Asks Chris Bowes, Senior Audiologist at the Hallamshire Physiotherapy Clinic.
Julie, a 24-year-old woman, presented at the clinic the diagnosis of labyrinthitis caused by infection her inner ear. Her symptoms were vertigo, disorientation whilst in the supermarket and nausea caused by eye movements such as crossing the road, watching TV or reading. She was unable to work or go out socially due to the symptoms and increasing stress levels. The initial assessment confirmed visual vertigo symptoms.
Visual vertigo was defined by Professor Bronstein in 1995 as being a ‘syndrome where symptoms are triggered or exacerbated in situations involving rich visual conflict or intense visual stimulation. The main reason why this occurs is a sensory conflict ormismatch between the visual, vestibular and musculoskeletal systems. It is thought that there is a possible discrepancy between what the person expected and the external information received. This results in an overdependence on vision to maintain balance and symptoms persist.
There are a number of causes of visual vertigo/motion sensitivity symptoms:
- Benign paroxysmal positional vertigo (BPPV)
- Vestibular neuritis
- Meniere’s Disease
- Migraine related vertigo
- Head injury
- Post-concussive and cervicogenic dizziness/whiplash associated dizziness, just to name a few.
Rehabilitation of this complex condition requires a clear diagnosis and a comprehensive explanation to the patient so they can start the process of recovery. This places the patient at the centre of the rehabilitation process and encourages them to challenge their symptoms in a graded manner. Fear and stress are common symptoms with many causes of loss of balance and can further exacerbate the symptoms. This is normal.
Julie made a good recovery with a graded exercise programme and slowly started to return to normal. Full recovery was achieved within four weeks. Most people recover quickly with the correct rehabilitation and this is dependent on the expertise of the rehabilitation team.
The Sheffield Balance and Vertigo team has the experience, skills and commitment to successfully treat your vertigo. Please ring the clinic to speak to a member of staff or make an appointment.
Further information about Visual Vertigo:
Visual Vertigo – Vestibular Rehabilitation
What is visual vertigo? Visual vertigo was defined by Professor Bronstein in 1995 as being a ‘syndrome where symptoms are triggered or exacerbated in situations involving rich visual conflict or intense visual stimulation.
What causes visual vertigo? The symptoms may develop a few days or weeks following an acute peripheral vestibular (inner ear, balance organ) disorder. Which would be experienced as a spinning dizziness also known as rotatory vertigo. Visual problems may also cause visual vertigo or reduced sensory information from the body’s skin, ligaments muscles, tendons or joints. Patients with a vestibular disorder and who develop a visual dependence are more likely to develop visual vertigo.
There are two main reasons as to why visual vertigo and motion sensitivity occur;
Motion sensitivity and visual vertigo are due to a sensory conflict or mismatch between the visual, vestibular and somatosensory systems. It is thought that there is a possible discrepancy between what the person expected and the external information received.
The combination of a vestibular disorder and subsequent visual dependence is what causes visual vertigo.
Both result in visual/motion sensitivity, both result from being over reliant on visual information and a mismatch of information in balance system.
There are a number of causes of visual vertigo/motion sensitivity symptoms: Benign paroxysmal positional vertigo (BPPV), labyrinthitis, vestibular neuritis, Meniere’s Disease, migraine related vertigo, head injury, post-concussive, and cervicogenic dizziness/ whiplash associated dizziness, just to name a few.
If I have visual vertigo what am I likely to experience? symptoms of visual vertigo include tiredness, nausea, imbalance, vertigo and disorientation. Visual vertigo can also lead to exacerbation of psychological disorders, stress, anxiety, hyperventilation and panic attacks. Symptoms can be provoked by moving traffic, travelling in a car, boat, plane, lift or escalator, or motion of the visual surroundings. Examples of movement in your surroundings or moving visual objects include; – scrolling on a PC or tablet, running water, crowds, traffic, clouds, trees, leaves or trees blowing in the wind or watching TV or a motion picture. Patterns, such as stripy shirts or wallpaper, railings or the light flickering through the trees.
How is visual vertigo diagnosed? The most important diagnostic tool is the patient history and the symptoms explained to the specialist. To confirm a diagnosis, questionnaires are often used which assess space and motion discomfort, particularly experienced in vestibular patients.
