Beyond the Spin: Why Direction, Not Just Difficulty, Defines Effective Dizziness Therapy
As a physical therapist specializing in vestibular and balance disorders for over two decades, I have seen countless patients struggling with dizziness. They often arrive with a history of generalized exercises, perhaps some vague advice, and a lingering sense of frustration. Why? Because effective dizziness therapy is not just about making exercises harder, it is about knowing precisely what to do and why. It is about direction, not just the degree of difficulty.
Let's unpack this critical distinction.
The Superiority of Directed Empirical Therapy
In our field, we often discuss 'evidence-driven' physical therapy, which means making decisions based on observation and outcomes. On the surface, this sounds ideal. However, in an unstructured clinical setting, this approach can often lead to a therapist relying on their discretion. But what truly guides their decision-making beyond simply observing signs and symptoms? While we certainly use signs and symptoms, they serve as crucial inputs for our deeper sensory strategy analysis, not as the sole basis for treatment.
Imagine a therapist observing a patient's unsteadiness and thinking, 'Okay, they're wobbly, let's make them walk on foam. This is an empirical observation leading to an action. But is it the right action? And is the difficulty appropriate for the underlying problem, or just a general challenge?
Here's where the pitfalls emerge:
The 'Gut Feel' Trap: Without a systematic framework, therapists often rely on instinct for treatment progression. This can lead to inefficient interventions, wasted time, and, critically, a lack of apparent progress for the patient. You might be moving, but are you moving in the right direction?
The Symptom/Sign-Focused Blind Spot: It is natural to want to alleviate a patient's dizziness or improve their observable steadiness. However, focusing solely on symptom reduction or immediate sign improvement can be profoundly misleading.
Counterproductive Reinforcement: Consider a patient with a high visual dependency VVM – Visual-Vestibular Mismatch or surface dependency SVM – Somatosensory-Vestibular Mismatch. If you encourage activities that heavily rely on these systems, the patient might feel better because they are becoming more efficient at their maladaptive coping strategy. You are not fixing the problem; you are just making them better at avoiding it. This is like giving someone a crutch and teaching them to rely on it more, instead of strengthening their leg.
Masking the Problem: Temporary symptom relief does not guarantee actual functional improvement or address the root cause of the dizziness and unsteadiness. The underlying maladaptive strategy remains, ready to resurface when environmental demands change.
Beyond Symptoms: The 'Why' Behind the Dizziness
At FYZICAL, we understand that a patient's manifested signs and symptoms – their dizziness, unsteadiness, disequilibrium – are not random. They are direct results of a maladaptive sensory mismatching strategy. This strategy is the true 'why' behind their presentation.
These strategies are specific ways the brain attempts to compensate for a vestibular deficit by over-relying on other sensory inputs:
VH-SOM (Vestibular Hypofunction with Somatosensory Dependency)
VH-VIS (Vestibular Hypofunction with Visual Dependency)
SVM (Somatosensory-Vestibular Mismatch)
VVM (Visual-Vestibular Mismatch)
SVVM (Somatosensory > Visual-Vestibular Mismatch)
VSVM (Visual > Somatosensory-Vestibular Mismatch)
Identifying which of these strategies a patient is using is the critical first step. It is the key that unlocks the direction of our treatment.
The FYZICAL Balance Paradigm: A Compass, Not Just a Treadmill
Our Sensory Strategy Analysis provides the essential directionality and precise control over the degree of difficulty that is often absent in independent practice. This is the core of our unique and practical approach:
1. The Power of Direction ('Action'): Knowing Where to Go
By accurately identifying the specific sensory Mismatch and strategy, we gain clear directionality for treatment. This eliminates guesswork and ensures every intervention is purposeful and aligned with correcting the specific maladaptive strategy.
Example 1: Somatosensory-Vestibular Mismatch (SVM). If a patient is over-relying on surface cues, our direction is clear: we must challenge their reliance on somatosensory input and encourage the use of their visual and vestibular systems. Our 'action' involves specific exercises that reduce stable surface feedback, forcing the brain to integrate visual and vestibular information more effectively. We are actively pushing them away from their comfort zone, in a particular direction.
Example 2: Visual>Somatosensory-Vestibular Mismatch (VSVM). If a patient is profoundly visually dependent, our direction shifts. We must carefully grade activities that reduce or distort visual input, even if they initially increase their symptoms. The 'action' here is to deliberately make their primary compensatory system less reliable, forcing accurate vestibular adaptation.
This is not a general 'balance exercise'. This is a targeted, strategic approach, a precise 'action' driven by a deep understanding of the patient's sensory profile.
2. The Art of Precision: Calibrating Degree of Difficulty
The identified strategy also dictates the appropriate degree of difficulty for exercises. We do not just progress based on general tolerance; we strategically challenge the weakest or over-relied upon systems to force accurate adaptation.
Difficulty is not just about adding more reps or standing on a smaller surface. It is about which sensory system we are challenging, and how much, to break the maladaptive pattern.
For the VSVM patient, the 'difficulty' is not just about balance; it is about performing tasks with reduced visual cues, which can feel incredibly challenging and even disorienting at first. This is a controlled, therapeutic challenge, not just making an exercise physically harder. It is about creating the right amount of sensory conflict to stimulate neural plasticity.
The FYZICAL Ecosystem: Consistency and Reproducible Outcomes
The FYZICAL Balance Paradigm provides a robust, evidence-based roadmap. We do not just treat symptoms; we identify the maladaptive sensory strategy, which then gives us the precise direction and degree of difficulty needed to guide the patient toward true, lasting vestibular and balance recovery.
This consistency and precision, supported by advanced testing and our exclusive Safety Overhead Support SOS system, which allows us to safely challenge patients beyond what is possible in a traditional clinic, ensures optimal and reproducible outcomes across our entire FYZICAL ecosystem. When you refer a patient to FYZICAL, you are not sending them to an individual therapist operating on 'gut feel'; you are sending them into a unified system designed for predictable and superior results.
Brian K. Werner, PT, MPT, National Director of Vestibular Education & Training at FYZICAL, has been a dedicated physical therapist specializing in vestibular and balance disorders for over a quarter of a century, helping countless patients regain their stability and quality of life.