Accessibility for Vestibular Disorders: How My Temporary Disability Changed My Perspective

Accessibility can be tricky. There are plenty of conditions to take into consideration, and many technical limitations and weird exceptions that make it quite hard to master for most designers and developers.

I never considered myself an accessibility expert, but I took great pride in making my projects Web Content Accessibility Guidelines (WCAG) compliant…ish. They would pass most automated tests, show perfectly in the accessibility tree, and work quite well with keyboard navigation. I would even try (and fail) to use a screen reader every now and then.

But life would give me a lesson I would probably never learn otherwise: last October, my abled life took a drastic change—I started to feel extremely dizzy, with a constant sensation of falling or spinning to the right. I was suffering from a bad case of vertigo caused by labyrinthitis that made it impossible to get anything done.

Vertigo can have a wide range of causes, the most common being a viral infection or tiny calcium crystal free floating in the inner ear, which is pretty much our body’s accelerometer. Any disruption in there sends the brain confusing signals about the body’s position, which causes really heavy nausea, dizziness, and headaches. If you’ve ever felt seasick, it’s quite a similar vibe. If not, think about that feeling when you just get off a rollercoaster…it’s like that, only all day long.

For most people, vertigo is something they’ll suffer just once in a lifetime, and it normally goes away in a week or two. Incidence is really high, with some estimates claiming that up to 40% of the population suffers vertigo at least once in their lifetime. Some people live all their lives with it (or with similar symptoms caused by a range of diseases and syndromes grouped under the umbrella term of vestibular disorders), with 4% of US adults reporting chronic problems with balance, and an additional 1.1% reporting chronic dizziness, according to the American Speech-Language-Hearing Association.

In my case, it was a little over a month. Here’s what I learned while going through it.

Slants can trigger vestibular symptoms#section2

It all started as I was out for my daily jog. I felt slightly dizzy, then suddenly my vision got totally distorted. Everything appeared further away, like looking at a fun house’s distortion mirror. I stumbled back home and rested; at that moment I believed I might have over-exercised, and that hydration, food, and rest were all I needed. Time would prove me wrong.

What I later learned was that experiencing vertigo is a constant war between one of your inner ears telling the brain “everything is fine, we’re level and still” and the other ear shouting “oh my God, we’re falling, we’re falling!!!” Visual stimuli can act as an intermediary, supporting one ear’s message or the other’s. Vertigo can also work in the opposite way, with the dizziness interfering with your vision.

I quickly found that when symptoms peaked, staring at a distant object would ease the falling sensation somewhat.

In the same fashion, some visual stimuli would worsen it.

Vertical slants were a big offender in that sense. For instance, looking at a subtle vertical slant (the kind that you’d have to look at twice to make sure it’s not perfectly vertical) on a webpage would instantly trigger symptoms for me. Whether it was a page-long slant used to create some interest beside text or a tiny decoration to mark active tabs, looking at anything with slight slants would instantly send me into the rollercoaster.

Horizontal slants (whatever the degree) and harder vertical slants wouldn’t cause these issues.

My best guess is that slight vertical slants can look like forced perspective and therefore reinforce the falling-from-height sensation, so I would recommend avoiding vertical slants if you can, or make them super obvious. A slight slant looks like perspective, a harder one looks like a triangle.

Target size matters (even on mouse-assisted devices)#section3

After a magnetic resonance imaging (MRI) scan, some tests to discard neurological conditions, and other treatments that proved ineffective, I was prescribed Cinnarizine.

Cinnarizine is a calcium channel blocker—to put it simply, it prevents the malfunctioning inner ear “accelerometer” from sending incorrect info to the brain. 
And it worked wonders. After ten days of being barely able to get out of bed, I was finally getting something closer to my normal life. I would still feel dizzy all the time, with some peaks throughout the day, but for the most part, it was much easier.

At this point, I was finally able to use the computer (but still unable to produce any code at all). To make the best of it, I set on a mission to self-experiment on accessibility for vestibular disorders. In testing, I found that one of the first things that struck me was that I would always miss targets (links and buttons).

I’m from the generation that grew up with desktop computers, so using a mouse is second nature. The pointer is pretty much an extension of my mind, as it is for many who use it regularly. But while Cinnarizine helped with the dizziness, it has a common side effect of negatively impacting coordination and fine motor skills (it is recommended not to drive or operate machinery while under treatment). It was not a surprise when I realized it would be much harder to get the pointer to do what I intended.

The common behavior would be: moving the pointer past the link I intended to click, clicking before reaching it at all, or having to try multiple times to click on smaller targets.

