Vestibular Treatment

Original Editor - Jess Bell based on the course by Bernard Tonks
Top Contributors - Jess Bell

Introduction[edit | edit source]

Vestibular disturbance is a significant issue globally, with 80 percent of people aged over 65 years experiencing dizziness. Individuals who have vestibular impairment generally have problems with gaze and motion stability, as well as balance and postural control dysfunction. Vestibular rehabilitation is an evidence-based approach to managing these issues.[1]

Goals of Treatment[edit | edit source]

The focus of vestibular rehabilitation is to:[2]

  • Improve postural control and balance
  • Improve the patient’s ability to see clearly during head movement (gaze stability)
  • Improve the patient’s overall general physical condition
  • Reduce the patient’s social isolation
  • Decrease the patient’s motion sensitivity

For treatment to be effective, an appropriate home exercise programme and patient compliance are essential. It is also important that patients feel that their programme is manageable and within their level of ability.[2]

Patient Tips[edit | edit source]

The following advice can be useful for patients engaging in vestibular rehabilitation programmes:[2]

  • “What makes you a little bit dizzy is good for you” (for chronic vestibular hypofunction)
  • “You don’t have to overdo it for the exercises to work - you just need to make yourself mildly to moderately dizzy, but it should settle fairly quickly”
  • “You don’t need to do all the exercises at once. It’s better to do brief, multiple episodes of exercises during the day”
  • “It can be helpful to engage in ‘grounding’ or ‘calming’ strategies before and even during the exercises”

Decompensation[edit | edit source]

It is important for patients and clinicians to understand that recovery following vestibular loss may be tenuous.[2] Patients may experience a recurrence in symptoms or a relapse with fatigue, stress, prolonged periods of inactivity, illness or occasionally a change in certain medications. This is termed ‘decompensation’.[2][3]

Predictors of Outcome[edit | edit source]

The following factors are predictive of a better prognosis in vestibular patients:[2]

  • Patients who have less initial disability
  • Patients who are seen earlier after onset
  • Patients with stable unilateral vestibular deficits
  • Partially compensated patients whose symptoms are provoked only by movement

Treatment Approaches[edit | edit source]

Surface Orientation Exercises[edit | edit source]

Surface orientation exercises are performed as follows:[2]

  • Patients lie on a firm surface (i.e. bed or floor)
    • Alternatively they can sit or stand
  • Patients breathe deeply and relax
  • They should concentrate on the sensation of lying quietly on the bed and remain quiet / still for 5 to 10 seconds
  • They should then close their eyes for five seconds

These exercises draw the patient’s attention to somatosensory input, which can have a positive effect on this patient group. It can help to calm the central nervous system, improve sensory integration and enhance postural control and balance. They are particularly useful for post-concussion syndrome patients.[2]

Vision Exercises[edit | edit source]

Vision exercises can be introduced in the following order:[2]

  • Peripheral field expansion
  • Smooth pursuits
  • Saccades

Peripheral field expansion[edit | edit source]

These exercises encourage the patient to soften his / her gaze and work on increasing peripheral visual field awareness.

Soft Focus[edit | edit source]

The patient holds the star chart at a reading distance. The following instructions are given:[2][4]

  • Look 'hard' at the dot in the centre of the star
  • Notice how the dot reduces in size and your awareness of the periphery decreases
  • Next look at the dot 'softly'
  • Notice how your periphery opens up
  • While making sure you keep looking at the dot, touch each number in order with your finger

100 Number Exercise[edit | edit source]

The purpose of this exercise is to stimulate a patient’s peripheral visual fields in a tabletop activity. When patients learn to actively ‘soften’ their gaze, visual information can enter without using their focal system.[2] The exercise is performed as follows:[2]

  • The patient sits with the 100 number grid in front of them - either lying flat or on an angle using an incline board
  • Patients are asked to choose a number to look at
  • Without moving the focus of their vision from this number, they aim to see as many numbers as possible away from the number they are focusing on

