How NOT To Do Vestibular Rehab

Devon Konrad has been a practicing vestibular physiotherapist for 14 years. In that time, she has worked with many people with vestibular deficits who were given misleading, confusing or just poor advice in how to deal with their symptoms. In this blog, Devon highlights her biggest pet peeves in the world of vestibular rehab.

There’s a certain level of anger I experience when I walk into a new vestibular assessment and I can already feel the client’s walls are up. I then often learn that the person sitting in front of me has been through 1, 2 or more “vestibular therapists” who didn’t help or made things worse. They often come into this appointment with a lot of hesitation and reluctance, expecting the same treatment they’ve had in the past.

Here’s the problem: there is no official accreditation in Canada to call yourself a “Vestibular Therapist”. Anyone can say they are a vestibular therapist, no matter how many (or how few) courses they take or how much mentoring they have received. As a result, Canada is filled with people who highlight “vestibular rehabilitation” as a specialty without actually having the knowledge or expertise to do so.

Balance and Dizziness Canada is trying to change that. They have a list of curated professionals from across the country - physiotherapists, audiologists, occupational therapists - who have taken the gold standard courses in their field. If you are looking for someone who has expertise in vestibular conditions and vestibular rehabilitation, this is a great place to find them.

Until we have a system of accreditation, this will continue to be a problem. So this blog is for all the people out there in the vestibular rehab world, either as patients or practitioners - a What Not To Do, of sorts.

How NOT To Do Vestibular Rehab

1. Keep pushing through symptoms, no matter what

One of my biggest pet peeves is when people have been told they just need to keep pushing and ignore their symptoms; that their symptoms will decrease eventually as long as they just keep pushing.

This. Doesn’t. Work.

Not only does this often put people in a state of perpetual symptoms, it often drives anxiety. And while we don’t have the research yet to implicate poor treatment approaches in developing chronic forms of dizziness, we do know that about about a quarter of people with vestibular deficits go on to develop Persistent Postural-Perceptual Dizziness (PPPD). We also know there is a massive link between anxiety and developing PPPD.

By pushing people into a state of constant symptoms with no locus of control around those symptoms, I argue this is setting people up for longer term problems. Which leads me to my next point…

2. Not learning how to reduce symptoms

When I’m working with someone who has “failed” vestibular rehab, I’ll pick a task that I know will slightly increase their symptoms and then ask them to settle their symptoms.

More often than not, they look at me like I have three heads. Here’s the response I often get: “I don’t know how to settle them! If I knew that, I wouldn’t be here!”

Let me be clear: I’m very good at making people feel dizzy. But my job is to make them feel better and I cannot do that if I’m not teaching them HOW to feel better.

With vestibular rehab, we definitely want to introduce exercises that increase symptoms. You cannot drive the brain changes needed to feel better if you aren’t challenging the brain! But I’d argue it’s even more important for people to learn how to settle these symptoms after increasing them.

Here’s my cues in how to “ground out” and settle symptoms:

• I want the person to look at something they are sure is not moving. This could be a light switch, the corner of a table, a lamp shade. Something inoffensive and stable. NOT the curtains, the dog or another human - those things cannot be trusted.

• Next, I want the person to really feel their feet. I want them in a wide base of support and paying attention to what their feet are telling them. Some people like to weight shift, some people don’t - it’s whatever feels right for them.

• Then, the biggest one - I want slow, deep breaths. The vestibular system and the autonomic system are highly intertwined: when dizziness starts, so does the fight-or-flight response. Breathing cues to the parasympathetic system to bring balance back to the autonomic nervous system, bringing symptoms down.

• Finally, I don’t allow people to add more touch points while they recover (unless they’re a falls risk or safety risk - then, by all means, please sit!). If the exercise was done in sitting, they can keep sitting while settling their symptoms. If they were standing, they do not get to lean on a door frame or touch the counter for support. Their brains need to learn how to settle their symptoms without this additional touch point.

I give people about 5 minutes to settle their symptoms in this way. After that, I let them do what they’d like to get their symptoms under control - sit down, lie down, close their eyes, get some fresh air: whatever it is for them.

A good vestibular exercise should stimulate their symptoms enough to be uncomfortable and be able to get back to their pre-stimulated levels of symptoms within 5 minutes. If there’s no symptoms at all, we need to make it harder. If symptoms are taking way longer than this to settle, the exercise is too hard.

Whether they are doing their exercises in the clinic or at home, I drill into them that this “settling piece” is a non-negotiable piece of their rehab. They need to develop a locus of control around their symptoms and have strategies to get those symptoms down. In my opinion, this is the number one goal of vestibular rehab.

3. Not teaching people why things trigger them

A Triangle of Balance captured in the wild!

In my clinic, you’ll see a lot of triangles written on white boards with “vision”, “vestibular”, and “touch & proprioception” written on them. This is because we spend so much time teaching people about how their vestibular system works as well as how it interacts with their other balance systems. (Want to know more? Check out our other blogs on vestibular rehab!)

Why do we do this? Because people need to understand why they feel the way they do. They need to be able to figure out why their symptoms are up if they’re a passenger in a car, or watching their kid’s soccer game, or skiing in the alpine. By giving them that ability, they can use their strategies to immediately reduce their symptoms and keep them involved in their own lives and doing the things they love to do.

I’m a big believer in making myself obsolete. I want people to leave here filled with knowledge about their vestibular system and how to make their lives work for them. I want them to be able to use their tricks to enjoy the movies on the big screen and play on the playground with their kids.

4. Ignoring symptom burden with exercises and looking exclusively at performance

I see this a lot: instead of asking how people feel during and after their exercises, therapists watch their performance of a specific exercise and make it harder solely on that.

I can see the therapist’s point a bit more in this one - in order to learn new motor patterns, you need to make mistakes so the brain can learn how to correct them. With a perfect performance, you’re not learning much so it makes sense to make the exercise harder.

But what that therapist isn’t taking into account is how awful that exercise is making the person feel. For a lot of these clients, they have just learned how to perform an exercise while feeling awful.

This is not the goal! We are not just trying to make people perform. We are actively trying to strengthen the vestibular system so people feel better. By looking at performance alone, we often miss the most important piece.

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This Not To Do list is far from complete but it’s a start! If you’re looking for a good vestibular therapist and don’t know where to start, head to Balance and Dizziness Canada for some great recommendations.

If you’d like to book with us, call us at (778) 630-8800, book online or email us.

The Autonomic Nervous System - What It Is and How We Can Train It

The nervous system is incredibly complex. Everything we do, think and feel involves the nervous system at multiple levels. In this blog, we are going to focus on one specific area - the autonomic nervous system: what it is, why it’s important and how we can train it.

What is the autonomic nervous system?

The autonomic nervous system (ANS) plays a pivotal role in regulating vital functions, doing so unconsciously. It serves as the body's autopilot system, controlling involuntary actions such as heart rate, digestion, respiratory rate, and glandular secretion.

It consists of two main branches: the sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS), which work together to maintain your body in homeostasis (in other words, to keep everything in balance, from body temperature and heart rate to the amount of oxygen and carbon dioxide in your blood).

1. Sympathetic Nervous System (SNS):

• Often referred to as the "fight or flight" system, the SNS mobilizes the body's resources during times of stress or danger.

• Functions include increasing heart rate, dilating airways, and redirecting blood flow to vital organs, preparing the body for action.

• In rehabilitation, an overactive SNS may contribute to conditions like high blood pressure, anxiety, and muscle tension, requiring interventions to promote relaxation and stress management techniques.

2. Parasympathetic Nervous System (PNS):

• Known as the "rest and digest" system, the PNS promotes relaxation, digestion, and energy conservation.

• Functions include slowing heart rate, constricting airways, and stimulating digestion, facilitating restorative processes.

• In rehabilitation, enhancing PNS activity can aid in promoting recovery, reducing stress, and improving sleep quality, through techniques such as deep breathing exercises, meditation, and progressive muscle relaxation.

(Note - for those of you with an in-depth knowledge of the nervous system, you understand that this is an incredibly simplistic way of talking about the ANS and misses a lot of things, like how poly-vagal theory challenges this framework and the concept of the freeze response. But hey, we all have to start somewhere, right?)

Like anything else in the human body, the ANS can become dysfunctional, leading to wide-ranging effects. Autonomic dysfunction, or dysautonomia, is well documented in spinal cord injuries, Parkinson’s disease, traumatic brain injury and long COVID. There is more and more research looking into stress-induced dysautonomia as a cause for heart disease. Dysautonomia has also been suggested as one of the mechanisms underlying chronic fatigue syndrome and complex regional pain syndrome.

When ANS dysfunction occurs, a multitude of symptoms may result including:

• Balance problems

• Nausea & vomiting

• Brain fog, forgetfulness or trouble focusing

• Fatigue

• Fast or slow heart rate

• Feeling like you cannot regulate your temperature

• Sweating more or less than usual

• Fainting or passing out

• Shortness of breath

• Dizziness or lightheadedness

• Heart palpitations

• Headaches

• Exercise intolerance

• Mood swings or anxiety

• Vision issues

What can I do to help my autonomic nervous system?

While we cannot consciously control much of the ANS, certain practices and interventions can influence its function. Here are some techniques for training the ANS:

1. Breathing Exercises:

• Deep breathing exercises, such as diaphragmatic breathing or box breathing, can stimulate the PNS, leading to a relaxation response.

