and custom-fit your treatment program. Our physiotherapists can guide you so that you understand what you are experiencing and are able to make responsible decisions about your care.

Audiogram testing is necessary if you have noticed any hearing loss. Although vestibulopathy is not characterised with hearing loss, it may be necessary to rule out other pathology, like Meniere’s Disease or a vestibular schwannoma.

Your physiotherapist can refer you to an audiologist for your hearing test.

Electronystagmography (ENG) is a specialised audiology tests that identifies functional problems with the vestibular system by measuring eye movement with vestibular stimulation, by moving your eyes, head or a caloric test. This can determine the exact vestibular organ affected and the extent of the dyscrepancy between the left and right vestibular apparatus.

Your physio will refer you if necessary.

An MRI scan can be used to rule out any other pathology, like a space-occupying vestibular schwannoma. This image can only be ordered by your specialist and is not needed to confirm vestibulopathy.

Your brain is sensitive to sensory mismatch. When the messages from your body’s proprioception, eyes and ears are different, the result is dizziness. This is a fantastic strategy to keep you safe, during the acute phase of your recovery.

Your brain has the amazing capacity for healing and creating new pathways with neural plasticity, it won’t “waste time”. It will force the quickest compensation that keeps you safe. You may cope well with “easy” single focus tasks, like walking down your hallway. But you may have difficulty with tasks that require multi-sensory integration, like walking down the aisle of the grocery store, with the announcements blasting, other shoppers and the list of what you need. You need to retrain this integration we all take for granted with adaptation and habituation exercises.

With rehabilitation, we can ensure compensation and habituation that is functional and lasts. Waiting to long may mean we need to unlearn bad strategies before we relearn compensation. Don’t waste time, get the help you need.

• Waiting too long

The biggest risk with chronic vertigo symptoms is developing persistent postural perceptual dizziness (PPPD). PPPD/3PD is a chronic condition causing constant dizziness of varying intensity, usually first triggered by an intense attack. It is worsened by movement, such as being in a car, and perceiving your surroundings as moving when they are not.

• Misdiagnosis

Many people are diagnosed with BPPV as the cause of their dizziness, when it is not.

• Misconceptions about treatment

When patients are wrongly diagnosed with BPPV, they expect a quick fix with a repositioning manoeuvre. Rehabilitation takes time and effort. No recovery is linear; there will be bad days, and you may feel frustrated and afraid. Nothing worthwhile is easy; be patient and put in the work.

• Misuse of vestibular suppressant medication

Taking motion sickness medication for prolonged periods of time can suppress any type of compensation from occurring.

Our priority is to determine the extent of your disability and your risk of falling. Vestibular rehabilitation is then aimed at addressing your unique situation and challenges. Your rehabilitation program will be custom designed to challenge and condition you. Adaptation and habituation exercises reduce dizziness, by improving visual acuity during head movements, improves postural stability and reduces your risk of falling. Balance training and a progressive walking program aids in your dynamic stability and confidence when moving in real life situations. This gives your brain and body more strategies to adapt to your environment by encouraging the correct the compensation.

The aim with vestibular rehabilitation is to change your uncompensated vestibulopathy to a compensated vestibulopathy. This means that you have learned new strategies where your brain can interpret the information it is receiving from your sensory environment and supply you with effective ways to maintain your visual focus and balance.

The current clinical guidelines recommend, from strong research evidence, that patients with unilateral vestibular hypofunction receive supervised rehabilitation three times/day for 12 minutes during the acute to subacute phase (onset – 3 months) and three-five times/day for 20 minutes once symptoms have been present for 3 months or more. Timely intervention is therefor important.

Patients with bilateral vestibular hypofunction are recommended to do their exercises three-five times/day for 20-40 minutes for seven weeks.

The guidelines prescribe continuing with vestibular rehabilitation until your goals are met, symptoms resolved or a plateau is reached.

Everyone has a unique situation and set of goals, we aim to get you safer and feeling better in the quickest time possible.

• An audiologist can fit suitable hearing aids if your hearing is affected.
• A General Practitioner can prescribe anti emetics/vestibular suppressants for symptom relief. This is only recommended in the acute/sub acute stage (onset-3 months), as continuous use can delay compensation and cause prolonged symptoms.
• A psychologist may assist you with implementing cognitive behavioural therapy (CBT) into your lifestyle.
• Neuro optometry evaluation may be needed if you have suffered from a traumatic injury.

Surgical intervention will be dependant on the unique cause of your vestibulopathy. When your symptoms cannot be controlled by lifestyle modification, oral medication or vestibular rehabilitation, a surgical or ablative approach can be considered.  The goal of ablative surgery is to convert a fluctuating deficit into a stable deficit, by destroying the remaining cells. Functionally your rehabilitation will be aimed at compensating strategies as the vestibular system is not functioning anymore.

• Cerebrovascular Accident (CVA/stroke)

Acute onset dizziness lasting 24 hours or more needs to be screened for central origin which may potentially be life threatening. PICA/AICA strokes pre dome may be new onset dizziness. If you have vascular risk factors, like hypertension or aterosclerosis, see your doctor.

• Meniere’s disease

This condition causes vertigo, intense attacks that last for minutes to hours, hearing loss, ear fullness and tinnitus.

• Pharmacological interaction

Many medications can cause dizziness due to the effect on your blood pressure or heart rate, make sure to have your list of chronic medications for your health care provider.

• Labyrinthine concussion

Vertigo caused by a traumatic injury, like a fall or accident, can last hours to days

• Postural Orthostatic Tachycardia Syndrome (POTS)

An increase in resting heart rate of 30 beats per minute on standing can cause dizziness, fatigue, lightheadedness and palpitations.

• Vestibular loss
• Unilateral vestibular hypofunction (UVH)
• Bilateral vestibular hypofunction (BVH)
• Vestibular impairment