Male patient holding his head needing vestibular therapy.

Vestibular Therapy: Restoring Balance in the Injured Employee

By Michael Morgan PT, DPT, OCS | 12/24/2019

No Value.Dysfunctions of the vestibular system can be involved in workers' compensation claims, either as the cause or a result of a workplace injury, and yet, most people outside medicine would be hard-pressed to say with any confidence what the vestibular system is.

Here is a clue. Workforces at risk of head trauma (from falls from heights, for example) or workforces with a significant number of employees over age 40 are more likely to experience vestibular dysfunction and the need for vestibular therapy.

I serve as Concentra's associate director of therapy operations in the Arizona market and as physical therapy director in Concentra's Peoria, Arizona clinic (14155 N. 83rd Avenue). In the first three quarters of 2019, Concentra clinics in the Arizona market treated about 2,000 injuries to the head and face and 800 injuries of the cervical spine, representing nine percent and four percent, respectively, of total injuries treated by Concentra in Arizona. A portion of these injuries involves vestibular system deficits.

So, what is the vestibular system anyway?

The vestibular system is a sensory system we all have. It provides the brain with information about motion, head position, and spatial orientation. It helps with balance, stabilizes the head when the body is in motion, and helps maintain posture. The vestibular system is comprised of several structures and tracts, but the main components are found in the inner ear in a system of interconnected compartments called the vestibular labyrinth.

Prevalence and Incidence of Vestibular Disorders

The non-profit organization Vestibular Disorders of America (VeDA) states that, in the general population, as many as 35 percent of Americans over age 40 and 80 percent of people over age 65 will have a vestibular disorder at some point in life; for some, the disorder may become chronic. The VeDA website discusses 26 different types of vestibular problems, but in this article, I will focus on the occupational health aspects of one vestibular disorder, benign paroxysmal positional vertigo (BPPV). BPPV is reported in about 28 percent of people with head trauma. Besides being the most common vestibular disorder, BPPV also is the best understood. In the workplace, motor vehicle accidents, falls, and assault/direct blows to the head can cause vertigo symptoms, which may be diagnosed as BPPV.

Understanding Benign Paroxysmal Positional Vertigo (BPPV)

Inside the inner ear, the tiny vestibular labyrinth includes three loop-shaped structures (semicircular canals) that contain fluid and fine, hair-like sensors that monitor the rotation of the head.

Other structures (otolith organs) in the inner ear monitor movements of the head — up and down, right and left, back and forth — and the head's position related to gravity. These otolith organs contain crystals that make the vestibular system sensitive to gravity. When these crystals become dislodged due to trauma, they can move into one of the semicircular canals where they do not belong. This causes the semicircular canal to become sensitive to head position changes it would normally not respond to, which in turn causes episodes of vertigo (dizziness).  While these episodes of vertigo may be temporary or intermittent, they can be extremely debilitating and cause significant loss of function and pose safety concerns.

Concentra® provides treatment for BPPV through vestibular therapy, a type of physical therapy. Before we turn to an explanation of how vestibular therapy helps, let's consider an actual employee encounter pulled from Concentra's workers' compensation case files.

Corrections Officer Takes a Blow to the Head

A corrections officer from a local correctional facility came into a Concentra medical center. He had been struck in the head by one inmate's elbow when breaking up a fight. As the adrenaline from the situation wore off, he reported pain where he had been hit in the head. He also had an intense sensation of spinning when he went to lie down at the facility. The employee went to the emergency department, where he was given a CT scan, which read normal.  He was released and went home for the night, with instructions from his employer to return to Concentra the next morning.

Upon arrival at Concentra the next morning, the employee had a black eye and localized soreness in the orbital and temporal areas of his head (at the eyes and the temples, respectively).  He said he was continuing to have episodes of an intense spinning sensation when he reclined or got up from lying down, but he had no history of vertigo. The physician determined the symptoms were consistent with positional vertigo, which could be treated immediately in the therapy department right at the center.  The corrections officer was surprised to learn therapy could help and was eager to begin.

The physician introduced the officer to the therapist, and treatment began right away. The therapist performed a vestibular evaluation, a neurological evaluation, and what is called the Dix-Hallpike test to confirm a diagnosis of BPPV.

The Dix-Hallpike test involves bringing the person from a sitting position to a supine position (laying down) quickly with the head turned 45 degrees to one side (the side of the involved ear that made the officer dizzy and produced nystagmus, or the shaking of his eyes that his spouse had noticed that morning). The therapist explained BPPV to the officer and how it could be treated through a repositioning maneuver in the clinic.

The therapist performed a repositioning treatment technique called the Epley's maneuver with the officer. This technique takes the patient through several position changes on the treatment table with the intent of restoring the normal resting position of the inner ear. This was followed by another Dix-Hallpike test.

When the therapist did the second test, the corrections officer was amazed. He no longer felt dizzy. He was also pleased the therapist educated him about head and eye exercises to perform at home to restore his vestibular system, as well as positions to avoid.

Two days later, the officer returned to therapy to report he had no more episodes of dizziness. He found the head and eye exercises the therapist had given him to be "super easy" after overcoming some initial nausea. The therapist conducted another Dix-Hallpike test, which showed him symptom-free. Next, the therapist had the officer perform work simulation involving multiple positions, all possible vertigo triggers. Still symptom-free, the officer paid a visit to the treating physician and was released to return to duty.*

How Vestibular Therapy Works

As we saw in the corrections officer's case, BPPV is diagnosed through physical and neurological examination and positional testing. The most common positional tests are the Dix-Hallpike test, as in the corrections officer's case, and the Supine Roll test. During the diagnostic testing and treatment procedures, the therapist monitors the patient’s eye movement for nystagmus, which is an involuntary, rapid, and repetitive movement of the eyes — either horizontally (side-to-side), vertically (up and down), or rotary (circular). These positional tests help the therapist confirm a BPPV diagnosis and determine which semicircular canal of the inner ear is involved.

Treatment in the clinic makes use of what is called canalith repositioning procedures (the Epley maneuver in the corrections officer's example). These procedures consist of several simple and slow maneuvers where the therapist will change the position of the patient's head in relationship to gravity. The goal is to move particles from the fluid-filled semicircular canals of the inner ear into a tiny bag-like open area (vestibule) which houses the otolith organs in the ear where these particles are resorbed.

Traumatic BPPV typically requires more therapy sessions of repositioning maneuvers than BPPV cases unrelated to head trauma, according to research studies. Numerous studies show the success rate for repositioning maneuvers is in the 90 percent range.

Conclusion

A review of workplace injuries involving dizziness on the Occupational Safety and Health Administration (OSHA) website demonstrates the wide range of industries and occupations that can encounter vestibular problems. The reports include employees from construction, manufacturing, agriculture, utilities, service industries, plumbers, pipe fitters, forestry employees, and more.

Concentra excels in occupational injury care, and our clinicians have the specialized knowledge in vestibular therapy needed to treat your employees who experience head trauma and dizziness.

Find a Concentra medical center near you.

*Results like this positive outcome are always Concentra’s goal, but are not promised for, or indicative of, every patient’s experience.

NOTES:

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