Vestibular Rehabilitation

Vestibular Rehabilitation

Susan L. Whitney

Yael Raz

Persons with vestibular disorders often present with complaints of dizziness, being off balance, and sometimes nausea and vomiting. They may also report falls as a result of their vestibular disorder. Dizziness is a very common complaint in an otolaryngologist’s office. The diagnosis and management of persons with dizziness can be perplexing, since there are so many causes of dizziness. Medication-induced dizziness is very common as is dizziness associated with headache. Thorough history and examination, often with laboratory testing, are necessary to confirm the presence and nature of vestibular dysfunction.

Balance and dizziness disorders are generally considered to affect older adults (1), although younger people also encounter vestibular disorders (2). The prevalence of dizziness/vertigo in a 1-year period has been estimated to be approximately 29% in women and 17% in men within the German population (2). In a large US study (n = 5,086), it is estimated that 35% of people over the age of 40 have had vestibular dysfunction based on their ability to stand in modified Romberg on a firm and compliant surface, with active dizziness increasing the odds of falling by 12 (3). Of 546 persons presenting to the emergency room (ER) with no known cause for a fall initially, when probed, 80% had reported dizziness within the last 12 month (4), suggesting that the dizziness may be related to falls. Persons with vestibular disorders become concerned about falls, resulting in their being more sedentary and further increasing their risk of falling.

Nine percent of older adults seen for chronic medical problems in an outpatient geriatric setting for nonbalance or dizziness complaints had unrecognized benign paroxysmal positional vertigo (BPPV) (5). These older adults also had greater reports of falls and impairments of the activities of daily living (ADL) (5). Vestibular physical therapy has been used to improve balance, decrease dizziness, and improve quality of life in persons with BPPV and other central and peripheral vestibular disorders. There is mounting evidence that vestibular physical therapy is effective in the treatment of vestibular dysfunction in adults and children (6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68). Two Cochrane meta-analyses of 21 and 27 randomized trials suggested that there was moderate to strong evidence to support that vestibular rehabilitation is a safe and effective intervention for persons with peripheral vestibular disorders (38, 39).

Vestibular disorders are most commonly treated by physical therapists. Other health care providers such as occupational therapists and audiologists also deliver interventional care. Knowledge related to the treatment of BPPV is commonly taught within physical therapist curricula. Standards related to the knowledge base that is critical for the identification and treatment of vestibular disorders have recently been published (69). The newly published international guidelines written by a Barany Society subgroup provide a starti ng point for therapists to determine what additional knowledge they should acquire in order to optimally treat persons with balance and vestibular dysfunction (69). The treatment of vestibular disorders in many physical therapist curricula is considered advanced knowledge beyond an entry level doctor of physical therapy degree program. Any physical therapist who is a neurologic clinical specialist should have background in specific examination and intervention techniques for persons with vestibular disorders.

Developing a relationship between physicians and physical therapists interested in treating patients with vestibular disorders is important for the patients’ optimal recovery. Good communication will enhance the care that patients receive and should ultimately speed their recovery. As a physician initially seeking referral to a physical therapist, it is reasonable to ask the intended provider what his or her experience is with the treatment of persons with balance and vestibular disorders. There are advanced training options that could also further develop their skills and experience in the treatment of persons with balance and vestibular disorders if they were interested in learning more.

Medications rarely help with persons with peripheral vestibular disorders, except in the acute phase. However, chronic use of medications is often beneficial in persons with Meniere disease for long-term symptom control. As persons improve, it is optimal to taper and stop the antidizziness and antinausea medication as it may actually slow down central compensation and the recalibration process of the vestibuloocular reflex (VOR). Long-term use of antidizziness medication is not advised, especially in older adults. The drowsiness often associated with the antiemetics and vestibular suppressants might increase an older adult’s risk of falling. Vestibular suppressants, which are typically used to manage symptoms in persons with acute vestibular disorders, may slow vestibular compensation (70). Venosa and Bittar (71), in a prospective trial, suggest that persons who performed exercises acutely (symptoms that began less than 5 days prior to the start of the study) were less likely to use medication at 3 weeks than those who were not provided vestibular exercises. Patients in the vestibular exercise group had a greater number of normal Fukuda step tests and normal post head shake testing. Three weeks post exercise, 13% of the vestibular exercise group and 82% of the control group were taking medication daily (71). Medication for central vestibular disorders is effective (70).