NB: The harder patients try to ‘focus’, the worse they tend to perform. It is, therefore, important that patients ‘soften’ their gaze in order to see the peripheral numbers. Some patients may wish to use ‘blinders’ to block other numbers when focusing on a specific block.[2]

Saccade Training[edit | edit source]

Wall Clock Saccades[edit | edit source]

This exercise is performed as follows:[2]

  • The patient stands in front of a wall
  • 12 visual targets are placed on the wall (e.g. post-its) in a circle like a clock
  • An X is placed in the middle of the clock
  • Patients are instructed to move their eyes as quickly as possible from each post-it note to the centre X, moving first in a clockwise and then in a counter-clockwise direction
  • This exercise can be combined with gaze stability exercises (see below)

Adaptation or Gaze Stability Exercises[edit | edit source]

Adaptation exercises are aimed at “inducing long-term changes in the neuronal response of the vestibular system to a specific error signal – retinal slip.”[5] They should lead to adaptation (i.e. when there is an error signal, the central nervous system tries to reduce it, and modifies gain of the vestibular system.[2][6]

They aim to:[5]

  • Increase the gain of the vestibulo-ocular reflex (VOR)[2]
    • VOR gain is defined as the ratio of eye velocity to head velocity during head movements
    • Ideally, the gain of the VOR approximates 1.0. This indicates that eye velocity matches head velocity, thus providing accurate gaze stability[7]
  • Improve visual acuity / reduce the amount of blurring with head movements
  • Decrease dizziness with head movements
  • Improve postural stability
  • Reduce symptoms

They are indicated when patients have:[2]

  • Oscillopsia
  • Decreased visual acuity with head motion (positive head thrust or dynamic visual acuity tests)
  • Blurring or jumping of the visual field with head movement

Adaptation exercises require patients to move their head while focusing on a small stationary target (i.e. X1 adaptation exercises) or on a target that moves in the opposite direction of the head movements (i.e. X2 adaptation exercises).[5] It is possible to use a tennis ball on a string to create a moving target.[2] Additional challenges can be added (e.g. walking forwards or backwards).[2][5] It should be noted that:[2]

  • Adaptation takes time
  • It is context specific, so it is necessary to vary the exercise
  • Adaptation is affected by voluntary control
  • It is necessary to keep the target in focus

[8]

Treatment variables:[2]

  • Duration: 1-2 minutes - (Tonks has found that clinically patients respond well to sets lasting less than 90 seconds)[2]
  • Add in background distraction
  • Change body position (e.g. sit, stand, walk)
  • Alter speed (slow, fast)
  • Vary frequency (2 to 3 times per day, 5 days per week)
  • Alter the distance from the target (3ft (0.9m), 8ft (2.4m), 10ft (3m))

NB: The frequency of head movement should be greater than 2 Hz in order to facilitate adaptation.[2]

[9]

Adaptation of the VOR[edit | edit source]

After an acute unilateral vestibular lesion (UVL), VOR gain returns to normal in 1 to 3 months, but only with low frequencies of head movement.[10] During rapid, unpredictable head movements toward the lesioned side, there is a marked deficit in VOR function. Retinal slip results in an error signal that the brain attempts to minimise by increasing the gain of the vestibular system (adaptation).[2][3] Gaze stabilisation exercises assume that repeated periods of retinal slip will induce adaptation.[2]

However, while adapting VOR gain works for well for lower frequencies of head movement,[2] a substitution strategy involving saccades is more effective for higher frequencies of head movement (see BVL section below for examples).[11] It is important here to understand the difference between covert and overt saccades. [2][12]

  • Covert saccades occur during head rotation and cannot be seen
  • Overt saccades occur after head rotation and can be seen

Covert saccades are important in the recovery of gaze stability[2] and they are beneficial for the dynamic visual acuity of patients with bilateral vestibular hypofunction.[13]

Riska and colleagues have found that: [14]