• Techniques like coherent breathing, where inhalation and exhalation are paced evenly, can improve heart rate variability and promote ANS balance.

2. Mindfulness Meditation:

• Mindfulness practices involve non-judgmental awareness of the present moment, which can help regulate ANS activity by reducing stress and promoting relaxation.

• Regular mindfulness meditation has been shown to increase PNS activity, decrease SNS arousal, and enhance overall well-being.

• New to mindfulness practice? Try an app like Calm, Headspace or Insight Timer to get started!

3. Physical Activity and Exercise:

• Aerobic exercise and physical activity can have profound effects on ANS function, promoting cardiovascular health and improving autonomic balance.

• Moderate-intensity exercise, such as walking, swimming, or cycling, can enhance PNS activity while reducing sympathetic arousal.

4. Relaxation Techniques:

• Progressive muscle relaxation and guided imagery are relaxation techniques that can help reduce ANS activation and promote relaxation.

• These techniques involve systematically tensing and relaxing muscle groups, visualizing calming scenes, or inducing sensations of warmth and heaviness in the body.

5. Yoga and Tai Chi:

• Mind-body practices like yoga and tai chi combine physical postures, breathwork, and mindfulness, promoting ANS balance and stress reduction.

• These practices have been shown to increase heart rate variability, improve baroreflex sensitivity, and enhance overall resilience to stress.

If you’re looking to add some ANS training into your day, try one! These simple options can help improve sleep, reduce stress and help heal and recover from injury.

Looking for help with your autonomic nervous system, or anything else rehab-related? Book online with us - physiotherapy, massage therapy or kinesiology!

Ask A Physio - What Happens To Balance As We Age?

As a vestibular physiotherapist, I talk a lot about the triangle of balance. There are three main inputs to our sense of balance:

1. Vestibular System - a complex network involving the inner ear, brain stem and cerebellum, the vestibular system is responsible for detecting head movements and the head’s position relative to gravity.

2. Visual System - another complex network, the visual system goes well beyond the eyes, involving several areas of the brain stem and cerebral cortex.

3. Touch & Proprioception - these are all the receptors in your muscles, joints and skin telling you what you are touching and where your limbs are in space. If you can touch your nose while your eyes are closed, congratulations! Your proprioception is working!

Vestibular deficits are one of the most common causes of imbalance. BPPV, vestibular neuritis & neuritis, vestibular migraine, and Meniere’s disease are all well-known vestibular causes of imbalance and are all very treatable.

But in reality, balance is a very complex interplay of not only those three things but also cognition, attention, emotion, perception, muscle strength, joint flexibility, pain, motor planning, general stress levels and so much more. Impairments in balance can come from anywhere and have a massive effect on people’s function, especially as we age. With 20-30% of seniors experiencing one or more falls each year and 1 in 5 of those resulting in serious injury, preventing and treating balance issues is imperative.

Other Factors Leading to Imbalance with Age

There are a myriad of factors that can add to imbalance as we age. Here are some of more common ones:

• Dehydration - as we age, the part of the brain responsible for telling us we are thirsty becomes less active, leading us to reach for the water bottle less and less. This dehydration can very quickly lead to light-headedness and imbalance.

• Medications - several medications list dizziness as a side effect. There’s also a host of medications listing vision changes, light-headedness and drowsiness as side effects, all of which can affect balance.

• Walking speed & instability - the slower someone walks, the higher their chance of falls. Combine that with a limp or unsteadiness and imbalance increases significantly.

• Foot problems - if people have impaired sensation in their feet, balance problems are likely to follow. Bunions, numbness, thick calluses and ulcerations can directly impact how people are feeling the ground.

• Heart issues - a common symptom of cardiovascular disease is dizziness and light headedness especially when untreated.

• Vision problems - aging often affects how our eyes adjust to light and distance, taking longer and longer to shift. It’s common for prescriptions to change as we age and people often struggle adjusting to bifocal or progressive lenses.

• Cognition changes - so many aspects of cognition affect balance. Multi-tasking takes a lot of brain power and often leads to impaired balance. Cognitive processing and reaction time are critical for maintaining balance. Memory problems are also linked to imbalance.

• Fear of falling - one of the leading predictors of imbalance and falls is a fear of falling. People with this fear often do not move nearly as much, leading to inactivity and muscle weakness.

Top Ten Things To Do For Balance (That Aren’t Balance Exercises)

1. Stay active - the old adage “use it or lose it” is very true, at least when it comes to muscles and the brain. The more active you are, the better. It really doesn’t matter what your passion is, just keep doing it at whatever level you can! Go to the gym or an exercise class to keep your muscles lean, mean and flexible.

2. Stay hydrated - brains are thirsty and, as we age, our brains forget to tell us. Pay attention to how much water you drink during the day and try to drink at least 8 glasses per day.

3. Learn something new - your brain never stops changing. It adds new connections and removes connections that aren’t being used. By trying something you’ve never tried before, you are inducing neuroplasticity in your brain. This helps your cognitive power and can help improve balance. The McKee House Seniors Society in Ladner has a whole range of things to try, from line dancing and yoga to water colour painting and ukulele.

4. Walk with friends - this one checks all the boxes: exercise? Check! Head turns and vision challenges while looking around and looking at your friend? Check! Carrying on a conversation while dodging obstacles? Check! Soul-filling and stress-relieving? Absolutely. Walking with friends should be a part of everyone’s weekly routine.

5. Cook complex meals or maintain a garden - these are just two examples but the idea is to do complex tasks that take longer than a day to plan for and complete, then require movement to do the task. Other examples are fixing cars, large art projects, being on an organizing committee - the options are endless!

6. Bring your stress down - stress has a massive effect on your brain. Cognition can become impaired through several mechanisms leading to reduced ability to multi-task, process information and react appropriately. There are several ways to de-stress: yoga, Tai Chi, meditation, boxing, knitting, reading or anything that feels relaxing.

7. Review your medications with a pharmacist - more than 4 medications is associated with an increased risk of imbalance. Pharmacists are experts in drugs and drug interactions and are the best source of this information.

8. Be proactive about mental health - anxiety and fear of falling are two of the biggest drivers of imbalance and falls in seniors, with one in five resulting in serious injury. Mental health experts such as clinical counsellors are wonderful resources to address these issues at the root cause.

9. Have a great relationship with your optometrist - eyes change as we age. Find yourself an optometrist and see them annually.

10. Treat what needs to be treated - if you’re diabetic, make sure your sugars are in check to avoid peripheral neuropathy. If you have cardiac issues, follow your cardiologist’s advice on medications and exercise. The better you are to your body, the better your balance.

For more on age-related imbalance, head to Balance and Dizziness Canada. You can also find a vestibular therapist in your corner of the world on their practitioner’s list.

Vestibular Exercises for Tired Caregivers of Little Ones

Does this story sound familiar? You go see your favourite physiotherapist who gives you a bunch of great, well-intentioned exercises perfectly targeted for you and your body. By the time you get home, life hits - the laundry needs attention, someone needs to make dinner and someone is crying. How are you supposed to get it all done?!

For caregivers of littles, this often presents a huge challenge - how do you get your exercises in while still managing everything you have going on at home?

When it comes to vestibular exercises, I have come up with a great list that you can try at home. As always, check in with your vestibular therapist to make sure these exercises are appropriate for you.

Devon’s Top Ten Exercises for Vestibular Stimulation With Babies & Toddlers

1. Create an obstacle course with tape

Grab some masking or painter’s tape and start taping lines on the ground. Tape a long, straight piece down and walk heel to toe on it; tape a zig-zag on the ground to walk along; tape some shapes to jump into - you are only limited by your creativity!

Bonus points if you use different colours of tape and assign different rules to different tape colours. For instance, move slowly on the yellow tape, fast on the green tape and backwards on the blue tape.

2. Play Floor is Lava

Grab all the pillows you can find and scatter them around the room. Go from one pillow to the next, making up rules as you go. Let your little one pick a pillow to “sink into the lava” or decide that all the blue pillows sunk.

3. Peak-A-Boo with movement

For the super-littles, a game of peak-a-boo is a great place to get some vestibular input. When you close or cover your eyes, move either forward/backward or up/down - that movement with eyes closed will give your vestibular system a nice kick. Remember to do this one in sitting if you’re quite off-balance with eyes closed in standing!

4. Ring Around the Exersaucer

If you have a little sitting in an exersaucer, jolly jumper or even on a blanket on the ground, walk around them in some kind of silly walk while making eye contact and having your head turned toward them. You could be a penguin, a hopping bunny, a gorilla - whatever you’d like! The bigger and more exaggerated the movement, the better!

5. The Hokey-Pokey

If you want to get your body moving, do the Hokey Pokey! You can move as much as you want and even close your eyes for parts of it to give you a real challenge. Putting your head in? Drop that head as far down as you can!

6. Toy handoff

A common vestibular exercise I prescribe is looking at something in your hand while moving your head. This is easy to do here - when you grab a toy to hand your kid, look at the toy as you turn and move towards your kid without allowing your eyes to come off of the toy.

7. Yoga

You may be thinking, how am I supposed to do yoga with little kids around? My kids and I started down Cosmic Kids Yoga together during the pandemic and they loved it. Give it a try! It even became a regular thing in our home before lunch.

