Multidisciplinary Considerations

Lea J, Pothier D (eds): Vestibular Disorders. Adv Otorhinolaryngol. Basel, Karger, 2019, vol 82, pp 164–169
DOI: 10.1159/000490285

Advances in Vestibular Rehabilitation

Shaleen Sulway a · Susan L. Whitney b
a Hertz
Clinic for Meniere’s Disease and Vestibular Dysfunction, Toronto General Hospital, University Health Network,
Toronto, ON, Canada; b Departments of Physical Therapy and Otolaryngology, School of Health and Rehabilitation Sciences,
 

University of Pittsburgh, Pittsburgh, PA, USA

Abstract Introduction
Vestibular rehabilitation is an exercise-based program
that has been in existence for over 70 years. A growing The use of exercises for the treatment of patients
body of evidence supports the use of vestibular rehabili- with vestibular symptoms dates back 70 years
tation in patients with vestibular disorders, and evolving ago, when two practitioners, Sir Terence Caw-
research has led to more efficacious interventions. thorne and Harold Cooksey, observed that pa-
Through central compensation, vestibular rehabilitation tients with vestibular injuries tended to do better
is able to improve symptoms of imbalance, falls, fear of when they were given exercises designed to en-
falling, oscillopsia, dizziness, vertigo, motion sensitivity courage eye and head movements in a graduated
and secondary symptoms such as nausea and anxiety. fashion [1, 2]. Since the late 1990s, there has been
Early intervention is advised for falls prevention and a significant increase in evidence regarding treat-
symptom management; however, symptomatic patients ment techniques used for patients with vestibular
with chronic vestibular disorders may still demonstrate pathologies, allowing interventions to become
benefit from a course of vestibular rehabilitation. Recent more refined and efficacious.
advances in balance and gait training, gaze stability train- The physical presentation and functional limi-
ing, habituation training, use of virtual reality, biofeed- tations of patients with similar diagnoses can of-
back, and vestibular prostheses are discussed in this ten be quite different. Although most vestibular
chapter in the context of unilateral and bilateral vestibu- rehabilitation therapy (VRT) exercise programs
lar disorders. utilize eye and head movements, the types of ex-
© 2019 S. Karger AG, Basel ercise and their prescription is individualized and
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exercises are targeted to the deficits and symp- try of vestibular function in the acute phase, the
toms of the patient, rather than being specific to a brain interprets this asymmetrical information as
particular diagnosis. Symptom complaints may though the head is moving and patients perceive
include imbalance (in static positions and in gait, a sensation of movement even at rest. As central
especially associated with head movements), falls compensation occurs, that constant sense of mo-
and fear of falling, oscillopsia, dizziness, anxiety, tion diminishes, however, the brain may perceive
nausea, vertigo, and motion sensitivity (to body motion with head movements, causing dizziness
movements or motion in the environment). and imbalance [7]. Furthermore, if there are defi-
A recent Cochrane review comprised 39 trials cits of the vestibulo-ocular reflex (VOR), patients
with more than 2,400 patients with unilateral ves- experience visual blurring and a perception of
tibular dysfunction [3]. The authors reported that dizziness with head motion. As a result, patients
there is moderate to strong evidence that VRT is tend to avoid moving their head, which can delay
a safe, effective management for unilateral pe- the dynamic compensation process and lead to
ripheral vestibular dysfunction. Not surprisingly secondary issues such as fear of movement, anxi-
for the specific diagnostic group of BPPV, the ety, and neck stiffness. Vestibular rehabilitation
canalith repositioning maneuver was the optimal aims to promote compensation and hence, many
first line intervention compared to exercise-based of the balance, gait, and gaze stability exercises in-
VRT; although some studies suggested that the corporate head movements. Recovery from uni-
use of vestibular rehabilitation after repositioning lateral vestibular hypofunction is quite good and
maneuvers promoted greater balance and mobil- most patients return to normal activities.