  • UVL patients who have primarily covert saccades perform better on dynamic visual acuity, gait and balance measures - they, therefore, have a reduced falls risk
  • Individuals who rely on overt saccades or a combination of overt and covert saccades are more likely to have an abnormal gait speed and be at risk of falls based on their DGI score

Visual / Vestibular Integration Exercises[edit | edit source]

These exercises require head movement with visual targeting.[2]

Blind spot check[edit | edit source]

  • Patients are asked to keep their head still and turn their eyes to the left
  • They then turn their head to look over their shoulder, still looking left with their eyes
  • They are then asked to return their head and eyes forward in one smooth motion
  • The therapist should watch the patient’s eyes to ensure they return forward without stopping along the way
  • Repeat the same sequence looking to the right[2]

Chair Spins[edit | edit source]

  • Patients are asked to spin their chair 180 degrees to the right and stop and fixate on a target
  • They should let any dizziness or disturbance settle before spinning the chair 180 degrees back to the left
  • Once again, they should focus on the visual target and let any dizziness or disturbance settle
  • Repeat this sequence as tolerated[2]

Habituation Exercises[edit | edit source]

Habituation refers to “the reduction in a behavioral response to repeated exposure to a provocative stimulus, with the goal of reducing symptoms related to the vestibular system.”[15]

The patient is asked to perform a number of repetitions of a specific movement that causes mild or moderate symptoms.[15] The specific exercises are chosen based on which movements / situations provoke a patient’s symptoms (e.g. busy environments).[2] Habituation exercises are used to decrease motion sensitivity - i.e. repeated, controlled exposure to a provocative stimulus can cause a decrease in symptoms of dizziness.[2][15] 

They are indicated in patients who:[2]

  • Have dizziness with quick head position changes
  • Avoid specific movements

Patients who are experiencing anxiety with motion may also benefit.[2]

Treatment variables to consider include:[2]

  • Intensity
    • There needs to be enough speed and range of motion to cause mild to moderate dizziness
    • The patient should return to his / her baseline symptoms within 1 minute
  • Number of positions
    • Up to 3 (easy to hard)
  • Symptom duration
    • Should not exceed 1 minute
  • Frequency
    • 2 to 3 times per day
    • 2 to 3 movement patterns per set
    • 2 to 3 repetitions per movement pattern

Treatment considerations:[2]

  • Symptoms must return to baseline before continuing
  • It is necessary to wait an additional 30 seconds after each repetition
  • It is not possible to habituate headaches, oscillopsia or nausea
  • Symptom duration and intensity should decrease after 2 to 3 weeks
  • Patients may have to increase the intensity of the movement to bring on the same amount of dizziness
  • It is important to be creative with these exercises - consider the activities that cause dizziness / symptoms and focus on these

[16]

Cawthorne-Cooksey Exercises[edit | edit source]

These exercises were developed in the 1940s to address patient’s complaints of vertigo and impaired balance. They are similar to habituation exercises and could be indicated in patients who have dizziness, motion-provoked symptoms and imbalance. However, the Cawthorne-Cooksey is a generic exercise programme that is not customised to a patient's specific needs.[2][15]

Static and Dynamic Postural Control Balance Exercises[edit | edit source]

When introducing postural control balance exercises, it is important to try to incorporate all aspects of balance:[2]

  • Visual
  • Somatosensory
  • Vestibular

Other considerations during balance retraining include:[2]

  • Head position - static / moving
  • Eyes open / closed

Physical Conditioning[edit | edit source]

Physical conditioning is an extremely important component of a vestibular rehabilitation programme. For patients who are able to participate, a regular walking programme can have a number of benefits:[2]

  • Prevent deconditioning
  • Provide balance challenges
  • Improve compensation
  • Decrease social isolation
  • Other exercises can also be completed during the walk

Tai Chi[edit | edit source]

There are a number of articles that highlight the benefits of Tai Chi, including balance, flexibility and lower extremity strength. However, patients do typically need to attend a specialised class.[2][15][17]

Efficacy of Treatment for Unilateral Vestibular Dysfunction[edit | edit source]