Success Criterion 2.5.5 Target Size (Level AAA) of the World Wide Web Consortium (W3C)’s WCAG recommends bigger target sizes so users can activate them easily. The obvious reason for this is that it’s harder to pinpoint targets on smaller screens with coarser inputs (i.e., touchscreens of mobile devices). A fairly common practice for developers is to set bigger target sizes for smaller viewport widths (assuming that control challenges are only touch-related), while neglecting the issue on big screens expected to be used with mouse input. I know I’m guilty of that myself.

Instead of targeting this behavior for just smaller screen sizes, there are plenty of reasons to create larger target sizes on all devices: it will benefit users with limited vision (when text is scaled up accordingly and colors are of sufficient contrast), users with mobility impairments such as hand tremors, and of course, users with difficulty with fine motor skills.

Font size and spacing#section4

Even while “enjoying” the ease of symptoms provided by the treatment, reading anything still proved to be a challenge for the following three weeks.

I was completely unable to use mobile devices while suffering vertigo due to the smaller font sizes and spacing, so I was forced to use my desktop computer for everything.

I can say I was experiencing something similar to users with mild forms of dyslexia or attention disorders: whenever I got to a website that didn’t follow good font styling, I would find myself reading the same line over and over again.

This proves once again that accessibility is intersectional: when we improve things for a particular purpose it usually benefits users with other challenges as well. I used to believe recommendations on font styles were mostly intended for the nearsighted and those who have dyslexia. Turns out they are also critical for those with vertigo, and even for those with some cognitive differences. At the end of the day, everybody benefits from better readability.

Some actions you can take to improve readability are:

• Keep line height to at least 1.5 times the font size (i.e., line-height: 1.5).
• Set the spacing between paragraphs to at least 2.0 times the font size. We can do this by adjusting the margins using relative units such as em.
• Letter spacing should be at least 0.12 times the font size. We can adjust this by using the letter-spacing CSS property, perhaps setting it in a relative unit.
• Make sure to have good contrast between text and its background.
• Keep font-weight at a reasonable level for the given font-family. Some fonts have thin strokes that make them harder to read. When using thinner fonts, try to improve contrast and font size accordingly, even more than what WCAG would suggest.
• Choose fonts that are easy to read. There has been a large and still inconclusive debate on which font styles are better for users, but one thing I can say for sure is that popular fonts (as in fonts that the user might be already familiar with) are generally the least challenging for users with reading issues.

WCAG recommendations on text are fairly clear and fortunately are the most commonly implemented of recommendations, but even they can still fall short sometimes. So, better to follow specific guides on accessible text and your best judgement. Passing automated tests does not guarantee actual accessibility.

Another issue on which my experience with vertigo proved to be similar to that of people with dyslexia and attention disorders was how hard it was for me to keep my attention in just one place. In that sense…

Animations are bad (and parallax is pure evil)#section5

Val Head has already covered visually-triggered vestibular disorders in an outstanding article, so I would recommend giving it a good read if you haven’t already.

To summarize, animations can trigger nausea, dizziness, and headaches in some users, so we should use them purposely and responsibly.

While most animations did not trigger my symptoms, parallax scrolling did. I’d never been a fan of parallax to begin with, as I found it confusing. And when you’re experiencing vertigo, the issues introduced by parallax scrolling compound.

Really, there are no words to describe just how bad a simple parallax effect, scrolljacking, or even background-attachment: fixed would make me feel. I would rather jump on one of those 20-G centrifuges astronauts use than look at a website with parallax scrolling.

Every time I encountered it, I would put the bucket beside me to good use and be forced to lie in bed for hours as I felt the room spinning around me, and no meds could get me out of it. It was THAT bad.

Though normal animations did not trigger a reaction as severe, they still posed a big problem. The extreme, conscious, focused effort it took to read would make it such that anything moving on the screen would instantly break my focus, and force me to start the paragraph all over. And I mean anything.

I would constantly find myself reading a website only to have the typical collapsing navigation bar on scroll distract me just enough that I’d totally lose count of where I was at. Autoplaying carousels were so annoying I would delete them using dev tools as soon as they showed up. Background videos would make me get out of the website desperately.

Over time I started using mouse selection as a pointer; a visual indication of what I’d already read so I could get back to it whenever something distracted me. Then I tried custom stylesheets to disable transforms and animations whenever possible, but that also meant many websites having critical elements not appear at all, as they were implemented to start off-screen or otherwise invisible, and show up on scroll.

Of course, deleting stuff via dev tools or using custom stylesheets is not something we can expect 99.99% of our users to even know about.

So if anything, consider reducing animations to a minimum. Provide users with controls to turn off non-essential animations (WCAG 2.2.3 Animation from Interactions) and to pause, stop, or hide them (WCAG 2.2.2 Pause, Stop, Hide). Implement animations and transitions in such a way that if the user disables them, critical elements still display.

And be extra careful with parallax: my recommendation is to, at the very least, try limiting its use to the header (“hero”) only, and be mindful of getting a smooth, realistic parallax experience. My vertigo self would have said, “just don’t freaking use parallax. Never. EVER.” But I guess that might be a hard idea to sell to stakeholders and designers.

