Vestibular Rehabilitation After Destructive Procedures

Meniere’s disease is a common disorder that has a classical presentation including fluctuating hearing loss, tinnitus, and ear pressure with episodic vertigo episodes. Although a great deal of work has focused on these symptoms, little attention has been directed at other functional disabilities associated with Meniere’s disease. In particular, individuals with chronic Meniere’s disease often develop symptoms of unsteadiness and disability. These are symptoms that have been shown to respond to vestibular physical therapy intervention in other vestibulopathies. However, little work has been done documenting the use of physical therapy in Meniere’s disease except for its use after definitive destructive therapy. One area where rehabilitation has an established role in the therapy for Meniere’s disease is after vestibular neurectomy or labyrinthectomy. In both cases, the surgical procedure creates a fixed and complete unilateral vestibular loss. This sudden vestibular deafferentation may produce a significant amount of unsteadiness. The amount of unsteadiness will be dependent on the amount of vestibular function that was present before the surgical procedure. Those who had the most function will generally have the greatest degree of dysfunction after ablation surgery. Prior evidence to support the advantages of rehabilitation after destructive surgery comes mostly from the acoustic neuroma literature. A number of groups have shown improved outcomes in terms of time to recovery using vestibular physical therapy rehabilitation instituted early after translabyrinthine tumor resection. Although the disorders are not the same, the end result of complete loss of unilateral vestibular function allows for the conclusion that, like patients undergoing translabyrinthine excision of acoustic neuromas, those undergoing vestibular deafferentation via labyrinthectomy or nerve section with Meniere’s disease should also benefit from early therapy. It can then be surmised that after destructive procedures for Meniere’s disease, vestibular rehabilitation therapy should demonstrate efficacy in the speed of recovery and postural stability. Therefore, in many centers, vestibular physical therapy rehabilitation after destructive procedures is the accepted best practice for ensuring decreased postural sway and improved daily function for patients with Meniere’s disease. Results indicate that customized vestibular, visual, and somatosensory training hasten adaptive processes. Sensory conflicts are resolved more efficiently, resulting in a reduction of disequilibrium within 3 weeks. There is evidence this postural stability prevails months later.

Vestibular Rehabilitation After Vertigo Resolution

Another logical use of vestibular physical therapy rehabilitation is in individuals in which episodic vertigo has abated without a surgical or chemical ablative intervention, but disequilibrium persists. Clendaniel and Tucci demonstrated the value of a defined exercise program in treating this “postvertigo” disequilibrium. Much like using vestibular physical therapy rehabilitation in the postoperative patient, using rehabilitation to treat chronic unsteadiness is consistent with other proven instances in which vestibular physical therapy rehabilitation has been successful.

Work in our lab confirms Clendaniel and Tucci’s findings. Patients presenting to our tertiary care center with symptoms of Meniere’s disease were eligible to enroll in a study approved by the Institutional Review Board. Subjects underwent a history and standardized physical examination, as well as a complete auditory-vestibular test battery that included rotational chair testing (Micromedical, Chatham, IL, USA) and computerized dynamic posturography (CDP) (Neurocom Inc, Clackamas, OR, USA). The patients also underwent a set of vestibular functional tasks to measure balance function. These tests included Romberg, tandem Romberg, tandem gait, gait with head motion, head thrusts, headshake dynamic visual acuity, Fukuda step tests, and 3 standard cerebellar tests. Patients who demonstrated abnormal function in any of the vestibular testing procedures, complained of disequilibrium or unsteadiness, and had episodic vertigo were treated with medication to control vertigo. When patients reported no vertigo attacks for at least 3 months they were further assessed and entered in a vestibular physical therapy rehabilitation program. The Dizziness Handicap Index (DHI), Activities Balance Confidence Scale (ABC), Dynamic Gait Index (DGI), and computerized dynamic posturography (CDP) sensory organization test (SOT) were administered as vestibular physical therapy intake and outcome measures.

Vestibular physical therapy exercises targeted VOR, cervico-ocular reflex (COR), depth perception (DP), somatosensory retraining (SS), and aerobic function. The VOR, COR, and DP exercises were graded in difficulty based on velocity of head and object motion and by progression of body positioning from sitting to standing to walking. The SS exercises were graded in difficulty by narrowing the base of support, making the surface uneven, or changing the surface from firm to soft. Varied walking exercises were graded in difficulty by changing direction, requiring performance with the eyes closed, increasing speed of ambulation, walking on soft surfaces, or navigating stairs. An aerobic exercise home program progressively increased the time, speed, or distance that the patient could tolerate. Patients were treated once a week for 8 weeks. In 1 year, 26 individuals met criteria for inclusion in the study. All outcome measures showed significant improvement with significance defined as P less than .05. CDP SOT score improved from 51.1 before therapy to 68.5 after therapy. The results for the remaining 3 outcome measures also approached significance and are shown in Fig. 1 . The DGI nearly normalized with a group mean of 23.2 of a possible 24 at the end of therapy.

Outcome after 8 weeks of vestibular rehabilitation in patients who had no vertigo attacks for at least 3 months before starting therapy.

This Meniere’s study showed the benefit of postvertigo resolution vestibular physical therapy rehabilitation. Our population was composed exclusively of those with unilateral Meniere’s; therefore, we can make no conclusion regarding bilateral disease. In fact, Cohen noted that in bilateral disease vestibular physical therapy rehabilitation is not effective and advocated adaptive strategies (eg, equipment) for this patient population.