A recent Cochrane review found that:[18]

  • There is moderate to strong evidence to suggest that vestibular rehabilitation is safe and effective for patients who have unilateral peripheral vestibular dysfunction
  • It is not associated with adverse effects

Hall and colleagues found that:

  • “Strong evidence indicates that vestibular rehabilitation provides clear and substantial benefit to patients with acute or subacute unilateral vestibular hypofunction, so, with the exception of extenuating circumstances, vestibular rehabilitation should be offered to all patients who are still experiencing symptoms (dizziness, dysequilibrium, motion sensitivity, and oscillopsia) or imbalance due to unilateral vestibular hypofunction”[15]

Shepard and Telian examined the effectiveness of vestibular rehabilitation for patients with chronic vestibular dysfunction. They compared a customised 3 month vestibular exercise programme with a generic 3 month exercise programme. [19] They found that:[19]

  • Dizziness decreased by 85 percent in the vestibular exercise group and 64 percent in the generic group
  • Only the vestibular exercise group had a decrease in dizziness with activities of daily living
  • The vestibular exercise group had significant improvement in dynamic and static postural control and a reduction in motion sensitivity
  • The generic exercise group only had improvements in static balance

Strupp and colleagues found that patients with acute unilateral vestibular hypofunction who participated in one month of vestibular rehabilitation had significantly improved postural stability compared with an untreated control group.[20]

Yardley and colleagues investigated the benefits of an unsupervised, customised vestibular exercise programme compared to an untreated control group.[21] Outcome measures were:[21]

  • Symptom severity
  • Anxiety
  • Motion sensitivity
  • Sharpened Romberg test

The authors found that there were significant improvements in all measures in the vestibular habituation exercise group versus the control group who did not exercise.[21]

Two studies by Cohen and Timball found that vestibular rehabilitation resulted in increased independence in activities of daily living, decreased subjective reports of dizziness, reduced ataxia and better postural control in patients who had chronic dizziness caused by UVLs. They also noted that improvements were not affected by age, gender or a history of vertigo.[22][23]

Topuz and colleagues explored the effect of vestibular rehabilitation exercises on 122 patients with chronic unilateral vestibular dysfunction. They compared home exercises with supervised exercises and found that subjects in the supervised sessions “demonstrated rapid recovery while the home exercise group did not”.[24]

Finally, Herdman and colleagues demonstrated that UVL patients who participated in adaptation exercises had improved dynamic visual acuity.[25]

Treatment Approaches for Bilateral Vestibular Lesion (BVL) Patients[edit | edit source]

  • Exercises that foster the substitution of visual and somatosensory information to improve gaze and postural stability should be included in the rehabilitation programme of BVL patients
  • Patients should be encouraged to develop compensatory balance strategies
  • Adaptation exercises may enable some patients to augment their remaining vestibular function[2]

Prognosis for BVL Patients[edit | edit source]

  • Recovery following BVL is slower
  • Recovery may be compromised by other medical conditions
  • Patients may need to continue exercises on a regular basis to maintain function
  • Postural stability will never be normal
  • There is an increased risk for falls in low-vision environments, on uneven surfaces, or when patients are fatigued[2]

Treatment Approaches for BVL Patients (which can also be used for UVL patients)[edit | edit source]

Gaze Stability Exercises[edit | edit source]

Exercises such as the X1 adaptation exercise[26] (see above) can help to improve BVL patients' remaining vestibular function.[2]

Substitution Exercises[edit | edit source]

  • Active eye-head movements between two targets foster saccadic or pursuit strategies
  • Imaginary targets help to foster central pre-programming[2]

Postural Stability[edit | edit source]

The same treatment approach used for patients with UVL can be used for BVL, but the following considerations are important for BVL patients.[2]

  • Avoid simultaneous alteration of somatosensory and visual cues
  • Note that patients are easily overstimulated
  • Safety education is essential to ensure that a patient does not fall
  • Progress exercises slowly

