Levanna Doing Exercise, painting by Maria Primachenko
The Vestibular Ocular Reflex (VOR) is the mechanism that allows a person to keep their eyes on a fixed target while their head is moving, for instance when you are looking at your friend and nodding your head “yes” or “no”. The reason we are able to do this is because our inner ear system acts like little gyroscopes that tells our brain when our head is in motion. Your brain then takes that information, and tells the eye muscles what to do to keep your eyes on the target.
The VOR exercise is especially important when a person has had damage to their inner ear system. The brain, which was used to getting normal inner ear information previously, will have to relearn how to use the information that has lessened due to illness or injury.
I’ll give you a common example. Let’s say that a person has an inner ear infection that affects their Left inner ear system, and decreases responsiveness of the Left vestibular system (the balance part of the ear) to send information during head motions. When the person now moves their head, the left ear is sending less information than the healthy right ear. This difference in input to the brain being sent from the two ears can result in symptoms of dizziness, nausea, or unsteadiness. Ironically, some patients will avoid moving their head so that they don’t get dizzy, but movement is the only way for the brain to learn how to use the inner ear information again!
Vestibular Ocular Reflex exercises help the brain through this retraining process, because the exercise forces the brain to receive inner ear information and practice using it to keep the eyes on a fixed target. Patients start with slow head turns, keeping the eyes on a fixed target placed on the wall at eye level 4 feet away. They start in a seated position and move the head 20 degrees to each side in a back and forth head motion. They also do the exercise in an up and down head motion as if nodding “yes”. As they are able to do the exercise symptom free, we increase the duration of the exercise to 2 minutes.
The next step is to gradually increase the speed of the head motion. If you are doing the exercise correctly, your symptoms will decrease over the next few weeks. If you aren’t doing the exercise correctly, you may think the exercises don’t work! This is why working with a vestibular specialist is so important. If you are not improving, they can figure out what you are doing wrong and help you learn how to perform the exercise correctly, and hence, recover as much inner ear function as your body will allow.
VOR stands for the Vestibular Ocular Reflex. This is basically the coordination that one has between head and eye movements. The way it works is this: when a person is moving their head, the ears send information to the brain to tell the brain how the head is moving. The brain then uses this information to coordinate the eye movements so that the person can stabilize their gaze on an object even though their head is in motion. We do this all the time! For instance, if I am talking to someone, and nodding my head yes or no, then I am using my VOR.
When a person has a weakness in one ear following an inner ear infection, for example, the brain that was used to getting the same amount of information from each ear, realizes that the information from the two ears is no longer balanced. The affected side is not sending the same amount of information as the healthy ear anymore. Initially, this can cause dizziness, nausea, and imbalance. To avoid these symptoms, patients will often avoid head motions. While this may seem logical at first, to continue avoiding head motions only makes the problem worse. You see, the brain needs to learn the difference that now exists between the two ears, and the only way the brain can do this is by experiencing the movement! The brain won’t learn how to recalibrate itself if the person continues to avoid moving their head. By doing the VOR exercise, we force the brain to pay attention to the inner ear information when the head is moving, because the brain must in order to coordinate the eye motions and allow the person to keep their eyes fixed on the target without the target looking blurry, double, or as if it is jumping around…
Initially, this exercise may cause dizziness, or increase the person’s baseline dizziness. The patient should first do this exercise at a slow speed, and for a short duration (30 seconds). That way if the exercise causes dizziness, the dizziness should dissipate in a few minutes after stopping the exercise. With practice, the exercise will no longer cause dizziness or nausea. Once this happens, then we work on increasing the duration of the exercise little by little until eventually they can do it for 2 minutes and feel fine afterwards. At that point, we work on increasing the speed of the head motion, so that the brain learns how to process faster and faster head motions, and not feel dizzy. After that, we move on to other variations. You see, there is a progression to the exercise, and a vestibular specialist will be able to teach you how to do the exercise correctly, and guide you in your journey toward recovery.
Man with His Head Full of Clouds- Painting by Salvador Dali, 1936