The Situational Characteristics Questionnaire (SCQ), Dizziness Handicap Inventory (DHI) and the Motion Sensitivity Quotient (MSQ) are the most frequently used tools in the diagnosis of motion sensitivity. An examination of your eye movements and other vestibular function tests can be performed to rule out central or peripheral vestibular pathology. The Clinical Test for Sensory Interaction and Balance (CTSIB) is a very important assessment tool to assess the sensory information which is received from the balance organs, visual system and information from your body which keeps our balance.
Why has my dizziness not improved? Often when a person has dizziness or a balance problem they naturally start to avoid certain movements that make them feel worse. Avoidance behaviour leads to maladaptive behaviour which is used to further prevent vertigo symptoms.
Why do something that makes you feel more dizzy or ill?
Recovery cannot occur if movements are avoided. The brain cannot learn or compensate
from the changed information from your eye, balance organs or the body. If the brain does
not sense dizziness then it does not realise something is wrong and cannot begin
compensation (i.e it cannot learn to adjust to the new information).
How is visual vertigo treated? Treatment for visual vertigo involves customised vestibular rehabilitation as well as educating the patient about compensation strategies. The three strategies used are Adaptation, Compensation and Habituation.
The balance organs in both ears normally work together. If one side stops working effectively there becomes in imbalance of information often causing a rotatory vertigo. e.g. after a vertigo attack the patient might veer off to one side when walking. The brain needs to adapt to new information and adjust the balance system to these changes. Customised exercises are used to provide the brain with the information it needs to make these changes.
There is a memory bank in your brain which stores information from your eyes, body and balance organs. If there has been an upset within the balance system, the memory bank losses information. Balance retraining exercises help to restore this information with new information which strengthens the balance system, thus reducing your vertigo and improving your balance.
Continually repeating the actions that bring on the symptoms of dizziness or vertigo will eventually accustom the body to those actions and strengthen neural pathways.
Exercises are selected by identifying the motions and positions that provoke symptoms. Over time, with repeated motions, the vertigo symptoms reduce and therefore further exercises can be introduced. Studies have shown that patients suffering from motion sensitivity benefit from optokinetic stimulation (OKS). We are able to provide you with a DVD containing video clips of moving black and white stripes and a rotating disk for use on your P/C, laptop or DVD player. We also have virtual reality equipment which is used to reduce visual-vestibular conflict. As compensation occurs, the patient moves from a visual dependent postural control to a more proprioceptive postural control with use of vestibule-proprioceptive cues.
Arshad Q, Patel M, Goga U,et al.Arshad Q, Patel M, Goga U, Nigmatullina Y, Bronstein AM, 2015, Role of handedness-related vestibular cortical dominance upon the vestibular-ocular reflex, Journal of Neurology, Vol:262, ISSN:0340-5354, Pages:1069-1071
Bronstein AM. The visual vertigo syndrome. Acta Otolaryngol.1995;520:45-48.
Bronstein AM. Vision and Vertigo: Some visual aspects of vestibular disorders. J Neurol. 2004;251:381-387.
Bronstein AM, Patel M, Arshad Q, 2015, A brief review of the clinical anatomy of the vestibular-ocular connections-how much do we know?, Eye, Vol:29, ISSN:0950-222X, Pages:163-170.
Guerraz M, Yardley L, Berthon P, et al. Visual vertigo: symptom assessment, special orientation and postural control. Brain. 2001;124:1646-1656.
Herdman SJ. Vestibular Rehabilitation. 3rd Ed. Philadelphia: FA Davis Company; 2007.
Pavlou M, Davies RA, Bronstein AM. The assessment of increased sensitivity to visual stimuli in patients with chronic dizziness. J Vestib Res. 2006; 16(4-5): 223-31.
Pavlou M, et al. The effect of repeated visual motion stimuli on visual dependence and postural control in normal subjects. Gait Posture. 2011 Jan; 33(1):113-118.
Sawle G. Visual vertigo. The Lancet. 1996;347:986-987
Smith-Wheelock M, Shepard NT, Telian SA. Physical therapy program for vestibular rehabilitation. American J Otolog. 1991; 12(3):218-225.