ity skills [3]. After repositioning, some patients
continue to have balance deficits up to 1–3 Balance and Gait Training
months post repositioning [4, 5]. Static balance training is an important aspect of
A clinical practice guideline was also recently VRT. The patient may be asked to maintain bal-
developed by international experts to optimize re- ance in a variety of situations, such as with eyes
habilitation outcomes in patients with peripheral open or eyes closed on level ground and on com-
vestibular hypofunction. Based on strong evi- pliant surfaces such as thick carpets or a foam
dence and a preponderance of benefit over harm, pad. Exercises with the eyes closed decrease vi-
the guideline suggests that clinicians should offer sual dependence on balance; whereas exercises on
vestibular physical therapy to persons with unilat- compliant surfaces alter somatosensory inputs
eral and bilateral vestibular hypofunction (BVH) required for balance and promote the use of vi-
with impairments and functional limitations re- sual and vestibular inputs to maintain balance.
lated to the vestibular deficit [6]. This chapter will Once patients are able to master these balance
focus on recent advances in VRT for patients with conditions, the addition of head movements in all
unilateral and bilateral vestibular disorders. planes add perturbations to their balance and fa-
cilitate compensation [8]. External perturbations
are also widely used to increase a patient’s stabil-
Unilateral Vestibular Hypofunction ity and generate strategies to maintain balance
and avoid falls.
Patients presenting with unilateral hypofunction In an effort to minimize symptoms of dizziness
of the vestibular system are good candidates for and unsteadiness, patients tend to adopt en-bloc
VRT [3, 6]. Signals from the vestibular labyrinth postures (head and trunk remain rigid together)
provide accurate information to the brain regard- when they are in motion. The addition of head
ing head movements. When there is an asymme- movements is often incorporated during walking
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Lea J, Pothier D (eds): Vestibular Disorders. Adv Otorhinolaryngol. Basel, Karger, 2019, vol 82, pp 164–169
DOI: 10.1159/000490285
exercises. Head movements are encouraged in oratory. A trial is ongoing to determine if long-
different planes to allow the brain to desensitize term adaptation can occur from training at a pre-
these movements and compensate for the asym- set VOR gain [13].
metrical vestibular function so that patients can
learn to normalize their balance in gait [8]. Timing of Intervention
People with acute unilateral vestibular loss are of-
Gaze Stabilization ten responsive to early VRT interventions [14].
Gaze stability exercises are used for VOR adap- Hall et al. [6] reported that early VRT intervention
tion; these exercises are provided with the aim of after vestibular loss reduced falls, improved activ-
increasing the VOR gain and stabilizing vision ities of daily living, and demonstrated improve-
during active and passive head movements. This ments in quality of life. Early exercise can also pre-
dynamic process is mediated through visual in- vent complications such as fear of movement,
puts (retinal slip) and relies on the occipital lobes, anxiety, and falls. In cases where the vestibular
midbrain, and cerebellum to use the error infor- loss is chronic and uncompensated, VRT is still
mation to recalibrate the VOR gain [9]. The first indicated, however, the therapist must identify the
exercise many patients start with is referred to as maladaptive strategies or conditions that have
“VOR × 1.” Patients are asked to maintain gaze on prevented compensation and manage them. Some
a stationary target in front of them, while they of the barriers to recovery that may need to be ad-
move their head on the horizontal plane for 1–2 dressed include avoidance of certain movements,
min, then in the vertical plane for 1–2 min, with psychological factors (fear of falling, anxiety /de-
the goal of keeping the target in focus [10]. Such pression), use of vestibular suppressants, medical
exercises are usually given as part of the home ex- comorbidities such as migraines, or visual, senso-
ercise program, and patients are expected to com- ry or central pathologies [15]. If such issues are
plete them 3–5 times daily. The patient gradually present, psychological support, education, and a
increases the velocity of head movement to the multi-disciplinary approach may be beneficial.