8. Silly walks

Create your own silly walks with your littles! High kicks, wobbly knees, spins… take turns creating a silly walk and having everyone else copy it. If you have one walking little and one non-walking little, holding the baby while doing your silly walk gets your bonus points!

9. Tickle fights

Honestly, the vestibular system and spontaneous movement are made for each other. Tickle fights are such a great way to engage in unpredictable movement patterns and react to their movements. Add some rolling around and you’ve got the whole package!

10. Patty Cake

When playing patty cake, keep your eyes switching back and forth between your hands - this gives your vestibular system some great stimulation.

Remember - make sure you’re safe to do any and all of these exercises, especially ones in which you are closing your eyes and moving through space. The last thing you need is a fall! If in doubt, check in with a vestibular therapist about which exercises are appropriate for you.

If you need the help of a vestibular therapist, call us at (778) 630-8800, book online or email us.

Ask A (Vestibular) Physio - Why Is My Vision Blurry?

Here’s a classic story from a new dizzy patient:

I spent a few days really dizzy, with the world seemingly spinning around me even though I was staying still. After those first few days, the spinning and moving stopped but my balance has been terrible since.

Not only that, but everything is blurry! When I try to read, I can’t keep the words in focus. I went to my eye doctor but they said my vision hasn’t changed, even though I can’t see anything!

What’s going on?!

This, dear reader, is a direct result of inner ear dysfunction! But wait, you may ask - how does the ear control the eyes!?

It’s time for a deep dive into the VOR.

What is the VOR?

The Vestibulo-Ocular Reflex, also known as the VOR, is the most adaptable (re: trainable) reflex in the human body. Here’s how it works:

• When your head turns to the left, the semi-circular canals in your ears sense the head rotation and send that signal to your brain.

• The brain then quickly (and I mean quickly - this happens in a few milliseconds!) sends a signal to your eye muscles to move your eyes the same amount to the right

This allows your eyes to keep things in focus even when your head is moving. (Want to know a secret? I love this reflex - I get rather excited talking about it! Can you tell?)

When does the brain use the VOR?

In short, all the time! When you walk, when you breathe and even when your heart beats, your head is moving. The VOR is critical to stabilizing vision so everything stays in focus when you are out and about in the world.

Without a fully functional VOR, things can quickly become blurry and out of focus. This occurs with vestibular neuritis and labyrinthitis.

How does the VOR actually work?

Who’s ready to get nerdy with me? It’s time for a deep dive into neurology!

Your inner ears send signals to your brain constantly. When your head is stationary, both ears send signals at about 100 beats per second to your brain. When you turn your head to the right, your right ear sends a faster rate of signals (for example, 120 beats per second) and your left ear sends a slower rate (say, 80 beats per second).

It’s this difference between the signals from your ears that triggers reflexive eye movement. Your eyes can stay focused on your target (whether that’s a book, the basketball hoop you’re shooting at or the person you’re in conversation with) without you even thinking about it.

Without this reflex, the world very quickly becomes blurry and out of focus. Any head movement can lead to blurry vision.

How does a problem with the VOR occur?

Anything that disturbs the function of the inner ear and the signals it sends can affect VOR. When your inner ear has a deficit, it sends signals to your brain at a lower rate.

For example if you have a right ear deficit, your right ear’s baseline rate of firing at rest may only be 80 beats per second. If your left ear is still sending signals to your brain at 100 beats per second, your brain perceives this difference and thinks you are rotating to the left.

Inner ear dysfunction such as labrynthitis and vestibular neuritis, concussions, vestibular migraines and other vestibular and neurological conditions can lead to VOR deficits.

Can we fix a broken VOR?

You bet we can! The VOR is the most adaptable and trainable reflex in the human body. Vestibular therapists give specific exercises with the primary purpose of training this reflex back to function.

If you’re looking for a vestibular therapist in Canada, visit Balance and Dizziness Canada for a list of certified vestibular therapists. We love what we do and would love to help you!

To book with one of our vestibular therapists, book online, send us an email or give us a call at (778) 630-8800.

What is Kinesiology?

Kinesiology, also known as human kinetics, is the study of human movement, performance, and function. Kinesiologists work with people of all ages and physical abilities to help them achieve their health and wellness goals as well as improve their quality of life. 

A kinesiologist (kin for short) uses knowledge of anatomy, physiology, neurology and biomechanics to maximize the effectiveness of exercise rehabilitation. A kinesiologist can implement your exercise program, provide support in your rehab,  and help improve physical performance in sport, work or daily life.

In more simple terms, kinesiologists are exercise rehab rock stars!

Kins use exercise to get you back to the things you love. They will discuss your goals and current treatment plan with you and your physiotherapist (if you have a physio) and help develop an exercise program to meet your needs. They work with you for one-on-one exercise sessions to ensure your technique is perfect while they help progress you through your recovery process. Strength, endurance, balance, and general fitness goals will all be addressed - there will be no stone left unturned!

What kind of training does a kinesiologist have?

Kinesiologists have completed a 4 year bachelors degree from an accredited university. Both UBC and SFU have fabulous programs! Our kinesiologists are also active members of the British Columbia Association of Kinesiologists (BCAK).

Is a kinesiologist like a personal trainer? 

The primary difference between kinesiologists and personal trainers is education level. Kinesiology requires a four year university degree whereas personal training education is generally a few weekend courses. The increased scientific knowledge base and use of evidence-based research translates to a higher quality of care, a more comprehensive approach to your exercise, and more capability of helping you troubleshoot issues that may arise.

What can a kinesiologist do for me?

There are many reasons people can find kinesiologists valuable. Kins can:

• Create an exercise plan that is safe and realistic

• Identify muscle imbalances through assessment of your movement

• Help with maintaining fitness while you deal with an injury

• Develop an exercise rehab program to address an injury

• Ensure proper exercise technique to avoid unnecessary injury

• Provide motivation and accountability to stick with your exercise program

• Help you have fun while achieving the results you want!

Is kinesiology covered by my extended health benefits?

Usually yes! For most people kinesiology, active rehab, and physiotherapy assistant appointments (which are, for this purpose, mostly interchangeable terms) are included within your physiotherapy coverage. Some plans have separate categories for “Physiotherapy” and “Kinesiology”. It is always best to first check with your insurance provider to confirm your coverage.

Do I have coverage if I was in a car accident?

Yes! With ICBC coverage, within the first 12 weeks of a car accident you are automatically approved for:

• 12 visits with a kinesiologist

• 25 visits with a physiotherapist

• 12 visits with a registered massage therapist

If your accident was more than 12 weeks ago or you have had treatment for your accident at another clinic, please let our front desk know so we can help you sort out the logistics.

Do I have coverage if I have a WorksafeBC claim?

Yes! Our kinesiologists works closely with our physiotherapists to aid in the delivery of your recovery program.

What will my session look like?

Your first visit with your kinesiologist will be an hour long. Your kinesiologist will meet you and begin the session with a quick chat. They will ask you about your reasons for coming in, your goals and your current exercise program. They will then take some time to assess your movement, strength and capabilities before taking you through an appropriate exercise program.

The kinesiologist is in constant collaboration with your physiotherapist to ensure your exercise sessions are as effective and pleasant as possible. Follow up sessions can be 30 minutes, 45 minutes, or 60 minutes long. If you are a WSBC or ICBC client your appointments will always be 45 minutes.

If you want to learn more or you would like to book a session with a kinesiologist please contact the clinic via:

• phone at 778-227-8030

• email at clinic@ladnervillagephysio.com

• book online

We look forward to meeting you!

Cognition and Vestibular Disorders - So Much Brain Fog!

Anyone who’s had any kind of vestibular dysfunction knows this simple fact: your brain leaves you. It’s like someone has taken out the best parts of your brain and replaced it with air. You cannot pay attention or multi-task, things are more confusing and memory has taken a vacation. Yet somehow it feels like your brain is working overtime.

As someone who has experienced this, I can tell you first hand it is one of the most frustrating parts of vestibular dysfunction - the feeling of stupid. There’s no other way to describe it.

You just feel dumb.

Luckily, we finally have that research that shows what vertigo sufferers have known for years - it DOES affect our cognition! It DOES affect more than just our sense of balance! Vestibular dysfunction affects so many different parts of the brain involved in cognition.

When we talk about the vestibular system, we usually just think of the snail-looking thing in the inner ear - the semicircular canals and vestibule that make up the vestibular end organ. What we don’t usually discuss is where this information goes - and let me tell you, it goes far and wide. The brain lights up like a Christmas tree on an MRI when stimulated with vestibular input. There are projections to the hippocampus, thalamus, parietal cortex, the cerebellum, the midbrain… I could go on!

When you boil it all down, the vestibular system is directly involved in four main cognitive processes:

1. Memory - short term memory is especially impaired with vestibular dysfunction.

2. Attention - those with vestibular dysfunction show difficulty both with staying on task as well as accuracy with the task at hand.

3. Executive Function - the planning, organizing and prioritizing part of your brain is heavily influenced by the vestibular system. This is why those with vestibular dysfunction have so much difficulty multi-tasking!

4. Spatial Navigation - this is the brain’s ability to digest and manipulate information in 2D and 3D. You use this skill when reading a map or manipulating shapes to go into a puzzle.

