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.

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!

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!

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.