Early vestibular exercises in persons with an acute vestibular disorder resulted in better Dizziness Handicap Inventory (DHI) scores (72), less anxiety, less reliance on visual cues, and better gait (73). Quality of life scores, as measured by the Medical Outcomes Study Short Form 36, improved after vestibular rehabilitation in persons with acute vestibular disorders (8, 52). Perceived dizziness also has been noted to improve after a trial of vestibular physical therapy (52). Animal studies have suggested that there may be a critical period whereby immobilization had a negative impact on recovery from a vestibular deficit (74, 75). People with peripheral vestibular disorders who underwent balance exercises within 6 months of onset had much better disability scores than those who presented after 6 months (8).

Dizziness severity and quality of life measures were predicted by when the balance exercises were initiated, with earlier onset relating to less dizziness and better quality of life measures (8). A delay in the onset of Cooksey- Cawthorne (vestibular) exercises led to worse scores in all cases studied, and late onset of exercise was considered to be a negative predictor for recovery (8). Early exercise in persons with peripheral vestibular disorders resulted in fewer symptoms at 3 weeks compared to a no-exercise control group (66, 73). Also, people with late intervention for BPPV were more likely to experience residual dizziness within a 3-month period (76).

In summary, early exercise appears to decrease dizziness, prevent long-term complications such as anxiety, improve quality of life, possibly decrease the patient’s chance of falling, and improve balance confidence. In addition, customized exercises appear to be more effective than a generic exercise program or no exercise (28, 77). Acute physical therapy intervention for the person with dizziness and balance dysfunction appears to be a safe and efficacious treatment for persons with vestibular disorders (39, 66).


After the person presents to the physical therapist, an in-depth examination begins with a thorough history of the dizziness. Just as in the physician’s examination, the history is critical for the physical therapist in determining the optimal interventions. Sharing pertinent health information, examination results, and laboratory findings with the treating therapist will expedite and enhance patient care. Typically, the therapist will ask the patient questions regarding the frequency, duration, timing, and intensity of the symptoms; other comorbid medical conditions; medications; requirements of work; and living status (78).

Positions or movements that increase or decrease symptoms are very important in developing the treatment plan for the person with a vestibular disorder. Often, questions are asked related to movements that increase dizziness such as bending, getting out of bed, or even walking in a grocery store. A quick neurologic exam is also performed to assess the integrity of the smooth pursuit and saccadic eye systems and cranial nerves III, IV and VI. The integrity of the VOR, VOR cancellation, and the vergence system are also clinically assessed. The therapist may perform the head thrust test (79, 80, 81, 82, 83, 84, 85), dynamic visual acuity (35, 36, 37, 85, 86, 87, 88, 89, 90), and vibration-induced nystagmus test (91, 92, 93, 94). All of the above assist the therapist in treatment planning and determining if additional testing is required as some patients may be self-referred or have not seen an otolaryngologist prior to seeing the physical therapist.

Strength, range of motion, sensation, and coordination are assessed at baseline. Range of motion of the cervical spine is particularly important to determine prior to performing the Dix-Hallpike maneuver. The physical therapist performs the Dix-Hallpike and the roll test ideally with infrared goggles, to determine if the patient has BPPV. If the Dix-Hallpike or roll test are positive, the appropriate canalith repositioning maneuver (CRM) will be performed based on the patients health and medical comorbidities.

Balance testing is an integral part of the typical physical examination including Romberg, semitandem standing, and tandem standing. Semitandem standing consists of having the patient stand with one foot in front of the other but not heel to toe. It is a transitional balance test between standing feet together (Romberg position) and heel to toe (tandem standing) and is often a difficult position for older adults to maintain. The patient’s gait, as described above, will be assessed, and determination will be made whether an assistive device is in order to improve gait and safety. An attempt is made to avoid providing an assistive
device unless it is necessary, as many older adults will never stop using the assistive device once it has been prescribed. Persons who often do need an assistive device are those with bilateral vestibular loss because they fall frequently (95), especially on uneven surfaces or low light/no light conditions. If the person is very frail and afraid of falling, occasionally a rollator walker will be suggested. Rollators have four wheels, brakes, and a seat. The rollators allow patients to walk safely at a much faster gait speed than a standard walker. Gait speed has been shown to be an overall indicator of health (96). Walking at a more normal speed may have long-term cardiovascular and respiratory benefit. Standard canes are also used to provide support for persons with vestibular disorders and have been shown to decrease postural sway (97).

Once the examination is complete, the physical therapist will develop a plan of care. Patients are seen anywhere between one and three times per week, with frailty, depression, light sensitivity, a history of migraine, fear of falling, and anxiety being important factors in how often the patient is seen. Persons who are afraid to exercise, who are depressed, or very anxious may be unable or unwilling to perform the exercises at home without supervision/encouragement.