These four areas are crucial to functioning in our world. It’s so difficult to get the kids to school, get yourself to work, figure out what’s for dinner and remember that dentist appointment when your vestibular system is throwing wrenches into the system. While your brain recovers, it’s important to use some strategies (and not beat yourself up about temporarily needing them!):

• Write It Down - Whatever it is, get it in writing. Put it in a calendar, jot down a list or put that post-it somewhere easy to see. If you don’t have a system, now is the time to create one! If you’re not one for technology, get an old-fashioned agenda and take that thing with your everywhere. If you’re like me and attached to your phone, use it to your advantage by using the reminder and alarm functions.

• Take Brain Breaks - A great way to encourage attention is to give yourself scheduled breaks, preferably with some physical activity involved. Set an alarm for a period time - when that alarm goes off, get up and away from the task at hand. Do a quick set of yoga, dance in the kitchen or go for a brisk walk. Whatever it is, move your body!

• Remove Visual Distractions - Not only does a busy environment have a negative effect on focus, symptoms of vestibular dysfunction are often triggered by busy visual fields. Do yourself a favour and create a calm, relaxing space free of clutter.

Vestibular dysfunction doesn’t just affect your ears and vestibular rehabilitation doesn’t just help your balance. The right approach to rehabilitation will challenge your entire brain (aka neuroplasticity - never heard of it? Check out our blog on neuroplasticity). The challenge should always be hard for you - not impossible but outside your comfort zone. Symptoms should be triggered and then brought back down.

If you have any questions about vestibular rehabilitation, feel free to contact us through email or phone us at (778) 630-8800. If you would like to book an appointment, you can do so online.

Ask A Physio (COVID Edition): Why Is My Dizziness Worse?

The unexpected effects of COVID seem to be never ending. From toilet paper shortages to Clorox winning the stock market, we are living in a reality none of us could have predicted. It was impossible to buy yeast for months -that’s weird!

A big unexpected effect for me and my vestibular clients has been a sharp increase in dizziness. Almost daily, I'm seeing clients from months and years past saying the same thing:

My symptoms are coming back and I don’t know why.

Here’s my break down of why I think this is occurring and what you can do to combat it.

The success of vestibular rehabilitation relies on three key components:

1. Appropriate exercises that target the right problems - when working with someone with a vestibular disorder, it’s important to zero in on the cause of the problems and give the right exercises (learn more about that here).

2. Getting enough activity and stimulation to keep everything firing - it’s the classic 'Use It or Lose It’. For any brain to learn and retain anything, it needs to be used. This is one of the principles behind neuroplasticity (learn more about that here).

3. Managing stress and fatigue - these two things are the biggest inducers of vestibular symptoms. When stress or fatigue increase, symptoms typically aren’t far behind.

For most people, this pandemic has thrown two of the three components right in the trash. Stress is way up and activity levels are way down. Since the beginning of the year, there’s been a well documented rise in stress, anxiety and depression in the general population. This has spilled over into every area of our lives including the vestibular system. Combine that with less movement in our days - no exercise classes, working from home and staring at a screen for waaaaay longer than normal - and you have a recipe for a vestibular disaster.

So how do you combat this? How can you avoid this system crash?

1. Get outside. For your brain to be happy and stimulated, you need unpredictable stimuli. You need to see the birds swooping in the air and the cars driving by you. You need to navigate curbs, potholes and other people. You need to get outside the four walls of your home and let your brain experience something else.

2. Try something new. I know this is hard to do in a pandemic, but there are lots of pandemic-friendly activities that are also great for your vestibular system. Online exercise classes, diving headfirst into more complex recipes in the kitchen and dragging your bike out of the garage for a 10 km ride are all great ways to give your brain a real work out.

3. Go for a walk with a friend. This is very much a Dr. Bonnie Henry-approved activity and a great one for your vestibular system. Not only will it help you lower your stress levels but the activity of turning your head to talk to your friend as you walk is a great vestibular exercise!

4. Meditate. The research behind mindfulness practice and meditation is staggering in its breadth. It has been shown to decrease the symptoms of anxiety and depression, lower blood pressure, improve sleep, help control pain and improve quality of life. If you’re not sure how to get on the meditation train, guided meditations are a great starting point - you can find several on Youtube or through apps like Calm and Headspace.

5. Practice your vestibular exercises. If you’re a client of ours, you likely have a maintenance program you were given on your last day with the instructions to practice them three times per week. If you’ve fallen off the vestibular exercise wagon, it’s time to climb back on.

6. Get the right help. If your symptoms are skyrocketing, reach out! It may be that a vestibular therapist is the right person for you or it may be a counselor or psychologist is your best bet. A conversation with your family doctor is also a great place to start.

Whatever the reason for your symptom increase, know these two things: you are not alone and there are things that can help get your symptoms back under control. Reach out to us at (778) 630-8800 or by email. Through in person or virtual appointments, we are here to help!

Motion Sensitivity - Part 2: Top Ten Exercises!

Stephanie Yip is one of our vestibular therapists here at Ladner Village Physiotherapy. In Part 2 of her two part series on motion sensitivity, Stephanie gives some great exercise options for motion desensitization.

If you read my last blog post on what motion sensitivity is, and have now realized that this is what has been plaguing your existence, do not fret! Like I emphasized in my last post, this does not have to be your reality! I am here to share with you 10 easy exercises that you can start doing today to finally get over your motion sensitivity! 

Before we start, here are some disclaimers:

1. As mentioned, motion sensitivity rehabilitation DOES require triggering those icky symptoms. I know, so not fun. However, we only want to trigger mild symptoms that resolve within 3-5 minutes. Therefore, it’s really important that for all of these exercises, you start at a small enough dose that you aren’t making yourself sick for the next several hours. This may mean just trying the exercise for 15 seconds to start, and then gradually increasing the amount of time you expose yourself to the stimulus.

2. Motion sensitivity exercises work best when individualized to the person. You’ve probably already realized that the way you experience motion sickness is very different from your friends. Some people get really sick riding elevators/escalators but have no issues in the car. Others can’t stand being a passenger in a car, but have never had any issues with those spinny rides at amusement parks. In order for your motion sensitivity rehab to be optimal, the exercises you do should be as similar to your personal triggers as possible. Since this is just a generalized list of exercises, you may find that some of them do nothing for you, while others may make you feel awful.

With this in mind, here are some great ideas of motion sensitivity exercises that are easy to fit in to your day-to-day life!

My Top 10 Motion Sensitivity Exercises

1) Look out the side window of your car next time you’re the passenger

If you are one of my fellow car sick sufferers, you have probably noticed that you feel a lot better if you sit in the front seat and look straight ahead. This is because when you are looking straight ahead, your visual and vestibular systems are in agreement and saying the same thing. On the flip side, if you look out the side window, your visual system is seeing all sorts of quickly moving trees and street poles making you feel like you’re moving while your vestibular system is telling the brain you’re just sitting in your car; a mismatch that creates the icky feeling you get. It may not feel great, but if you start with just 15-30 seconds of looking out the side window, then resume looking straight ahead, settle your symptoms, and repeat – you’ll gradually increase your tolerance until sitting in the backseat will no longer be impossible. All your tall friends will love you for it!   

2) Play on the swing set

Next time your kids beg you to push them on the swings, see if you can take a turn on the swings instead! The world around you will blur as you swing through, really messing with your visual system, and really helping you with your rehab!

3) Go on the see saw

Since you’re already at the playground, having a blast on the swings, why not take a whirl at the see saw? This exercise is particularly helpful for those of you who get a horrible lurch in the stomach every time you take the elevator, aka those who can’t stand vertical motion.

4) Play some Mario-Kart or any other video game with a lot of looking around

Ever tried playing a first-person shooter game, tried to look around while walking forward and just felt queasy? If yes, and you need an excuse to play some video games guilt-free, you can now tell the world that you’re actually training your vestibular system and being very productive.

5) Watch the clouds while you walk

Do this one responsibly and do check that your coast is clear first! As you walk, your vestibular system will be telling your brain that you are moving forward, but the clouds floating about will be telling your visual system something totally different. Use this mismatch to your advantage and get training.

6) Log roll down a hill

This one is pretty self-explanatory and is definitely for those looking for an advanced level exercise. Be warned – go slow with this one and build up gradually.

7) Read while walking, as a passenger in the car, in a hammock or while sitting in a rocking chair

If you’re focused on non-moving words on a page, your visual system won’t be able to correlate with the vestibular system which is telling your brain you’re moving. You can adjust how much you move to make this one easier or harder.

8) Play some focused catch

If you watch a ball being thrown very closely, keeping the ball in focus the whole time, the background behind the ball will be both blurry and moving. This can confuse your brain and bring on those feelings of motion sickness.

9) Do some eyes closed yoga or t’ai chi

You wouldn’t expect something as simple as yoga or t’ai chi to really amp up your motion sickness. If you’re a regular yogi or t’ai chi practitioner, this is often a really nice way to slowly start tackling those gross feelings. When you take away your vision and add some movement, your brain really has to work overtime to figure out where you are!

10) Do some chair spins

That office chair you spend most of your day in? Give it a good twirl every once in awhile! Not only can this one be done quickly, you likely can do it a LOT throughout the day without too much effort.