Efficacy of Treatment in Bilateral Vestibular Dysfunction[edit | edit source]

There is strong evidence to suggest that vestibular rehabilitation has significant benefits for patients with bilateral vestibular hypofunction”.[15][25][29] [30][31]

Exercise Prescription Suggestions[edit | edit source]

As little as 12 minutes of gaze stabilisation exercises per day over 3 exercise sessions may be enough to cause recovery in acute and subacute post-operative vestibular patients.[15] In patients with chronic unilateral vestibular hypofunction, it appears that performing gaze stability exercises 3 times per day for a total of 20 minutes may be enough to encourage recovery.[15]

The following table summarises treatment choices for UVL and BVL patients:

Table 1. Treatment Approaches for UVL and BVL Patients.
Treatment UVL Asymetrical BVL BVL
VOR X 1 (adaptation exercise) Yes Yes (usually) Can try, but difficult
VOR X 2 (adaptation exercise) Yes as a progression Maybe as a progression No – too difficult
Habituation exercises Yes Yes (usually) Can try, but difficult
Cawthorne – Cooksey exercises No - not customised No - not customised No - not customised
Postural control exercises Yes Yes Yes
Physical conditioning Yes Yes Yes
Active eye head exercises No Generally no, but occasionally Yes
Imaginary targets No No Yes

References[edit | edit source]