level just before they lose focus of the target. As
VOR function improves, patients are able to per- Visually Induced Dizziness
form the movement with fewer symptoms at fast- After vestibular hypofunction, some patients
er head velocities. The exercise is progressed to tend to over-utilize visual information, and this
the use of more visually stimulating targets, such can result in symptoms being provoked or made
as checkerboards and eventually moving targets, worse when confronted with disorienting visual
where the target moves opposite to the head stimuli or motion in the environment, such as in
movement – often referred to as “VOR × 2” exer- crowds, traffic, grocery stores, when watching
cises. Speed, backgrounds, distance to the target, movies or when visualizing complex patterns.
and stance vs. gait are all manipulated as part of Bittar and Lins recently looked at the characteris-
the exercise program. tics of patients with persistent postural perceptu-
The VOR exercises have been shown to im- al dizziness, a recent diagnosis that has been in-
prove dynamic visual acuity [11, 12]. Proposed cluded in the International Classification of Dis-
mechanisms include an increase in the VOR gain ease 11. They found that 74% of patients with
independent of peripheral vestibular recovery persistent postural perceptual dizziness com-
and an increase in the number of compensatory plained of visually induced dizziness and a high
saccades during head rotations [11, 12]. Recent percentage of these patients showed symptomatic
evidence suggests that the angular VOR can be benefit from medications such as selective sero-
selectively trained on the involved side in the lab- tonin reuptake inhibitors [16]. According to
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Lea J, Pothier D (eds): Vestibular Disorders. Adv Otorhinolaryngol. Basel, Karger, 2019, vol 82, pp 164–169
DOI: 10.1159/000490285
Bronstein et al. [17], relying primarily on vision falls are often more pronounced in this patient
after a vestibular disorder is a negative predictor population [26]. Central compensation with
of successful rehabilitation. Physical therapy in- BVH occurs through sensory reweighting [27].
terventions have been shown to reduce visually With BVH, the goal is to: (1) augment vision and
induced dizziness [18–21], however, exercises proprioception to compensate for the vestibular
may need to be combined with medications to de- loss, (2) develop compensatory strategies in situ-
crease sensitivity to provocative stimuli [15]. ations of imbalance, and (3) develop substitution
Habituation type exercises are generally pre- strategies to assist with gaze stability. Vestibular
ferred to decrease visual symptoms. The exercises rehabilitation assumes an important role in re-
are applied through graded, repetitive exposure covery/compensation of these three areas with
to the movements or situations that provoke the goal of enhanced patient safety and an in-
symptoms, with the goal of desensitizing the pa- creased independence.
tient to that stimulus. This can involve training
balance and the VOR with a variety of visual Biofeedback Training
backgrounds, through the use of virtual reality or Patients with BVH often become unsteady in the
other immersive environments [18, 22, 23] or dark or on uneven ground, therefore, the VRT ex-
through use of optokinetic exercises such as disco ercises used often involve learning to stand and
balls, screen savers or with take home DVDs balance with eyes closed or on compliant surfac-
showing optokinetic stimulation [19, 20]. Devel- es. In balance situations, where vision and pro-
opments in the gaming industry have resulted in prioceptive information are compromised (i.e.,
low cost virtual reality systems like the Nintendo on a compliant surface with eyes closed), patients
Wii Fit Plus, which also uses force plate technol- typically fall. A recent advance in VRT has come
ogy to gather center of pressure information to from the use of biofeedback devices that code for
provide visual feedback on the screen during bal- head and body orientation and provide auditory
ance games [24]. Meldrum et al. [25] utilized the or vibrotactile feedback to enhance postural con-
Wii Fit in a recent randomized trial, but focused trol [28–31]. With auditory biofeedback, patients
on balance exercises rather than on visual symp- are provided with sound coding related to their
toms. The use of the Wii Fit and conventional bal- body sway. Dozza et al. [28] reported that the au-
ance exercises yielded functional improvements ditory biofeedback compensates for missing ves-
but there were no differences in outcomes. Pa- tibular information; a patient with bilateral ves-
tients did, however, report that they enjoyed the tibular loss on a compliant surface with eyes
virtual training [25]. Given that it is an enjoyable closed benefits far more than a healthy individual.
