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Physical Therapy for Meniere's Disease

For patients who have been referred for vestibular therapy. 

Timothy C. Hain, MD Page last modified: August 31, 2017


Meniere’s disease is a fluctuating vestibular condition and physical therapy cannot change the underlying disease process. In fact, adaptations made in response to temporary situations where the inner ear is malfunctioning may be overall maladaptive for patients during the much larger periods of time in which patients have nearly normal inner ear function.   For this reason, it has been traditionally taught that physical therapy is inappropriate for Meniere’s disease.  In our opinion, this general approach remains reasonable, but nevertheless there are a number of ways that physical therapy for can benefit patients.

A recent meta-analysis stated that there is a lack of evidence for helpfulness in Meniere's. They stated in their abstract: "Conclusion Based on the low quality of the selected studies, it is inconclusive whether there is a positive effect of vestibular rehabilitation in patients with MD on balance and dizziness-related quality of life." The author's abstract says it all (Van Esch et al, 2017).


Table 1: Physical therapy goals for patients with Meniere’s disease.

  1. Improve baseline balance
  2. Educate patients how to avoid injury due to imbalance or vertigo
  3. Rehabilitate patients after destructive treatments that result in static unilateral or bilateral vestibular loss.
  4. Treat the “spin-offs” of Meniere’s disease –
    1. Visual dependence
    2. Neck stiffness (within reason -- Meniere's patients do not need aggressive neck PT, and do not generally need "manual therapy", or "dry needling").
    3. Depression and anxiety (usually better done by a psychotherapist)
  5. Discourage patients from participating in dubious or harmful treatments for Meniere's.
    1. There are an immense number of "left field" treatments for Meniere's disease.
    2. The general principal of "do no harm" should be followed.
      1. Surgery generally has only a small place in treatment of Meniere's disease. For example, endolymphatic shunt surgery and vestibular neurectomy should never be the first option for treatment. These are last resorts -- "nuclear" options.
      2. Treatments based on manipulation of body parts, such as chiropractic treatment, are irrational in Meniere's disease.
      3. Diagnostic procedures involving substantial radiation should be looked at with skepticism (such as temporal bone CT scans).
      4. Harmless treatments that are irrational (such as ear drops for Meniere's), are placebos, but are not necessarily always to be avoided. Sometimes faith can have a healing effect.

Balance in Meniere’s varies from being entirely normal in between attacks, to moderately impaired as the disease takes a toll on inner ear structures as well as people adapt their movement strategies to minimize the risk of a sudden attack.   The PT evaluation can be helpful in assessing risk of fall due to baseline imbalance, and vestibular rehabilitation can be helpful in training people to improve their balance. (Nyabenda, Briart et al. 2003; Gottshall, Hoffer et al. 2005) Nevertheless, the main risk to persons with Meniere’s disease is of injury associated with sudden unpredictable bouts of dizziness, for which no amount of balance training is likely to prevent. For example, if you are driving down the highway and suddenly everything starts to spin, vestibular PT is not likely to help you here.

Dowdal-Osborn suggested that the definition of vestibular rehabilitation should be broadened  to include education and prevention of Meniere’s disease (Dowdal-Osborn 2002).  This is most appropriate when the vestibular physical therapist is part of an integrated health care team so that duplication of effort – both evaluation and counseling – is avoided between various other health professionals – primarily physicians, nurses or audiologists who might play a similar role. That being said, we are dubious that the physical therapist who treats necks, backs, knees, and took a course on vestibular rehabilitation are the right person to educate patients about Meniere's disease. For the most part, we think patients needing education about Meniere's should be educated by persons who have an appropriate experiential framework.

Today intractable and disabling Meniere’s disease is commonly treated with destructive treatments – particularly low-dose intratympanic gentamicin.  Older clinicians may favor more drastic destructive treatments such as labyrinthectomy and vestibular nerve section. These treatment frequently result in a modest to severe reduction in balance function overall, in return for a dramatic reduction in unpredictable attacks of dizziness.  Here the physical therapist can be very helpful in rehabilitating patients with unilateral vestibular reduction (Wiet, Kazan et al. 1981)

Finally, Meniere’s disease may be accompanied by several behavioral and compensatory “spin offs” that can be extremely troubling by themselves.  Patients may develop visual dependence – an abnormal sensitivity to complex visual surrounds. (Lacour, Barthelemy et al. 1997) They may have difficulty driving or shopping for groceries. This symptoms results from an unsophisticated compensation strategy in which the individual down-weights vestibular information in favor of visual input.  Physical therapists may help individuals with this particular problem by training them to be aware of their visual dependence and develop a capacity to switch over to somatosensory or vestibular inputs, when visually challenged.

Another compensatory strategy that can be troublesome to Meniere’s patients is a predilection to stiffen the neck in order to reduce the speed of head motion. This both reduces vestibular stimulation as well as makes head orientation more predictable.   While this strategy can be effective, an unsophisticated use can result in neck pain and discomfort. Again, the physical therapist may be helpful to patients by training them to be aware of their use of this compensatory strategy, and encouraging them to develop a larger repertoire of compensations for their erratic and unreliable vestibular system.

Many studies have documented that patients with Meniere's disease tend to have more psychological disability than the normal population, possibly including depression and/or anxiety. (Savastano, Marioni et al. 2007). This is a natural consequence of having a chronic condition that can result in unpredictable spells of dizziness, reduced hearing, tinnitus and imbalance. The physical therapist can be helpful here by providing supportive psychotherapy - -the therapist can validate the patient’s feelings,  provide them with emotional support, and offer them activities that may provide some measure of control over their body. There is sometimes danger in "validating" patient feelings, as teaching the patient that they are so impaired as to be incapable of working or caring for themselves can encourage inappropriate use of family members as well as social support mechanisms.

References

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Copyright August 31, 2017 , Timothy C. Hain, M.D. All rights reserved. Last saved on August 31, 2017