Can other symptoms be related to vestibular issues?

Disclaimer: During our Dizziness Can Be Stubborn webinar, many inquirers asked for specific treatment recommendations for their particular scenario. Please be advised that as per our College regulations, I am not permitted to provide treatment advice for an individual’s symptoms without performing an assessment. Hopefully my more general responses will help answer your questions, but the best approach is to discuss your particular symptoms with your Doctor and Vestibular Therapist.

Can my other symptoms contribute to vestibular issues?

Q: Does tinnitus (ringing in the ears) contribute to dizziness / vestibular issues?

A: There are numerous conditions that can cause both dizziness and hearing issues, but tinnitus in and of itself does not cause vestibular problems. Vestibular Rehabilitation does not treat tinnitus. If your tinnitus seems to be influenced by your neck or jaw, then regular orthopedic physiotherapy on those areas may be helpful, but not vestibular rehabilitation. Otherwise, look for an audiologist who specializes in tinnitus management.

Q: My Lifemark Physiotherapist was a wonderful resource when I suffered initial hearing loss/vertigo and determined I had labyrinthitis. I am wondering if my vision issues are common - fatigued eyes when reading or as passenger in vehicle for long period of time. Also, I am sensitive to glare from sun or reflections from the snow on a sunny day.

A: With one inner ear not working as well as the other, your brain will be making the eye muscles work harder. This keeps the eyes stable and helps control them such that you can stay focused when the head is in motion. This can give people a feeling of eye strain/fatigue but this usually goes away over time as the system resets those ear-to-eye reflexes. In general, people with vestibular issues are more sensitive to visual stimulation, particularly those with vestibular migraine.

Q: I had my first really bad vertigo attack where I was paralyzed from the neck down. In fact, I needed to be taken to hospital by ambulance 15 years ago. I still get vertigo at least every few months. I know the exercise to do but still need my meds that the doctor ordered at that time.  Is this common? 

A: Nothing related to the vestibular system could give paralysis, so that must have been from something else at the time. Some of the more common culprits for episodic vertigo, as discussed in the webinar, would be vestibular migraine, Meniere’s disease, or if someone had frequent reoccurrences of BPPV.

Q: Do you have to have symptoms when you see the therapist? Often you can't get to rehab quick enough while the symptoms are really bad.

A: This is a great question. It’s often easier to figure out what’s going on if you’re still a bit symptomatic, but sometimes with episodic conditions, even if you are between spells, we can hone in on the problem by getting a very detailed description of your events. Between that and seeing what is and isn’t present during our testing, we can narrow it down even further and provide guidance.

Plus, once your full assessment is done, you’ll have an easier time getting an appointment on short notice because we don’t need as much time. Your therapist may also tell you to contact them directly if you get another spell so that they can figure out how to slip you into their schedule for even just a brief check with the goggles while you’re symptomatic to see if it aligns with what they’re suspecting.

The relationship between vestibular disorders and other conditions

There is no relationship between macular degeneration and vestibular disorders. Although, if you have a vestibular problem, you’re going to be more reliant on your visual information so anything that affects vision can increase your symptoms a little.

There is no specific correlation between dementia and dizziness. If a person with dementia has a vestibular problem, the rehab would still be expected to be successful, however they would likely need guidance on their exercises so that they’re done correctly.

Q: How do you manage dizziness when it is caused by anxiety? 

A: If it is entirely caused by anxiety, then the treatment would involve addressing the anxiety – so counselling +/- medication, lifestyle changes like exercise, meditation, mindfulness, etc. I think it is far more common for the dizziness to come first from whatever condition, vestibular or otherwise, and that spawns the anxiety, so making sure there isn’t some underlying medical condition that can produce dizziness would be important.

Q: Can an increase in blood pressure aggravate a feeling of internal dizziness and does this affect your vision, mental acuity, and balance? 

A: Yes, blood pressure problems can provoke these sorts of symptoms, other than perhaps the balance part, and the treatment would be medical management, not vestibular rehabilitation.

Q: What about multiple sclerosis (MS)? If I do the exercises at first will my brain learn them and then I will never be dizzy again? As I'm listening though perhaps relapsing MS means that the dizziness will come back?

A: You bring up a good point. Vestibular rehabilitation works best for stable losses/changes. If your MS is affecting the transmission of vestibular information to or within the brain and you do a good job teaching your brain to compensate for that with rehab, but then your MS fluctuates, you might have to teach the brain to compensate all over again because you have a new level of nerve transmission.

Q: A few people asked about middle ear issues, like Eustachian tube problems or ruptured eardrums, and resulting symptoms of disequilibrium, pressure, tinnitus and other auditory changes.

A: Vestibular rehabilitation does not deal with middle ear issues. For this you would want to see an Ear, Nose, Throat (ENT) Specialist or Neuro-otologist. There are a few middle ear conditions that can end up influencing the inner ear, which is what is going to start giving unsteadiness or dizziness for which vestibular rehabilitation could have a role to play, but the middle ear issue would still need to be addressed.   

Ear wax is an outer ear issue that would not cause vestibular problems and should be managed by your Doctor or Audiologist, NOT by alternative therapies like ear candling, etc. 

While I’m on the topic, please note that if your Doctor looks into your ear with their otoscope and says it looks fine, that is just the outer ear and eardrum they’re talking about and nothing to do with what may or may not be going on in your inner ear!

Q: Is there any correlation between dizziness and transient ischemic attacks (TIAs)?

A: There sure can be! If the inner ear(s) or the areas of the brain that process their information are briefly deprived of blood-flow, dizziness could certainly result. The inner ears are particularly sensitive to decreases in blood-flow because they only have one tiny little artery that supplies them and no others in the area that can help out if that one is compromised.  

Q: I had shingles in my right ear and now have balance problems. Can this ever be corrected?

A: If the shingles left behind some damage to the vestibular nerve, vestibular rehabilitation should work just as well for that as for any other condition that leaves you with the ears telling the brain two different things. I think you would be a very good candidate for vestibular rehabilitation, but remember, it doesn’t ‘fix’ the damage, but rather teaches your brain to compensate for it so that it becomes less of a problem.

Vestibular disorders and medications

Many people asked about medications, in particular Betahistine (Serc). As a physiotherapist, medication comments are outside my scope, however I can say that while commonly prescribed, is controversial as to whether or not it is actually effective. It seems that there may be a role for it for reducing symptoms during acute events like the first day or two of an inner ear infection or a Meniere’s attack.  Beyond that, the evidence is scarce and many specialists actually feel that it may interfere with long-term compensation.

There were also questions about the kinds of medication useful for the “hyper-vigilance” condition I described (which was 3PD or Persistent Postural Perceptual Dizziness).  SSRIs and SNRIs at low doses are often helpful.

Q: How would you know that the imbalance is due to a drug you are taking, and not related to a vestibular problem?

A: Generally, medication-related dizziness is more vague or generalized, and doesn’t fluctuate or increase/decrease with certain head movements or position changes like vestibular dizziness tends to.

To learn more about vestibular rehabilitation, check out our services page. If you’re interested in booking an assessment with a vestibular therapist, you can do so online or find a clinic near you.