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What are your favourite exercises to combat motion sickness? Add some ideas in the comments below!

If you’re suffering from motion sickness, we can help - book online, send us an email or give us a call at (778) 630-8800.

Motion Sensitivity - Part 1: What Is It?

Stephanie Yip is one of our vestibular therapists here at Ladner Village Physiotherapy. In Part 1 of her two part series on motion sensitivity, Stephanie explains what motion sensitivity is, why some people suffer from it and what we can do about it. Enjoy!

As a kid growing up, cars were my nemesis. I still have vivid memories of throwing up on pretty much every family road trip, and even worse, throwing up in my friend’s dad’s brand-new car on the way to a soccer game. Planes were even worse. One of my earliest memories is of me as a 5-year-old, non-stop projectile vomiting on a 12-hour flight, with everyone around us handing us their puke bags since I had used up all of my own. As I got older, my motion sensitivity got a bit better in the sense that I didn’t necessarily puke during every car ride, but I would still feel sick within minutes of being in any moving vehicle.

How many of you can relate to this? After sharing with friends, I discovered that there are so many of us out there, struggling with cars, buses, boats, and thinking that this is something we just have to live with. Well, I am here to share with you all the greatest revelation which has completely turned my world upside down.

This does not have to be our reality.

There is a solution. Just like how we rehabilitate and strengthen our ankle after a sprain, we too, can rehabilitate and strengthen our vestibular system to improve our motion sensitivity!

But let’s back this up, and start with…

What is motion sensitivity?

There are two main types of motion sensitivity. One is considered visually induced motion sensitivity in which you experience symptoms due to complex visual environments. Do you ever find yourself feeling sick at the grocery store as you scan the aisle for that one type of flour you need? Does scrolling on your phone too quickly make you feel loopy? If so, this may be the type of motion sensitivity you have.

The second type is the one we mostly think about when we think of motion sensitivity, and that’s why it’s called true motion sickness in which symptoms are caused by passive motion. Passive motion means that you are not actively moving but something is moving you i.e. being in a car or boat.

What are some common symptoms of motion sensitivity?

After sharing my experiences with friends, I’ve discovered that everyone experiences motion sensitivity quite differently, so this list of symptoms is definitely not all-encompassing. Personally, I get a weird background headache, followed by a woozy feeling in my head almost like I’m floating. Despite my earlier experiences of nausea and vomiting, I rarely feel sick to the stomach now unless I’m on a tiny boat with very choppy waves. On the flip side, many of my friends have described nausea as their main symptom. Other common symptoms include fatigue, imbalance, increased sweating, disorientation, palor (aka looking quite pale), excessive production of saliva, and burping.

So you’re probably thinking great, I definitely get motion sensitivity, but why does this have to happen to me?? Do you ever watch your kid reading in the backseat and think man, why can’t I do that?

Why do I get motion sensitivity?

If you’ve been an avid reader of our blog, you will already know that our sense of balance comes from three main sources: the vestibular system, the visual system, and the somatosensory system. (In case you missed it, check out our earlier blog posts on the vestibular system here and here.)

People who get motion sensitivity often rely too much on their visual system, which means their brains can easily be tricked. If you’re sitting in your parked car, and the truck next to you starts moving, your vestibular system is telling your brain that you’re not moving, but your visual system is saying the opposite. If you’re someone who over relies on their visual system, that system will take over, convince the brain that you are indeed moving, and make you feel really sick. This can also be referred to as visual vestibular mismatch, or VVM.

So what can you do about it?

Treatment for motion sensitivity

If you’re a lifetime sufferer of motion sensitivity, you’ve probably already tried Gravol, ginger pills, cracker nibbling, looking straight ahead when the car is moving, etc. etc. But all of these things are only band aid solutions to help you cope. What if you could cure your motion sensitivity?

Just like an ankle sprain, there is no magic wand that can cure you in an instant, but there are many exercises you can do to start training yourself so that you no longer experience motion sensitivity. There are two main elements you will need to work on:

1. We need to train the brain to stop its over-reliance on the visual system, and to start relying more on the vestibular system instead. How? Take the other two systems away. Stand on your cushy couch, close your eyes, and don’t fall over.

2. We need to gradually desensitize or habituate the brain so that it can tolerate these icky situations more and more. This means that yes, we do need to trigger those symptoms to train the brain, but only mildly. You should feel only mild symptoms that resolve within 5 minutes. What that may look like totally depends on the individual. For some, that may mean 1 minute in the car as a passenger. For others, it may mean getting on a roller coaster if that’s the only trigger they have.

For more exercises that you can easily incorporate into your everyday life, check out part 2 of our motion sensitivity series where I will be sharing my Top 10 Motion Sensitivity Exercises. Some of them are actually pretty fun and include playing video games or hanging out with your kids, so be sure to check out that post when it goes live!

If you want to get started on your motion sensitivity rehabilitation, give us a call at (778) 630-8800 or book online at ladnervillagephysio.com .

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References

Pavlou M, Quinn C, Murray K, Spyridakou C, Faldon M, Bronstein AM. The effect of repeated visual motion stimuli on visual dependence and postural control in normal subjects. Gait Posture. 2011;33(1):113-118. doi:10.1016/j.gaitpost.2010.10.085

Roberts RE, Da Silva Melo M, Siddiqui AA, Arshad Q, Patel M. Vestibular and oculomotor influences on visual dependency. J Neurophysiol. 2016;116(3):1480-1487. doi:10.1152/jn.00895.2015

https://www.360neurohealth.com/blog/207141/vestibular-rehab-in-patients-with-motion-sensitivity

How Do We Learn? Neuroplasticity, Of Course!

One of the biggest myths about physiotherapy is we only work on bodies. It’s true, we do that a lot! We use manual therapy, soft tissue massage, modalities like LASER, ultrasound and dry needling (aka IMS - intramuscular stimulation) - all to help your body heal and perform at its best. However, the most important thing we do is prescribe exercises. Why?

The number one thing we are trying to change is your brain.

Whenever we learn a new skill, be it playing a guitar or performing the perfect squat, we need to start with activating the right muscles in the right sequence to get the right outcome. And that, dear reader, doesn’t happen at the muscle level - that all starts from the brain.

So what is this brain change we speak of? How does it work? More importantly, how do we make it work for us?

Neuroplasticity is the brain’s ability to change. This change can be harnessed for good (that guitar chord progression is amazing!) or evil (stop leaning over to pick up that box - squat it out!!).

As a physiotherapist, we harness the power of the brain’s ability to change itself through specific exercises. If I want you to improve the range of motion of your shoulder, I’m going to give you exercises that force your brain to engage a specific muscle and build on top of that. Those silly movements we ask you to do? There’s a method to the madness, we swear!

So what makes for good neuroplastic change? Kleim and Jones wrote THE paper on neuroplasticity back in 2008. This became the guidebook with how we influence neuroplasticity for the forces of good. Here are their ten principles and how we relate this to our exercises:

1. Use It or Lose It - want to still be able to squat in 20 years? Squat now. Your brain is very good at eliminating circuits that aren’t being used. If you want to keep a skill at a certain level, you need to practice it regularly.

2. Use It and Improve It - when you practice a task, your brain becomes more efficient at that specific task. It strengthens the neurons and their synapses, prunes off the inefficient pathways and creates a faster circuit.

3. Specificity - if the goal is to improve your golf swing, working on your tennis form isn’t the best way to do it. Sure, some of the muscles used are the same and you’ll see a cross training effect. But to get the best results for your golf game, we need to focus on your golf swing - break down those movements, improve them and put it all back together.

4. Repetition Matters - how many times does an baby fall before they master the art of walking? Almost 14,000 times! (Thanks, Dr. Lara Boyd, for that nugget - I’ve been keeping that number in my head for 10 years!) Keep this is mind if you’re getting frustrated - “brains are stubborn, but so am I”.

5. Intensity Matters - when you’re working out or practicing a new skill, work hard and make it count. Sweat! Fail! Make it hard! The more you push it - either physically or mentally - the faster you’ll see change.

6. Time Matters - we know we get faster neuroplastic change if we start rehabilitation shortly after an injury. The sooner we start, the better.

7. Salience Matters - you need to care about what you’re doing to get change! You know that adage, “You can’t make a person change”? It’s true for the brain, too! If the person doesn’t care, they will not see neuroplastic change. This is why we ask you what you love to do - we need to make sure the exercises we are prescribing relate to something that matters to you and helps you get to your end goal. Otherwise, what’s the point?

8. Age Matters - younger brains are better at neuroplastic change. We used to think younger brains were the ONLY brains that could change, but research has blown that out of the water. Older brains change, too - here is no age limit to neuroplasticity!

9. Transference - this is the cross training effect. Let’s go back to the golf/tennis example. Both games demand good shoulder control, a strong core and good hand/eye coordination. If we focus only on your golf game, your tennis game will improve a bit as well.

10. Interference - I’ll use a personal example with this one. I have spent so much time playing ultimate frisbee that I cannot play tennis without flicking the tennis racket. I can’t do it! My wrist just flicks every time I hit the ball. The neuroplastic change I have developed to throw a frisbee has interfered with my ability to hit a tennis ball properly. I could put in the effort to induce enough neuroplastic change and separate these circuits if I wanted to, but it’s not salient for me (see what I did there?).