Patients are provided with written home exercises to perform between visits in order to speed their recovery. Typically the number of exercises provided is kept within reason, as patients often have difficulty finding the time to perform the exercises at home, especially if they are currently working. Often the therapist will attempt to build the exercise program into the patient’s daily routine, such as standing on one leg while washing the dishes. Even retired adults will complain if it takes too long for them to perform the home exercise program, so patient education and negotiation is often required in order to have the patient “buy into” performing the exercise program at home. The therapist attempts to “dose” the exercises appropriately so that the movements increase the patient’s symptoms, yet do not disable them.

If the exercise prescription is too aggressive, the patient will become too dizzy or might become fearful of the falling during the exercise and will stop performing the exercises. If the program is too easy, it will not be effective at maximizing the patient’s recovery. Therapist experience and dialogue with the patient will maximize the interaction resulting in an exercise program that is individualized and appropriate for the patient. Individualized exercise programs appear to be superior to generic exercise programs and better meet the needs of the patient (77).

Exercises consist of eye/head movements in every conceivable position progressing to gait, exercises that incorporate head movements during gait, and standard balance exercises. Most people are asked to begin a walking program in order to increase their endurance, strength, and tolerance to movement. Exercises can be simple or very complex. A simple example might include having a person stand on one leg progressing to standing on one leg while tossing a ball or moving the head to the right and left following a moving target with the eyes and/or head. Exercises are individualized based on the patients’ comorbid medical conditions and physical/mental health.


The DHI is often used to quantify subjective impairment and to report changes over time in the self-perceived handicapping effects of dizziness (72). Scores range from 0 to 100 with 0 the best score and 100 the worst score possible. Change of 18 or more has been suggested to be clinically significant (72). Scores of greater than 60 on the DHI have been related to increased reports of falling (98).

Balance confidence is also frequently reported as an outcome measure. Generally when patients feel less dizzy and have better self-reported dizziness, they are better. The Activities-specific Balance Confidence (ABC) scale is the most commonly used balance confidence measure used with persons with dizziness (99). For the ABC scale, a percentage score is reported that ranges from 0% to 100% with 100% the best score and 0% the worst score. Scores of 67% or lower on the ABC appear to represent significant fall risk (100).

Verbal and visual analog scales (101) are also frequently reported as outcome measures, which should improve as the patient begins to feel better (less dizziness, improved balance, and better quality of life). The analog scale scores can be compared across time to suggest that the patient is feeling worse, the same or better as a result of the intervention.

Measures of gait and balance often used include the dynamic gait index (DGI) (102), gait speed (96), the functional gait assessment (FGA) (103, 104), the clinical test of sensory integration and balance (CTSIB) (105), the Timed Up and Go test (TUG) (106, 107), the five times sit to stand test (FTSST) (108), and simple measures such as timed standing in Romberg, single-leg stance or tandem Romberg (67, 78). The DGI includes eight walking tasks, two of which require head movements in the pitch and yaw planes. Scores are based on an ordinal scoring algorithm with 24 the optimal score. Scores of 19 or less have been related to increased fall risk (109, 110).

Gait speed is probably the best overall gait measure, as slower gait speed has been related to increased mortality and morbidity and shortened life expectancy (96, 111). According to Studenski et al. gait speed, age, and gender are the optimal combination for predicting life expectancy. Patients who walk slower are also at greater risk for falling. Often one of the goals of the physical therapist intervention is to increase gait speed.

The FGA includes many of the original DGI items but was designed to be more difficult with the inclusion of
walking with eyes closed, walking backward, and walking heel to toe. Scores on the FGA vary between 0 and 30 with 30 the optimal score. Scores of ≤22 demonstrated the optimal sensitivity and specificity for fall risk (103). Scores ≤22 indicate that the person is at risk for falling.

The modified CTSIB is often performed in the physician office as well as by the physical therapist to determine fall risk and to assess vestibular function (112, 113). The modified CTSIB includes standing in the Romberg position eyes open and closed plus standing on foam eyes open and closed (114). Persons who fall on foam are more likely to fall when walking on uneven surfaces. The modified CTSIB should be performed with caution because many patients fall off the foam. Careful guarding is required in order to assure that the patient and physician are safe while performing the examination. Cass et al. (114) suggested timing how long the person can maintain each of the four positions.

The TUG is a simple measure of balance that has been related to increased fall risk. The patient stands from a chair with armrests upon command and is asked to walk at their normal pace 3 m, turn, and return to sitting in the chair. Scores of 13.5 seconds or longer have been related to falling in older persons (115), and a score of 11.1 seconds has the optimal sensitivity and discriminative properties in persons with vestibular disorders (107). The TUG is extremely easy to test because one only requires 3 m of space, a chair with armrests, and a stop watch. Patients can perform the test with an assistive device (cane, walker). Generally, persons who present to the clinic with a cane or walker are more likely to have fallen, so careful guarding is advised in examining those patients who present with an assistive device.

