Should you do vestibular exercises after BPPV?

A reader whose BPPV resolved with maneuvers wonders whether there is any benefit or downside to doing other vestibular exercises after BPPV is over, like turning the head left and right while walking or moving the head rapidly up- and downward or diagonally.

Read more: Should you do vestibular exercises after BPPV?

There are many different vestibular exercises that are used for an assortment of balance disorders. The best treatment for BPPV is to remove the particles from the semicircular canals by doing maneuvers.  If this results in a complete resolution of symptoms, then no other exercises are needed.  Moving your head when walking or sitting upright after BPPV is gone will not have any effect on whether positional vertigo will recur.  The only movement to avoid after BPPV is treated is lying flat on your back or placing your head below the horizontal, since this can move particles back into the semicircular canals. 

The head movements our reader described are designed to treat two slightly different conditions.  People who have lost balance function in one or both ears have difficulty stabilizing vision while making head turns, so their vision tends to blur momentarily.  This can be improved by moving the head rhythmically and at varying speeds and angles to gradually train the balance system to predict exactly how far to move the eyes to prevent this blurring.  If you do not have any damage to the inner ears, then these exercises will not really help anything, but will not hurt you either. 

The other situation where these exercises are used is in people who have BPPV that cannot resolve their symptoms with maneuvers.  In general, if you can make yourself dizzy by moving your head, you can also adapt to this dizziness by practicing that movement.  For example, before we had maneuvers to treat BPPV, people were told to sit on the edge of a bed and fall back repeatedly to set off the dizziness.  This worked very gradually to reduce the spells (Cawthorne exercises).  Most of this effect was due to ocasionally shaking some of the particles out of the canals, so it was simply a poor form of today’s maneuvers.  However, if you have consistent dizzy spells brought on by a particular movement that is not due to BPPV or cannot be resolved by maneuvers, you can become accustomed to the dizziness and greatly improve it by repeating the movements that provoke it.  The brain can gradually learn how to use vision to overcome some of this chronic dizziness. 

In general, moving your head while walking can help you relearn balance if you have any ongoing dizziness disorder affecting the ears and is usually included in vestibular therapy. This type of balance treatment is highly effective.   

Help! I fell after bending over

I’ve had plenty of vertigo in the past, but I wasn’t dizzy at all when I fell. I just bent over to pick up a heavy pot, and tipped right over. Sometimes when hiking on hills I’ll lose my balance, and I’ve fallen a couple of times. I’m in my 70’s, is this normal?

Read more: Help! I fell after bending over

Falling never seems normal, but it becomes more common as we age. All parts of our balance systems begin to decline, and gradually it becomes easier to fall. That means you have to take active steps to prevent hurting yourself.

One of the most common balance problems comes from a gradual loss of sensation in the feet and lower legs. The nerves that supply the feet have to stretch from the spine, where the main part of the neuron resides, all the way to the feet. Any problem along this extension can result in a loss of feeling, and this is frequent in older people. Get a cold metal object like a heavy spoon and run it along your fingers; you can easily feel the cold. Now run the same spoon over the bottom and sides of your foot. If you find numb places, or don’t feel the cold as strongly, you are losing sensation in the feet. This can also be tested by placing a vibrator or vibrating tuning fork on your feet and comparing that to your hands. A loss of vibratory sense correlates with a general loss of sensation.

Why would losing sensation in the feet make you more likely to fall? The three components of the balance system are the inner ears (which sense movement of your head in space), your eyes (which can see whether you are upright, moving or tilted), and the feeling in your legs and feet. Even if your inner ears are functioning well, you still need some input from the other two systems.

When you bend over, you can no longer use vision for balance as well. Normally we use the horizon, or vertical objects near us, to measure whether we are stable. If we are still, the horizon stays horizontal and vertical things like trees or walls look upright. If we bend over to look at the ground, we lose that vertical and horizon orientation. It’s much harder for the balance system to detect a bit of tilt in that position.

That forces us to rely upon the feeling in our legs and feet for balance. If I can feel the ground, and tell whether my ankles are bending, then I know I am stable. It doesn’t take much loss of feeling to make this less effective. A little numbness makes you more likely to fall when you bend or focus on the ground instead of the world around you. You also become more likely to fall when in the dark.

Fortunately there is something you can do when this happens. In most people, sensation remains very good in the hands even if they lose some in the feet. By touching something stable like a wall or post, the tendency to tip over when bending forward will be stopped. Using trekking poles in the hands while walking has a similar effect. You will basically be bypassing your numb feet and allowing your hands to feel the ground through the pole, which will restore your balance.