Want to have more neuroplasticity in your life? There are two things you can do to make your brain more efficient at neuroplasticity: aerobic and mental exercise. Both have shown to increase the brain’s ability to adapt and change. All the more reason to get out for that bike ride and rock that crossword puzzle!

As always, if you’d like to see one of our physiotherapists, give us a call at (778) 630-8800, email us at clinic@ladnervillagephysio.com or book online.

Happy learning!

Vestibular Rehab: Self-Isolation Edition

Hello reader! Your friendly neighhourhood vestibular therapist Devon here. My whole family is currently obsessed with Hamilton and the song I hear over and over in my head right now is “The World Is Upside Down”. It’s just so on point.

Given the current situation, you need to know two things. First:

WE ARE STILL HERE!!

Give us a call at (778) 630-8800 - we are answering the phone! Email us at clinic@ladnervillagephysio.com! I can help guide you through this and can do a vestibular assessment through Telehealth, aka physiotherapy over the internet.

Second, I want to give you as many tools as humanly possible. Please keep in mind: I am a registered physiotherapist with lots of post graduate training in vestibular rehabilitation. When you come into the clinic, I’m looking not just for what is bothering you but also ruling out the potential really bad things. I cannot replace everything I do in the clinic with a step by step guide of what you can do at home.

But I can give you as much as I can, right? So, let’s start.

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When it comes to vestibular rehab, the two most common offenders are BPPV and labrynthitis/vestibular neuritis. I can usually listen to your story and figure out which one it is before I examine you. Here’s the classic stories:

• BPPV: This person will tell me they are generally fine until they look up or down, lie down, sit up or roll over in bed. Usually, this starts in the middle of the night or in the morning - they sit up and their world SPINS. The first time their world spins, it can last all day. After that, they usually spin less than a minute, but it’s a roller coaster of a minute.

• Labrynthitis/Neuritis: This person’s symptoms can start anytime. They often have a harder time pinpointing when it started. They usually don’t use the word “spin” - it’s more off balance, brain foggy, light headed, hard to keep things in focus with their eyes, nausea +/- vomiting, and just a weird off feeling. They’ll tell me their symptoms are really hard to describe and articulate, they feel like maybe they’re crazy and no one understands. Often, their symptoms worsen as their fatigue, and stress makes them feel even worse.

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Courtesy of the Vestibular Disorders Association

For BPPV -

The best thing you can do is the Epley maneuver. The Epley is an exercise designed to get the crystals (aka otoconia) out of the posterior canal and back to where they should be (to the utricle). When done correctly, it is 90% effective with 1-3 treatments. It’s also a maneuver I teach everyone how to do when they are diagnosed with BPPV because 50% of people will get BPPV again within 5 years. If you have a history of BPPV, you should be able to do an Epley with your eyes closed and one hand tied behind your back (ok, not really, but you get my point).

There are a few precautions with performing an Epley. For someone with an arthritic or compromised neck, you want to make sure you do not push the neck too much. For someone with artery disease or reduced blood flow through the arteries to the brain, the Epley should not be performed without a check of these arteries. This is something I do in the clinic for every person before we do the Epley and can do through Telehealth.

If you think you have BPPV, side matters. If you get more dizzy when you roll to your right, you’ll want to do a right Epley. If the spins happen when you roll to the left, try the left Epley. I’ve attached instructions for each - just click on the links.

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For Labrynthitis/Neuritis -

You need to work your brain. When one or both ears are giving your brain the wrong information, we simply have to change how your brain listens to your ears.

Think of it this way: if you’ve ever had a toddler, your family are usually the only ones who can understand them. A toddler’s language skills aren’t exactly perfect but, as the family, you learn what your kid is saying. It’s the same thing with your ear - it’s speaking in toddler language and it’s up to your brain to figure it out.

I can get really nerdy and dissect the types of exercises we do for vestibular rehab and why we do them, but I won’t do that to you here. What you need to know is that you need to challenge your system and make your brain work. The way you know your brain is working is you feel symptoms - maybe a bit of nausea, some brain fog, some off feelings.

After you make your brain work, you get your symptoms back to the same level they were before you started the exercise. You do this by:

• Look at something that’s not moving - a light switch or a rock on the ground, for example. Make sure it’s something that your brain can trust is not moving; avoid a tree leaf.

• Feel your feet - touch and feel are important parts of your sense of balance. Get into them and feel what your feet are touching. If you are standing, resist the urge to touch something with your hands - make your feet do the work.

• Breathe - this is super important for getting the anxiety piece under control. Symptoms of vestibular dysfunction and anxiety look remarkably similar and often your brain doesn’t know which is which. Slow down your breathing with long, slow, deep breaths.

Here are some exercises that you can do:

• Stand in the corner with your back towards the corner. Stand close enough that, if you fall, the walls will stop you from falling but not so close you are already touching the walls. Place your arms across your chest and your feet together. Close your eyes and maintain your balance. Aim for 30 seconds.
  If this gets too easy, push one foot a bit forward - make it hard! Remember, you need to challenge your brain to work your brain.

• Write the letter “B” on a post it. Place it on the wall at eye level. Look at the B and move your head side to side at a speed that the B stays perfectly in focus. Do not allow the B to become blurry or separate into a 13 - if this happens, slow down your head speed and regain focus. Do this for one minute then settle your symptoms.
  (Pro tip - I often have people put a B at eye level opposite their toilet. They’re there for a minute anyway, might as well kill two birds with one stone!)

• Go for a walk outside for at least 20 minutes every day. During that walk, focus on walking in a straight line and not veering to one side. Once that is easy, spend 30 seconds of that walk looking to the right and left for 3 steps each. The further you turn your head, the harder it will be to stay in a straight line. After the 30 seconds is up, settle your symptoms and do it again!

For more exercises you can incorporate into your every day life, check out one of my old blogs: Top Ten List: Vestibular Exercises for Life.

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Vestibular rehab is a type of physiotherapy that works really well through Telehealth - if this is something you would like to try or if you just have questions you need answered, give us a call at (778) 630-8800 or email us at clinic@ladnervillagephysio.com.

Stay safe and healthy!

Quarantined? Keep Moving!

If you’re anything like me, the world is an anxiety-producing place right now. Every company I have ever given my email to is sending me their COVID-19 updates. I understand why but it’s not helping my mind calm down.

There is a huge body of research showing how exercise helps with a whole assortment of mental health conditions. As gyms, pools and public spaces shut down, several companies are stepping up and offering their services online, often for free.

Down Dog owns a series of online apps, all of which they are providing for free during the COVID-19 outbreak, helping people to stay as healthy as they can in their own homes. You can find their apps on iOS or Android. Here’s what they do:

• Down Dog Yoga - yoga from home! You can chose your practice type (restorative, flow, hatha, gentle, etc), your level (Beginner 1 on up) and how long you want your practice to be.

• Yoga For Beginners - completely useless at yoga? Try this one!

• HIIT Workouts - for something more intense, try this one. Again, you can choose your level of difficulty, your focus (total body? arm workout or glutes?) and how long you want to go for. The best part? NO EQUIPMENT REQUIRED. Just turn it on and GO.

• 7 Minute Workout - same idea as HIIT with a little bit less intensity. And hey, who can’t give 7 minutes a day for a little sweat?

• Barre Workouts - are you caught up in the barre obsession? This is a great way to get at home! I’ll probably break this one out with my kids too - they’ll love practicing their ballerina moves. Once again, it’s the same idea - pick your focus and your time, then go for it!

The Washingtonian, an online publication out of the states, published a list of fitness studios offering their classes (some for free!) by online stream. Take a look and see what strikes your fancy. They’ll also be updating their list as the days go on.

One of my favourite meditation apps is Headspace, available on iOS and Android. In response to the outbreak, they have created a “Weathering the Storm” category with free meditations, sleep stories and more! If meditation is something you’ve been meaning to get into, now is definitely the time and Headspace is a great way to get started.

Finally, one of my favourite home exercises is an oldie but a goodie: Twister with my kids. The pretzels I twist myself into are certainly a good workout!

As of March 16, 2020, the biggest rule is social distancing. That leaves all kinds of things available for us - a lovely bike ride on the dyke! Walking among the tidal flats at Centennial Beach! Going for a jog in the gorgeous sunshine! Get outside for now and stay moving for the long haul.

Do you have a favourite website, app or idea for this outbreak? Let us know and we will add it to the list!

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As always, if you’d like to book in with a physiotherapist, give us a shout at (778) 630-8800 or clinic@ladnervillagephysio.com. We are also now offering Telehealth services for those unable to come in person.

Labyrinthitis & Vestibular Neuritis - Why Do I Feel So Off?

As a vestibular therapist, the second most common thing I treat is typically caused by an inner ear infection. It can go by a few different names - labyrinthitis, vestibular neuritis, peripheral vestibular hypofunction - but at the end of the day, they all mean the same thing: your ear is not working properly. I don’t have the equipment to figure out if the problem is coming from the nerve or the end organ and, quite frankly, it doesn’t matter - they act the same. I group them together in one name: Unilateral Vestibular Hypofunction, or UVH for short.