The FTSST has been used to determine lower extremity strength and balance in persons with vestibular disorders (108). They are asked to stand as quickly as they can five times from a standard height chair (116). The test provides a good overall measure of function (116), especially in older persons with vestibular disorders.

Factors That Might Affect Recovery

Age does not seem to specially relate to recovery after vestibular insult. In a study by Jung et al. (117) persons over the age of 70 with dizziness complaints either received vestibular exercises (n = 103) or no treatment (n = 46). Significant improvements in dizziness and balance confidence were noted in the treatment group at both 3 weeks and at 3 months compared to the no intervention group. Comorbid factors often associated with aging such as diabetes, peripheral neuropathy, macular degeneration, glaucoma, impaired sensation, or restricted ability to move may affect compensation and recovery. Other factors not associated with aging that can also slow or hinder rehabilitative progress includes former eye surgery, a strabismus, a history of migraine, use of vestibular suppressants, avoidance behavior, and certain psychiatric conditions (obsessive compulsive disorder, anxiety) (8, 118, 119, 120, 121).

Persons with migraine may have difficulty with fast head movements and become nauseous more quickly than others. A history of motion sickness early in life may be associated with subsequent migraine. Persons who are prone to motion sickness often have more difficulty performing eye/head exercises. Care must be used in order to dose the intervention to allow for adaptation but to prevent the person from becoming ill with nausea, dizziness, or vomiting during or after the exercises. People who are afraid to move are also more difficult to treat, as exercise and movement appear to be the most efficacious way to promote recovery in the person with a vestibular disorder.

Persons with anxiety can be a challenge to treat. Psychologic factors appear to influence how people respond to and perceive dizziness (122). Anxiety appears to increase dizziness and distress, especially with movement. Fear of being dizzy and anxiety can trigger autonomic reactions that are very disturbing to the patient including increased heart rate and sweating. It appears that there is a link between anxiety and dizziness (123), with anxiety increasing the patients’ symptoms. At times, psychotherapy and vestibular rehabilitation are combined for optimal effectiveness. Cognitive behavioral therapy has also been shown to be effective in decreasing dizziness symptoms in persons with chronic uncompensated peripheral vestibular disorders (41).


Benign Paroxysmal Positional Vertigo

In the case of BPPV, repositioning maneuvers are effective, improve quality of life, and improve gait speed in people, especially older adults (124, 125). Those who had late intervention for their BPPV were more likely to experience residual dizziness within a 3-month period (76). Although BPPV often resolves within a median of 2 weeks (126), sick days, physician visits, and interruption of ADL were frequently reported (126). In some patients with BPPV, use of the CRM is the only intervention that is effective. It is unusual but we have seen people who have had BPPV for over 20 years without relief of symptoms before the appropriate diagnosis was made and treatment provided. The financial costs to make the diagnosis of BPPV can be very high. In 2000, the average cost to make the diagnosis of BPPV was $2,684 (127). Polensek and Tusa (128) reported that the number of diagnostic tests to identify BPPV had not changed even with better education about vestibular disorders, but costs had increased between 2003 and 2008. Based on two recent practice guidelines by the Academy of Head and Neck Surgery and the Academy of Neurology, repositioning maneuvers for BPPV are very effective and safe (68, 129). Thus, rendering a correct diagnosis quickly with appropriate treatment obviates costly and prolonged testing.

The Epley maneuver has been clearly illustrated by Furman and Cass (130) and can be quickly performed in the office setting after a positive Dix-Hallpike maneuver had determined the involved ear. The Epley maneuver involves rotating the head 45 degrees to the involved side and extending the head 20 to 30 degrees over the edge of a bed or table. The persons head is then rotated 90 degrees to the opposite side while maintaining neck extension, then rotated toward the floor, and to complete the maneuver the person is sat up. Each position is generally maintained until the nystagmus stops. Posttreatment instruction, including head restrictions, do not appear to affect outcome as reported in a recent meta-analysis (131).

BPPV is commonly seen in older persons. Imai et al. (132) reported that the mean age of their subjects (n = 108) was in their sixth decade of life. Seventy-seven percent of their subjects were between 51 and 80. In persons with posterior canal BPPV, it took a mean of 39 day for resolution of their symptoms without intervention (132

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May 24, 2016 | Posted by in OTOLARYNGOLOGY | Comments Off on Vestibular Rehabilitation
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