All central signs must be tested for before a diagnosis of BPPV can be made. This includes testing the Oculomotor, Balance and Vestibular Ocular Reflex systems, as well as screening for Vertebral Artery Insufficiency and Upper Cervical instabilities.
Treatment for dizziness with central involvement includes an education and exercise based program, along with some manual therapy dependent on the each patient’s specific problems. Generally, three main principle methods of exercise are prescribed to each patient; Gaze Stabilisation, Balance and Habituation.
Gaze Stabilisation exercises are prescribed when Oculomotor insufficiencies are found during assessment. They are used to improve eye control during head movements, therefore improving the clarity of the patient’s vision. Patients will often report issues with reading or focusing on objects when moving about. E.g. Oculomotor retraining exercises will generally consist of repeated head movements, while the patient attempts to fixate on a stagnant object.
Balance exercises are designed specifically to address each patient’s underlying balance issues. The exercises are to be challenging enough to incite some form of coordination strategy from the patient, but safe enough as to avoid injury. E.g. Balance exercises should include changes in base of support, visual input and involving one or more extra tasks, in order to increase the difficulty for patient’s.
Habituation exercises are prescribed when Vestibular Ocular Reflex (VOR) issues are found during assessment. Patients with VOR issues will report dizziness from self motion (moving around, especially with quick head movements or bending over) or from increased visual stimulus (shopping malls, action movies etc). The goal of habituation exercises is to reduce dizziness associated with these stimuli through repetitive provocation and resolution. Over time, the brain learns to ignore the abnormal signals it is receiving from the inner ear, in response to these stimuli. E.g. Patient views a video clip from someone else's point of view, moving through a busy shopping centre, while increasingly reducing their base of support as able.