Here’s my story: I got hit by a flu when I was a physiotherapy student at UBC. I remember sitting on the couch, trying desperately to stop Oprah from oscillating on my TV. After a few days of spinning, overwhelming nausea and an inability to walk without holding onto someone or something, I managed to get on the bus (big mistake) and go to class. The professor noticed that I wasn’t at my best - she looked into my eyes and simply said “go home”. What I didn’t know at the time was my eyes were jerking back and forth (called nystagmus) - my professor caught it and figured out what was going on. With vestibular exercises and some time, I got back to “normal”.

Why do I say “normal”? I will always have an inner ear deficit. When I’m really tired or fatigued, by brain can’t compensate for the deficit as well as it normally does and I get a bit symptomatic. Here’s the difference between me now and me then: I know what I can do about it. I know how to settle my symptoms and get control back. This is what I help other people learn to do.

Why do UVHs happen?

Most people hate this answer but it’s usually the common cold or flu - it was for me! Other viruses and bacteria have also been linked to UVHs but it’s usually a virus that needs to run its course. Unfortunately, it typically damages the ear in the process. When this happens, the signals between the inner ear and brain are disrupted. This results in a bunch of symptoms that can either pass on their own or stick around for a lot longer than you want them to.

What are the symptoms of a UVH?

This list is long! The vestibular system affects several aspects of the brain with vision and balance being the two most common ones. I don’t let people say they’re dizzy (learn why here), so people with a UVH often complain of the following:

• Weird head feelings - cotton head, foggy head, vice head, light headed…

• Blurred vision or difficulty reading - almost like the world is oscillating (sometimes a bit, sometimes a lot!)

• Off balance

• Nausea, often with vomiting

• Tinnitus, or ringing in your ears

• Decreased hearing

• Typically aren’t bad drivers but are terrible passengers

• Hates grocery stores and places with lots of visual stimulation (think Costco or your kid’s hockey game)

• Symptoms are worse with fatigue and stress

• Tends to veer to the side when walking - partners will complain they push them off the sidewalk

• Difficulty concentrating and multitasking

What can I do about it?

A lot! During your assessment, we figure out where your deficits are. Maybe your balance isn’t bad but you can’t keep your eyes stable for the life of you. Or maybe you can move your head beautifully but as soon as you look up, you fall backwards. We break down your symptoms and give you exercises designed to challenge your system’s weaknesses.

More importantly, we figure out how those symptoms are affecting your life. If you’re a golfer, it’s critical you maintain your balance through your swing and change your gaze direction quickly. If curling is your passion, your dynamic balance needs to be on point. Whatever you love to do becomes our goal and focus.

If you’d like a few exercises to try now, check out my previous blog on my Top Ten Vestibular Exercises for Life.

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As always, if you’re suffering from a vestibular condition and you’d like to book an assessment, book online or give us a call at (778) 630-8800.

Visual Vestibular Mismatch - Why Do I Feel Motion Sick in the Grocery Store?

Have you ever been sitting at a red light with a car beside you and the other car starts to move? We’ve probably all experienced that panic where we think we are the ones moving and jump on the brakes with as much force as we can muster. Only then do we discover it wasn’t our car that was suddenly taking on a life of its own but our brain playing a trick on us, telling us we were moving when we were sitting perfectly still.

That feeling is a result of Visual Vestibular Mismatch, a conflict in your brain where the visual information coming from your eyes does not match the vestibular information coming from your ears. Visual Vestibular Mismatch (otherwise known as VVM) is something that happens to us in every day occurrences. Think of that feeling you get when you’re watching the latest blockbuster movie and the only seats left were in the front row - sometimes, you’re not sure if it’s you or the screen that’s moving. That nauseous, unsteady, motion sick-like, gross feeling is a direct result of the VVM experienced in that moment.

When you have a concussion or vestibular disorder, VVM can be much more severe and affect every aspect of your life. Whenever you experience a lot of visual stimulation (especially if that stimulation is of the moving kind), the symptoms of VVM may rear their ugly head. Common situations for VVM include:

• The grocery store - aisles upon aisles of colours, from floor to ceiling, with people moving in and around you

• Crowded areas - think the mall at Christmas time. People without vestibular deficits feel gross there, never mind those of us who have vestibular deficits!

• Places with kids and pets - all that movement in your peripheral vision can really play tricks on your brain

• Patterns on the floors and walls - high contrast patterned wallpaper and rugs should be banished, in my humble opinion

Why Does This Happen?

We know our sense of balance comes from three main sources: the vestibular system, the visual system and the somatosensory system, also known as your sense of touch (for more information on these systems, check out my earlier blog on the vestibular system or head to the Vestibular Disorders Association). Our brain likes to use the vestibular system as the leader of the balance trio - it tends to be the one utilized most for figuring out where we are in the world.

With vestibular dysfunction, the brain will often switch to a vision-driven system - it doesn’t trust the information coming from the ears so it goes to it’s second choice. Now, the brain is using primarily visual information to figure out where it is in the world. Without having a trusty vestibular system to double check its information, the brain has a really hard time figuring out what is moving - you or the things around you.

What Can We Do About It?

A lot, actually! Vestibular rehabilitation can be very effective at treating VVM through balance exercises in eyes closed (if you can’t use your visual system to stay upright, you have to use something else!) and desensitization exercises to visual stimulation.

If you’re suffering from VVM, give us a call at (778) 630-8800 or book online at ladnervillagephysio.com.

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Interested in learning more? If you’re nerdy like me, take a look at Dr. Art Mallinson’s thesis on Visual Vestibular Mismatch.

Top Ten: Tips for Traveling with Vertigo and Dizziness

One of the main questions I get asked is how to deal with a plane ride. People are often terrified their vertigo and dizziness is going to explode when they’re on the flight and are fearful of getting on the plane.

Rest assured, dear readers - you will be fine! The pressure change that occurs when you are at altitude is across the ear drum which separates the outer ear from the middle ear - the inner ear isn’t involved! Only a few conditions are affected by pressure change, the most common one being Meniere’s Disease.

The worst part of air travel is dealing with the airport - the lines, the people, the busy-ness that everyone else hates, too. There are some ways to make sure the trip you are about to take is going to be a great one. Without further adieu, I present:

Devon’s Top Ten Times for Travel with Vertigo and Dizziness

1. Get to the airport early and give yourself time to get through the security line ups. The less stressed you are, the better you’ll feel.

2. Get a good night’s sleep the night before your flight. The less fatigue you start with, the more prepared your brain and vestibular system will be for the day’s journey and will result in less symptoms.

3. On the airplane itself, the worst parts are take off and landing - the acceleration and deceleration tend to trip up your vestibular system a bit. Once you’re airborne, there’s no crazy stimulation of your vestibular system. Knowing this, you can prepare yourself and use your strategies for setting your symptoms: feet firmly attached to the ground, look at something stable and BREATHE.

4. If you have to deal with a significant time change, give yourself a few days to switch to the new time zone. By giving yourself this time, you’ll enjoy your trip much more from the get go.

5. Riding on a bus? Sit close to the front with the few out of the front window. This way, if motion sickness starts to set in, you can combat that by looking out the front window and not the side windows.

6. Renting a car? Plan on doing a significant part of the driving. It’s less taxing on your vestibular system if you’re controlling the motion as the driver, instead of reacting to it as the passenger.

7. Plan for a rest in the middle of your day. It doesn’t need to be a nap but just a time where you can deal with any symptoms you may have and plan for the evening ahead.

8. Keep the alcohol to a minimum. Alcohol thins the fluid in your inner ear, making it more sloshy (you know how when you get drunk, you spin? Now you know why). Avoid drinking too much will help you avoid the worst of your symptoms.

9. Don’t overschedule yourself. Leave time in your day for optional adventures or time to just sit with a good book and a tea. Give yourself the extra space to ensure it’s going to be a great trip.

10. Stay hydrated. I always pack along an empty water bottle with I go on trips - it helps remind me to keep my fluid intake up.

If you are experiencing dizziness or vertigo and would like an assessment, give us a call at (778) 630-8800.

I Need More Sleep!

I don’t get enough sleep. Quite frankly, I don’t know anyone that does. That bake sale for the PAC? No worries, I’ll just stay up until 3am to get those cupcakes done. A huge presentation at work? I’ll have extra coffee tomorrow - it’ll be fiiiiine. Everyone I know is guilty of sacrificing sleep to get all those little things done.

Chronic fatigue is also a huge component of chronic injury. Simply put: you need sleep to heal. Without sleep, it is nearly impossible to recover from anything - it’s when we sleep that our bodies are able to dedicate the resources needed to repair the tissues. Sleep is one of the most underrated aspects of rehabilitation from any injury.

If you need a shake up in your sleep hygiene routine, here are some tips to help get you started:

• Keep a regular sleep schedule. It is vital to healthy sleep hygiene that you prioritize getting to bed at roughly the same time every night and waking up at roughly the same time. Your brain thrives on routine and getting into these circadian rhythms help your brain heal. Aim for 7-9 hours of scheduled sleep every night, preferably more than less.

• Expose yourself to natural light during the day. This helps your brain set those circadian rhythms and regulates the melatonin (the sleep hormone) circulating in your brain.

• Promote a sleep friendly environment. Keep your room dark when you are sleeping, using backout curtains if necessary. Block ambient noise by either using a sound machine, fan or ear plugs. Keep your room cool but comfortable.