activity that can be done at home, the Wii Fit or They noted a higher frequency of postural correc-
other newer low cost virtual reality devices on the tions in the BVH group [28]. Vibrotactile feed-
market may be useful tools for decreasing the re- back studies have demonstrated that patients
sponsiveness to visual stimuli, however, further with BVH are capable of using orientationally
studies are needed to validate this effect. correct vibrotactile cues on the head to stabilize
posture in standing [29] or on the trunk to im-
prove gait [30]. Further studies are needed to de-
Bilateral Vestibular Hypofunction termine if there is any long-term training effect
with these devices. Portable vibrotactile devices
Bilateral vestibular loss is a challenging condition that can be used at home are currently being test-
for patients, especially when the loss is complete. ed to determine if the devices can assist with fall
Symptoms of postural instability, oscillopsia, and reduction and improve postural stability.
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Lea J, Pothier D (eds): Vestibular Disorders. Adv Otorhinolaryngol. Basel, Karger, 2019, vol 82, pp 164–169
DOI: 10.1159/000490285
Gaze Stabilization These implants aim to detect motion and electri-
To manage complaints of oscillopsia, in addition cally stimulate the corresponding ampullary
to gaze stability exercises (as used with unilateral nerves to generate VOR responses. Preliminary
vestibular hypofunction), saccadic substitution results show that the stimulation can activate ves-
exercises are used, where patients are trained to tibular-ocular reflex pathways and generate
coordinate eye and head movements [10]. Stud- smooth and controlled eye movements [35]. Fu-
ies confirm that performing saccadic eye move- ture advances in this field, along with vestibular
ments has a positive effect on stabilizing gaze by rehabilitation to train patients to use the inputs
way of improving dynamic visual acuity. This from these implants, will hopefully lead to im-
improvement, however, does not seem to be due proved function and less disability in patients liv-
to increases in the gain of the VOR, rather a pro- ing with BVH.
posed mechanism for this improvement may lie
in the central programming of eye movements
[11, 32]. Conclusion
A recent systematic review attempted to deter-
mine the effect of VRT on adults with BVH. They Vestibular rehabilitation techniques have evolved
reported that there is moderate evidence that gaze over the past few decades, and there is reliable re-
and postural stability improve after VRT [33]. search into the efficacy of vestibular exercises for
peripheral vestibular dysfunction. Customized
Vestibular Prosthesis treatment programs focus on decreasing symp-
Despite its benefits, VRT does not lead to recov- toms of dizziness, oscillopsia and postural insta-
ery of the vestibular system in patients with BVH bility, and addressing the patient’s functional def-
and patients can still be left with significant im- icits. The aim of the exercises is to promote cen-
pairments, especially in environments where vi- tral compensation for the vestibular dysfunction.
sual or somatosensory cues are diminished or ab- While patients with unilateral vestibular dysfunc-
sent. BVH also leads to a considerable reduction tion tend to do quite well and can often return to
in quality of life and increases risk of falls [34], all or most of their activities of daily living, pa-
thus supporting the need for future advances in tients with bilateral vestibular loss continue to
VRT to mitigate these issues. Surgically implant- have difficulties with balance. Future advances in
ed vestibular prosthesis prototypes are being used the area of vestibular prostheses may prove ben-
in select patients in centers around the world. eficial for persons living with BVH.

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DOI: 10.1159/000490285
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Shaleen Sulway, PT
Hertz Clinic for Meniere’s Disease and Vestibular Dysfunction, Toronto General Hospital
University Health Network, 200 Elizabeth Street
Toronto, ON M5C 2W8 (Canada)
E-Mail [Link]@[Link]
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Lea J, Pothier D (eds): Vestibular Disorders. Adv Otorhinolaryngol. Basel, Karger, 2019, vol 82, pp 164–169
DOI: 10.1159/000490285