Vestibular Rehabilitation

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 by Bayan Al Othman, MD on June 30, 2020.


Overview

Cawthorne and Cookey created a series of exercises to manage patients with vertigo in the 1940s. [1] These exercises, known as vestibular physical therapy or rehabilitation, were shown in prospective trials to improve outcomes and reduce symptoms of vertigo in patients with vestibular hypofunction. [1] In 2015, a Cochrane review concluded that vestibular physical therapy was safe and effective for the management of peripheral vestibular dysfunction. [2] Vestibular rehabilitation is used to enhance the interaction of the remaining sensory systems with the central nervous system to compensate symptoms of vestibular lesions. [1], [3] These exercises can improve postural control and head position, stabilize head and trunk motion, reduce vertigo, and improve gaze stabilization. [1], [3]

Epidemiology

Vestibular dysfunction occurs in 35% people over 40 years. [4] Vestibular dysfunction increases with age with near 85% of people over 80 years have dysfunction of the vestibular system. [5] Individuals with signs of vertigo or vestibular hypofunction may benefit from vestibular rehabilitation. [1] The following table list several conditions that are managed with vestibular rehabilitation.

Peripheral Central
* Benign paroxysmal positional vertigo

[1]

* Bilateral vestibular loss [1], [5]

* Labyrinthitis [1]

* Meniere’s disease [1], [5], [6]

* migraines[6]

* Movement or visually provoked

dizziness [1]

* Multisensory dizziness [6]

* Vestibular hypofunction [5], [6]

* Vestibular neuronitis [1], [5]

* Vestibular schwannoma [1], [5]

* Vestibular surgery[5], [6]

* Brain injury [1]

* Cerebellar degeneration/disorders [1]

* Concussion [1]

* Multiple sclerosis [1]

* Parkinson disease [1]

* Presbystasis [1]

* Stroke [1]

* Vestibular migraine [1]

History

Before starting vestibular rehabilitation, a description of the symptoms, the inciting factors (location, activities), and the comorbidities of patient should be considered. [1]

Physical Examination and Signs

The assessment of the visual system, proprioception, physical strength, motor ability, and cerebellum function should be performed. [7] These exams will assist in the determination if vestibular rehabilitation is correct for the patient. The following testing should be performed as part of the evaluation.

  • Activities testing
  • Participation testing
  • Sensory integration testing
  • Vestibulo-ocular reflex testing
  • Vestibulospinal reflex (VSR) testing

Pathophysiology of Vestibular Compensation

After acute vestibular damage, plastic changes of the vestibulocerebellar pathways occurs by cerebellar modulation, inhibition of the vestibular pathways, to minimize the acute symptoms of vestibular dysfunction. [3] Remaining sensory systems then undergo modulation to replace the lost function of the vestibular system in a process known as sensory reweighting. [3] Further sensory calibration of the vestibular system occurs through continued exposure to movement during daily activities and postural training. [3] Vestibular rehabilitation enhances the plastic changes to maximize the functional recovery of the vestibular system. [1], [3]

General Treatment: Vestibular Rehabilitation

Vestibular rehabilitation exercise are divided into three categories: adaptation, habituation, and substitution. [1], [3], [7] To maximize the effect of these exercises, optokinetic and postural training are often performed simultaneously over the treatment course. [1]

Exercises

Adaptation:

The goal of adaptation is to reduce gaze instability caused by the reduction in vestibular response to head movement. [1], [5] In a functioning vestibular system, image projected onto the retina during head movement stimulates a vestibular response to correct the “retinal slip”, the movement of the image across the retina. [1] This allows for gaze stability and tracking of objects. [1] Adaptation exercises promote the remaining vestibular system to accommodate the “retinal slip”. [1] Exercises involve creating “retinal slips”, by moving the head in increasing amplitudes while focusing on a stationary object to train the remaining vestibular system to respond to stabilize gaze. [1], [5] Benefits of these exercises can be increased by increasing the

duration of the “retinal slip” by turning the head in the opposite direction of a moving target. [1] For maximum recovery, all frequencies and directions of “retinal slip” should be used during rehab. [1], [5]

Habituation:

Habituation seeks to reduce symptoms caused by movement through repeated exposure to stimuli that promotes symptoms of vertigo. [1], [5] The patient must identify movements that produce symptoms. Then, exercises are developed that mimic these movements to reproduce these symptoms. [1], [5] Over time, repeated exposure to symptom inducing exercises will decrease the severity of the symptoms. [1], [5] For a maximum response, exercises must increase in speed and occur in more challenging situations. [1], [5]

Substitution:

Sensory substitution enhances other sensory systems to improve balance and postural control. [1] With vestibular dysfunction, the appearance of moving objects can be perceived as self-movement, resulting in inappropriate balance correction that leads to instability. [1] Balance exercises involve training the body to maintain balance with a variety of visual input and posture adjustments. [5] Exercises can be improved with moving visual input combined with head movements. [1]

Optokinetic training:

Optokinetic training uses low frequency (<0.3 Hz) visual information to induce visual motion sensitivity, or motion sickness, through stimulation of the vestibulo-ocular reflex. [1], [5] This results in adaptation of the vestibular system to minimize symptoms from viewing moving objects. [5]

Postural training:

Postural exercises should accompany vestibular rehabilitation when a patient is at risk of falling, has instability, has a gait speed is <0.8 m/s. [1] Exercises include standing and walking on a variety of surfaces, head and eye movements, altered lighting, stimulating and moving backgrounds, and hand-eye coordination tasks. [1], [6]

Treatment timing and length

Vestibular rehabilitation works best when patients perform exercises at home with a customized exercise program tailored to the patients symptoms and deficits. [1], [3] The exercise program should be designed to restore balance, strength, and functional activity while preventing injury during performance of the exercises. [1] Home exercises are prescribed 2-3 times per day for a maximum of 10-15 minutes of rehab per day for acute vestibular symptoms and at a minimum of 20 minutes per day for chronic vestibular dysfunction. [1], [5], [8] Optimal treatment length is unknown, but generally treatment for unilateral vestibular hypofunction should continue for 4-6 weeks, with more time for bilateral or complete vestibular dysfunction. [1], [5], [8] Treatment should begin as soon as possible after symptoms begin to take advantage of the plasticity of sensory systems and minimize risk from falls from symptoms of vertigo. [5], [8]

Other considerations

Medications to control symptoms should be limited to less than 3-5 days as it can slow the recovery by vestibular rehabilitation. [1], [5], [6]

Patients with anxiety, panic attacks, or depression associated with onset of vestibular dysfunction should be co-managed with a psychiatrist or psychologist. [1]

Prognosis

Vestibular rehabilitation reduces risk of falling and symptoms of vertigo. [5], [8] Balance, gait, and quality of life is also often improved. [5], [8] For vestibular dysfunction, vestibular rehabilitation in conjugation with control of symptoms with medication is more effective for long term recovery than medication alone. [1]

While vestibular rehabilitation is often beneficial, consideration of a patient’s negative prognostic factors (see table) should be considered before prescribing rehab.

Negative Prognostic Factors to the Benefits of Vestibular Rehabilitation

Medical [1], [3], [5], [8] Psychiatric and Behavioral [1], [5], [8]
* Cognitive dysfunction

* Comorbid disease limiting movement

* Microvascular brain lesions

* Migraines

* Peripheral neuropathy and other

preexisting sensory deficits

* Pre-existing eye disorder limiting

vision

* Anxiety

* Fear of falling

* Fear of movement

* Feeling of “fogginess”

* Feeling that improvement is not possible

* Obsessive-compulsive disorder

* Perfectionistic personality

Due to impaired interpretation of sensory data, the following conditions will have minimal recovery with vestibular rehabilitation. [3]

  • Functional dizziness
  • Phobic postural vertigo
  • Chronic subjective dizziness

Additional Resources

C. D. Hall et al., “Vestibular Rehabilitation for Peripheral Vestibular Hypofunction,” J. Neurol. Phys. Ther., vol. 40, no. 2, pp. 124–155, Apr. 2016.

References

[1] S. L. Whitney, A. A. Alghwiri, and A. Alghadir, “An overview of vestibular rehabilitation,” in Handbook of clinical neurology, vol. 137, 2016, pp. 187–205.

[2] M. N. McDonnell and S. L. Hillier, “Vestibular rehabilitation for unilateral peripheral vestibular dysfunction,” Cochrane Database Syst. Rev., Jan. 2015.

[3] F. Tjernström, O. Zur, and K. Jahn, “Current concepts and future approaches to vestibular rehabilitation,” J. Neurol., vol. 263, no. S1, pp. 65–70, Apr. 2016.

[4] Y. Agrawal, J. P. Carey, C. C. Della Santina, M. C. Schubert, and L. B. Minor, “Disorders of balance and vestibular function in US adults: data from the National Health and Nutrition Examination Survey, 2001-2004.,” Arch. Intern. Med., vol. 169, no. 10, pp. 938–44, May 2009.

[5] C. D. Hall et al., “Vestibular Rehabilitation for Peripheral Vestibular Hypofunction,” J. Neurol. Phys. Ther., vol. 40, no. 2, pp. 124–155, Apr. 2016.

[6] A. Sealy, “Vestibular assessment: a practical approach,” Occup. Med. (Chic. Ill)., vol. 64, no. 2, pp. 78–86, Mar. 2014.

[7] A. Deveze, L. Bernard-Demanze, F. Xavier, J.-P. Lavieille, and M. Elziere, “Vestibular compensation and vestibular rehabilitation. Current concepts and new trends,” Neurophysiol. Clin. Neurophysiol., vol. 44, no. 1, pp. 49–57, Jan. 2014.

[8] S. L. Whitney, A. H. Alghadir, and S. Anwer, “Recent Evidence About the Effectiveness of Vestibular Rehabilitation,” Curr. Treat. Options Neurol., vol. 18, no. 3, p. 13, Mar. 2016.