  1. Tonks B. Introduction to Vestibular Rehabilitation Course. Physioplus. 2021.
  2. 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 2.19 2.20 2.21 2.22 2.23 2.24 2.25 2.26 2.27 2.28 2.29 2.30 2.31 2.32 2.33 2.34 2.35 2.36 2.37 2.38 2.39 2.40 2.41 2.42 2.43 2.44 2.45 2.46 Tonks B. Vestibular Treatment Course. Physioplus, 2021.
  3. 3.0 3.1 Han BI, Song HS, Kim JS. Vestibular rehabilitation therapy: review of indications, mechanisms, and key exercises. J Clin Neurol. 2011;7(4):184-96.
  4. Dr Lynn Hellerstein. Tips #12: PERIPHERAL VISION Soft focus. Available from: https://www.lynnhellerstein.com/tips-12-peripheral-vision-soft-focus/ (accessed 21 July 2021)
  5. 5.0 5.1 5.2 5.3 Herdman SJ. Vestibular rehabilitation. Curr Opin Neurol. 2013;26(1):96-101.
  6. Tjernström F, Zur O, Jahn K. Current concepts and future approaches to vestibular rehabilitation. J Neurol. 2016;263 Suppl 1:S65-70.
  7. Anson ER, Bigelow RT, Carey JP, Xue QL, Studenski S, Schubert MC et al. VOR gain Is related to compensatory saccades in healthy older adults. Front Aging Neurosci. 2016;8:150.
  8. Physical Therapy Nation. VOR X1 Exercises. Available from: https://www.youtube.com/watch?v=LnRQIVPKSb0 [last accessed 21/7/2021]
  9. Physical Therapy Nation. VOR X2 Exercises. Available from: https://www.youtube.com/watch?v=vChuwinJigU [last accessed 21/7/2021]
  10. Herdman SJ editor. Vestibular Rehabilitation. Phil: F.A. Davis Co., 2000.
  11. Tian J, Crane BT, Demer JL. Vestibular catch-up saccades in labyrinthine deficiency. Exp Brain Res. 2000;131(4):448-57.
  12. Millar JL, Gimmon Y, Roberts D, Schubert MC. Improvement after vestibular rehabilitation not explained by improved passive VOR Gain. Front Neurol. 2020;11:79.
  13. Hermann R, Pelisson D, Dumas O, Urquizar C, Truy E, Tilikete C. Are covert saccade functionally relevant in vestibular hypofunction?. Cerebellum. 2018;17(3):300-7.
  14. Riska KM, Bellucci J, Garrison D, Hall C. Relationship between corrective saccades and measures of physical function in unilateral and bilateral vestibular loss. Ear Hear. 2020 Nov/Dec;41(6):1568-74.
  15. 15.0 15.1 15.2 15.3 15.4 15.5 15.6 15.7 15.8 Hall CD, Herdman SJ, Whitney SL, Cass SP, Clendaniel RA, Fife TD et al. Vestibular rehabilitation for peripheral vestibular hypofunction: an evidence-based clinical practice guideline: FROM THE AMERICAN PHYSICAL THERAPY ASSOCIATION NEUROLOGY SECTION. J Neurol Phys Ther. 2016 Apr;40(2):124-55.
  16. Physical Therapy Nation. Habituation Exercises and Theoretical Progression. Available from: https://www.youtube.com/watch?v=YmArOdHT-Kk [last accessed 22/7/2021]
  17. McGibbon CA, Krebs DE, Parker SW, Scarborough DM, Wayne PM, Wolf SL. Tai Chi and vestibular rehabilitation improve vestibulopathic gait via different neuromuscular mechanisms: preliminary report. BMC Neurol. 2005;5(1):3.
  18. McDonnell MN, Hillier SL. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database Syst Rev. 2015 Jan 13;1:CD005397.
  19. 19.0 19.1 Shepard NT, Telian SA. Programmatic vestibular rehabilitation. Otolaryngol Head Neck Surg. 1995;112(1):173-82.
  20. Strupp M, Arbusow V, Maag KP, Gall C, Brandt T. Vestibular exercises improve central vestibulospinal compensation after vestibular neuritis. Neurology. 1998;51(3):838-44.
  21. 21.0 21.1 21.2 Yardley L, Beech S, Zander L, Evans T, Weinman J. A randomized controlled trial of exercise therapy for dizziness and vertigo in primary care. Br J Gen Pract. 1998;48(429):1136-40.
  22. Cohen HS, Kimball KT. Decreased ataxia and improved balance after vestibular rehabilitation. Otolaryngol Head Neck Surg. 2004;130(4):418-25.
  23. Cohen HS, Kimball KT. Increased independence and decreased vertigo after vestibular rehabilitation. Otolaryngol Head Neck Surg. 2003;128(1):60-70.
  24. Topuz O, Topuz B, Ardiç FN, Sarhuş M, Ogmen G, Ardiç F. Efficacy of vestibular rehabilitation on chronic unilateral vestibular dysfunction. Clin Rehabil. 2004;18(1):76-83.
  25. 25.0 25.1 Herdman SJ, Schubert MC, Das VE, Tusa RJ. Recovery of dynamic visual acuity in unilateral vestibular hypofunction. Arch Otolaryngol Head Neck Surg. 2003;129(8):819-24.
  26. Tee LH, Chee NW. Vestibular rehabilitation therapy for the dizzy patient. Ann Acad Med Singap. 2005;34(4):289-94.
  27. Vestibular Today. Two Target VOR (Vestibular Rehab). Available from: https://www.youtube.com/watch?v=aQBKgYLKr4o [last accessed 22/7/2021]
  28. Vestibular Today. Imaginary Target VOR (Vestibular Rehab). Available from: https://www.youtube.com/watch?v=Sg9F_odij1k [last accessed 22/7/2021]
  29. Krebs DE, Gill-Body KM, Parker SW, Ramirez JV, Wernick-Robinson M. Vestibular rehabilitation: useful but not universally so. Otolaryngol Head Neck Surg. 2003;128(2):240-50.
  30. Krebs DE, Gill-Body KM, Riley PO, Parker SW. Double-blind, placebo-controlled trial of rehabilitation for bilateral vestibular hypofunction: preliminary report. Otolaryngol Head Neck Surg. 1993;109(4):735-41.
  31. Rine RM, Braswell J, Fisher D, Joyce K, Kalar K, Shaffer M. Improvement of motor development and postural control following intervention in children with sensorineural hearing loss and vestibular impairment. Int J Pediatr Otorhinolaryngol. 2004;68(9):1141-8.