Also consider learning how to use the prefers-reduced-motion feature query. This is a newer addition to the specs (it’s part of the Media Queries Level 5 module , which is at an early Editor’s Draft stage) that allows authors to apply selective styling depending on whether the user has requested the system to minimize the use of animations. OS and browser support for it is still quite limited, but the day will come when we will set any moving thing inside a query for when the user has no-preference, blocking animations from those who choose reduce.

After about a week of wrestling websites to provide a static experience, I remembered something that would prove to be my biggest ally while the vertigo lasted:

Reader mode#section6

Some browsers include a “reader mode” that strips the content from any styling choices, isolates it from any distraction, and provides a perfect WCAG compliant layout for the text to maximize readability.

It is extremely helpful to provide a clear and consistent reading experience throughout multiple websites, especially for users with any kind of reading impairment.

I have to confess: before experiencing my vestibular disorder, I had never used Reader Mode (the formal name varies in browsers) or even checked if my projects were compatible with it. I didn’t even think it was such a useful feature, as a quick search for “reader mode” actually returned quite a few threads by users asking how to disable it or how to take the button for it out of Firefox’s address bar. (It seems some people are unwittingly activating it…perhaps the icon is not clear enough.)

Displaying the button to access Reader Mode is toggled by browser heuristics, which are based on the use (or not) of semantic tags in a page’s HTML. Unfortunately this meant not all websites provided such a “luxury.”

I really wish I wouldn’t have to say this in 2019…but please, please use semantic tags. Correct conversational semantics allow your website to be displayed in Reader Mode, and provide a better experience for users of screen readers. Again, accessibility is intersectional.

Reader Mode proved to be extremely useful while my vertigo lasted. But there was something even better:

Dark color schemes#section7

By the fourth week, I started feeling mostly fine. I opened Visual Studio Code to try to get back to work. In doing so, it served me well to find one more revelation: a light-text-on-dark-background scheme was SO much easier for me to read. (Though I still was not able to return to work at this time.)

I was quite surprised, as I had always preferred light mode with dark-text-on-light-background for reading, and dark mode, with light-text-on-dark for coding. I didn’t know at the time that I was suffering from photophobia (which is a sensitivity to light), which was one of the reasons I found it hard to read on my desktop and to use my mobile device at all.

As far as I know, photophobia is not a common symptom of vestibular disorders, but there are many conditions that will trigger it, so it’s worth looking into for our projects’ accessibility.

CSS is also planning a media query to switch color schemes. Known as prefers-color-scheme, it allows applying styles based on the user’s stated preference for dark or light theming. It’s also part of the Media Queries Level 5 spec, and at the time of writing this article it’s only available in Safari Technology Preview, with Mozilla planning to ship it in the upcoming Firefox 67. Luckily there’s a PostCSS plugin that allows us to use it in most modern browsers by turning prefers-color-schemequeries into color-index queries, which have much better support.

If PostCSS is not your cup of tea, or for whatever reason you cannot use that approach to automate switching color schemes to a user’s preference, try at least to provide a theming option in your app’s configuration. Theming has become extremely simple since the release of CSS Custom Properties, so implementing this sort of switch is relatively easy and will greatly benefit anyone experiencing photophobia.

Moving on#section8

After a month and some days, the vertigo disappeared completely, and I was able to return to work without needing any meds or further treatment. It should stay that way, as for most people it’s a once-in-a-lifetime occurrence.

I went back to my abled life, but the experience changed my mindset for good.

As I said before, I always cared for making my projects compatible for people using keyboard navigation and screen readers. But I learned the hard way that there are plenty of “invisible conditions” that are just as important to take into consideration: vestibular disorders, cognitive differences, dyslexia, and color blindness, just to name a few. I was totally neglecting those most of the time, barely addressing the issues in order to pass automated tests, which means I was unintentionally annoying some users by making websites inaccessible to them.

After my experience with vertigo, I’ve turned to an accessibility-first approach to design and development. Now I ask myself, “am I leaving anyone behind with this decision?,” before dropping a single line of code. Accessibility should never be an afterthought.

Making sure my projects work from the start for those with difficulties also improves the experience for everyone else. Think about how improving text styles for users with dyslexia, vertigo, or visual problems improves readability for all users, or how being able to control animations or choose a color scheme can be critical for users with attention disorders and photophobia, respectively, while also a nice feature for everybody.

It also turned my workflow into a much smoother development experience, as addressing accessibility issues from the beginning can mean a slower start, but it’s also much easier and faster than trying to fix broken accessibility afterwards.

I hope that by sharing my personal experience with vertigo, I’ve illustrated how we can all design and develop a better web for everybody. Remember, we’re all just temporarily abled.