• Make a bedtime routine. With babies and kids, we usually have a bedtime routine to help them get ready for sleep. Why not do the same for us? Get in some kind of bedtime habit – a shower, a book, meditation, etc. Do what works for you.

• No naps. Napping disrupts these rhythms you are working so hard to build. Instead, take a brain break during the day – do some yoga, meditation or listen to a podcast.

• Avoid alcohol, caffeine, nicotine, heavy meals and lots of liquids in the evenings. Aim for none of these things in the last 4-6 hours of your day.

• Avoid exercise before bed. If you can, get your exercise in the morning – it will help wake you up and keep you going through the day.

• Avoid screen time in the two hours before bed. When you look at bright lights, your melatonin levels decrease and your brain wakes up more. If you need to look at screens, add the night filter to your phone – it helps decrease the blue light and reduces the effect on your circadian rhythms.

• Use your bedroom for sleep and sex – that’s it. Don’t turn your bedroom into your gym, your office space, your afternoon lounging area. You want your brain to associate your bed with those two things; everything else is a distraction and will hinder your sleep.

• Can’t sleep? Get up. We all have those nights where we just can’t sleep. When that happens, give yourself 15-20 minutes to try and get to sleep. If that fails, get out of bed and go into another room. Read a book, do some meditation, have a light snack. When you are sleepy again, go back into your bed and try again. Do not turn on the TV or try to use that time to get some work done – keep those hours you have reserved for sleep as quiet, non-stimulating time.

Sometimes, these strategies are not enough. If these strategies are not working for you, talk to your doctor about medications or supplements that may help you find the sleep you need.

Top Ten List: Vestibular Exercises for Life

All my clients know this fact: you can’t change your ears, but you can change how your brain listens to them. Vestibular rehabilitation relies on this principle: by giving you exercises to challenge your vestibular system, we can decrease (and even eliminate!) your dizziness, nausea, brain fog and all the other symptoms that come with a vestibular deficit.

At the end of the day the goal is to keep your symptoms under control, but this relies on you continuing to exercise your brain. I get that you’re busy and doing daily exercises is hard to do. But what if you could do them on a daily basis without noticing that you’re doing a vestibular exercise?

Devon’s Top Ten List: Vestibular Exercises for Life

1. Check out flowers, airplanes and other interesting things while out for a walk - One of the easiest ways to keep your vestibular system stimulated is by simply looking around while you’re walking. This does several things: it separates your head from your body movements, it forces you to walk straight while putting your eyes on something else and it gets your semicircular canals firing.

2. Stand on one foot while brushing your teeth - Balance? Check. Movement? Check. Something you do twice per day? Check. It’s perfect!

3. Play on the playground - When you’re with your kids, play with them! Get on the swings, walk on the wobbly bridge, go down the slide - all of these things are great and fun ways to challenge all aspects of your vestibular system.

4. Walk on logs at the beach - I love doing this. I play a game with myself - how many logs can I walk on without touching the “lava” (aka sand)? My kids really get into this one too. It challenges your dynamic balance and forces you to look ahead a bit to plan your next movement.

5. Dance - Ok, I’m a terrible dancer. The beauty is, my kids don’t care! We shake it in the kitchen to the Beatles, 90’s rock (because I’m raising them right) and anything Disney. We spin, we jump, and we have a great time.

6. Go on a scavenger hunt at the grocery store - When you have those things on your list you don’t typically buy, turn it into a game. Set your watch and time how long it takes for you to find the extra hot horseradish, low sodium soy sauce and cinnamon sticks. When you’ve found your items, stop and take stock of your symptoms, then actively settle them down.

7. Try that yoga/pilates/Tai Chi/aquacize/rock climbing/pickleball/whatever class - Trying new things is the best way to keep things stimulated and challenged. Always push on the boundaries of your comfort zone!

8. Relax in a hammock/rocking chair with a book - Picture yourself on a beach, relaxing in a hammock with a mojito and a great page turner. The gentle rocking added to the reading is a subtle way to keep things working just a little harder.

9. Go for a bike ride - The saying is true about riding a bike: we don’t forget how to do it. Balance is challenged and things go by you a little faster than normally, challenging your brain to match the input from your visual and vestibular systems.

10. Play physical board games -  Games like Charades and Twister puts your body in different positions, and they’re fun! This is also a great way to get your gravity sensors going, not just your semicircular canals.

This is what I do! What do you do on a daily basis to help you keep control of your symptoms?

If you’re suffering from a vestibular condition, book an assessment online or give us a call at (778) 630-8800.

But I'm Dizzy! What Else Am I Supposed to Say?!?

I like to begin my vestibular physiotherapy assessments with a simple statement: Tell me your story. Everyone has one and they often begin the same way: they’re dizzy. Almost every time, I rudely interrupt them and say:

You’re not allowed to use the D word.

A perplexed, confused, sometimes angry look often crosses the story teller’s face. But why, they ask? That’s what they feel!

Here’s the thing with the word “dizzy” - it means completely different things to different people. Maybe your dizziness feels like the world is spinning around you, or maybe you’re spinning in the world. Maybe you feel like you’re on a boat, rocking side to side or forward and back in a rhythmical fashion. Maybe the ground just won’t stay where it’s supposed to and it comes up at you from the left, from the right with no sense of rhythm whatsoever. Maybe it just feels like you can’t stay on your feet and someone is pushing you to the side, that you’re off balance all the time.

All of these experiences can be very dizzying but they all come from different sources. When you tell your story, using words other than “dizzy” allows me to figure out where your story is going.

Hold on, blog readers - here’s where I go super nerdy.

The inner ear has two parts - the auditory half (this is the snail looking part, the cochlea) and the vestibular half. On the vestibular side, there are two parts:

1. Semi-circular canals - these fluid filled canals respond to rotation. You have three of them that are at 90 degree angles to each other so they can respond to all the different directions your head can rotate: turning left and right, looking up and down, etc. When you turn your head to the right, the fluid in the horizontal canals turn to the left, trip the little lever in the canal (aka the cupula) and tell you which way your head is turning.

2. Otoliths (utricle and saccule) - literally meaning “ear rocks”, the otoliths respond to gravity. The crystals, or otoconia, are attached to a glue membrane which together make up the macula. The otoconia are more dense than the fluid in the inner ear and sink, just like rocks in a pool. When you tilt your head, the otoconia pull on the glue membrane, which pulls on the hair cells and tell your brain which was is down.

Different problems with different aspects of your ears will give you different kinds of dizziness. If your story involves vertigo, my brain goes to the semi circular canals - since these are the guys that detect rotational acceleration, they are often somehow involved in your story. When you include a boat or rocking sensation in your story, your sense of gravity is off and the otoliths are often involved.

Maybe your story has a bit of everything - those stories are common! With a thorough vestibular assessment and a good overview of your story, we can often determine the cause of your dizziness (after this blog, how dare I use this word?!) and a treatment plan. If you’re struggling with vertigo, imbalance or anything in between, we can help. Give us a call at (778) 630-8800 or book online at ladnervillagephysio.com.

Thanks for getting nerdy with me!

What Am I Doing Here, Anyway?

As a vestibular therapist, I get this question a lot. Here’s how it usually goes: you wake up one morning and you’re DIZZY. It may be the easy to explain kind - the world is spinning! It may be the more vague, hard to describe kind - it’s kind of like being on a boat, or someone is gently pushing you to the side, or the ground just won’t stay DOWN where it should…

However your journey starts, it usually takes you (fairly quickly!) to a doctor, who then says some word you’ve never heard of and directs you to me. As you walk into our office, you wonder how being dizzy meant you are now sitting in a physiotherapy clinic.

One of the wonderfully unique things about physical therapists is we are awesome at training bodies to do things differently. That may be revamping your squat so your back doesn’t kill, retraining your pelvic floor muscles so you don’t pee a little when you laugh or changing your brain so the world doesn’t spin or tip around you.

Your balance centres get input from three main sources:

• Visual System: your eyes, telling you where things are

• Vestibular System: your ears, telling you where your head is in space and how far and fast it moves

• Somatosensory/Proprioceptive System: all those little nerve endings in your feet, knees and hips telling you what you’re touching, what your muscles are doing and what position your joints are in

If all three of these bits of information match, congratulations! Your world is probably very much stable and in focus. If one of these is giving you the wrong information, it can throw your world for a loop.

Pretend for a second your ears are telling you are turning in a circle but your eyes and feet disagree. Chaos quickly ensues in your brain - fatigue, nausea, vomiting, and blurry vision plague you. Bold patterns, bright lights and contrasting colours drive you nuts. You lean or veer to one side, and forget doing anything in the dark without needing to hold the walls. To add insult to injury, it’s almost as if someone has replaced your brain with cotton and anything requiring concentration is close to impossible.

These are all common symptoms of a vestibular disorder, something that hits 35% of us aged 40 or older. As a vestibular therapist I will watch you walk, test your balance, and check out what your eyes are doing in both room light and in the dark. Through these tests, I can get a good read on what’s going on in your vestibular system and give you exercises specifically designed to challenge and improve its function.

Just like retraining a squat, I can change your brain so you aren’t dizzy anymore. If you’d like to learn more, head on over to the Vestibular Disorders Association’s website - it’s a great resource for sufferers and health care professionals alike. If you’re suffering from dizziness and think this might be worth a go, give us a shout!