Physiotherapy and Hydrotherapy management of Vestibular disease

Vestibular disease is a condition affecting the inner ear or brain regions responsible for balance and coordination. Dogs with vestibular disease usually present with a loss of balance, disorientation, head tilt and irregular jerking eye movements known as nystagmus. Depending on the severity and localisation of the vestibular disease many, but not all dogs, will also be reluctant to or unable to stand or walk and may struggle to do so which can be quite distressing for the dog but also you, the owner. Most dogs will lean or fall in the direction of their head tilt. Damage to the vestibular system can result in some, but not necessarily all of the following clinical signs:

• Asymmetric ataxia i.e. drunken gait

• Abnormal posture e.g. leaning or head tilt (towards the side of the problem)

• Circling or deviating (towards the side of the problem)

• Wide-based stance

• Nystagmus (rapid eye flick)

• Vestibular (positional) strabismus i.e. a squint, typically in a downward direction when the head position is changed

• Vomiting usually due to motion sickness / dizziness

What is the cause of vestibular disease?

Vestibular disease can be either peripheral or central. Peripheral vestibular disease involves peripheral components including ear and nerve. Central vestibular disease involves the central components including parts of the hind brain.

For treatment and prognostic purposes it is vital to locate the source of the problem and distinguish between peripheral vestibular and central vestibular disease. The most reliable indication of central vestibular disease is depressed mental status (e.g. poorly interactive and disorientated) and postural deficits i.e. loss of strength and proprioception (i.e. the sense of where the limbs are in space). Disease causes of vestibular disease this can be divided into various components to include; metabolic, neoplastic, inflammatory, nasopharyngeal polyps, toxic or trauma to name but a few. Your neurology clinician will be able to advise you of the likely source causing your dog or cat to have vestibular disease.  

Following a sudden onset of vestibular clinical signs, vestibular disease may be strongly suspected. However, the most important ‘test’ is a thorough neurological examination as this is used to determine if the vestibular syndrome is peripheral or central and will indicate the necessary pathway to further investigation and treatment required. However diagnostic imaging is usually required to confirm a diagnosis. The most useful is MRI as this allows both the ears and the brain to be assessed. However, ear infections can also be identified on CT and in some cases with radiographs.

Vestibular disease is predominantly a non-surgical condition but some underlying causes of the disease may require a degree of surgical intervention. Either way, management vestibular disease requires a twofold treatment pathway:

Dealing with the underlying cause (if possible)

Management of peripheral vestibular disease underlying conditions can vary from medical intervention such as antibiotics or adjunctive surgical or radiotherapy treatment for example in neoplastic disease of the middle or inner ear whereby complete surgical resection of tumours can be difficult or has been unsuccessful.  However, cats diagnosed with nasopharyngeal polyps usually require surgical intervention to remove the polyps.

Management of central vestibular disease tends to involve medical management with antibiotics, corticosteroids, antifungal or antiepileptic medication. The specific underlying cause of the disease will determine which treatment is best for your pet.

What is the prognosis of vestibular disease?

The prognosis for recovery from vestibular disease is very much dependent on the underlying cause of the clinical signs. The rate and extent of recovery is variable and difficult to predict but can take days, to weeks or months and some patients may have some residual deficits e.g. a subtle head tilt.

Your pet may require treatment for a week or so, or maybe months to ensure the underlying cause of the vestibular disease is managed well. Whereas some of the central vestibular diseases may require life-long treatment. Your veterinarian will be able to give you a more accurate prognosis for your pet once they have performed a thorough neurological exam and have a made a definitive diagnosis of the cause of your pet’s clinical signs.

Physiotherapy and Hydrotherapy management  for Vestibular disease

Rehabilitation has an important role to play in management and treatment of vestibular disease. The degree to which an individual is affected can vary from patient to patient therefor an individualised physiotherapy treatment plan is required with ongoing evaluation and adjustment of the programme.t.

Aims of rehabilitation

In the initial days following diagnosis of vestibular disease:

• Provide supportive management of postures and transferring from one position to another

• Increase sensation and awareness of body position

• Maintain soft tissue flexibility

Following on from this and depending on your pet’s progress, the aims might include:

• Improve core stability

• Further raise awareness of body position and posture and posture

• Advance functional transfers of weight

• Facilitate supportive gait patterns

Once good recovery is established further aims are defined:

• Continue to strengthen core muscles

• Further enhance gait patterns including pace

• Enhance exercise tolerance and cardiovascular fitness

• Return to normal function or how to manage any residual disabilities

Physiotherapy treatment options

A major component of physiotherapy treatment is the advice that can be given especially in the initial phase after diagnosis. Handling techniques, home environment advice, exercise restriction and the use of assistive devices are essentials and will be taught and demonstrated by your pet’s physiotherapist.

Soft tissue massage and sensory stimulation are key and can be taught so you are able to perform them at home. In addition, an appropriate home exercise program (HEP) can be invaluable even early on. Specific exercise therapy allows stimulation of body awareness and muscle strengthening. Hydrotherapy treadmill is also utilised for strengthening, body awareness, gait re-education, core stability promotion and improving cardiovascular fitness.

The following table gives an example of a rehabilitation plan which may be designed for the management of a patient with vestibular disease:*

Timescale	Physiotherapy aims	Treatment options
0-2 weeks	Reduce potential risk of soft tissue trauma Reduce muscular guarding Increase sensory input and motor activity Possibly gait re-education according to deficits Improve core stability Increase sensation and awareness of body position	Correct positioning, handling techniques, non-slip surfaces, assistive devices Soft tissue massage and stretches. Laser therapy Neuromuscular stimulation Sensory techniques e.g. brushing, tapping Hydrotherapy treadmill Home exercise programme Neuromuscular electrical stimulation Proprioceptive facilitation
2-4 weeks	Maintain soft tissue length and flexibility Management at home	Home exercise programme Passive movements and stretches Exercise restriction Advice regarding flooring Advice regarding assisted walking with harness and sling if required Advice regarding cavaletti pole work, gradients, steps and different surfaces
4-6 weeks	Continue and progress as above	Progression of home exercise programme to challenge balance, body awareness and strength Advice on maintaining controlled exercise when dog is feeling better
6-12 weeks	Increase exercise tolerance Improve function	Increase exercise level Hydrotherapy treadmill Core stability and strength
12 weeks +	Return to full function or establish deficits and advise regarding long-term management.	Progress to off-lead exercise and previous exercise level if appropriate