Vestibular Rehabilitation

 Introduction

• Vestibular rehabilitation (VR), or vestibular rehabilitation therapy (VRT) is a specialized form of therapy intended to alleviate both the primary and secondary problems caused by vestibular disorders. 
• VR is an exercise-based program primarily designed to reduce vertigo and dizziness, gaze instability, and/or imbalance and falls.

Fig.1: Vestibular rehabilitation

Contraindications of Vestibular Rehabilitation

1. Vestibular rehabilitation is not appropriate for the unstable vestibular disorder (e.g., Ménière's disease, uncontrolled migraine, PLF, or unrepaired superior semicircular canal dehiscence).
2. Therapist's alert to:
1. Sudden loss of hearing
2. Increased feeling of pressure or fullness to the point of discomfort in one or both ears
3. Severe ringing in one or both ears.
3. The therapist must be observant for the discharge of fluid from the ears on the nose, which may indicate CSF fluid leak.
4. Patients with acute neck injuries may not be able to tolerate physical examination, CRM, gaze stability exercises.

Interventions for Benign Paroxysmal Positional Vertigo (BPPV)

1. Three different treatment approaches have been developed on the basis of the pathophysiology of the BPPV.
2. The techniques include the canalith repositioning maneuver, Liberatory (semont) maneuver, and Brandt–Daroff exercises.

Canalith Repositioning Maneuver (CRM) 

1. Also known as the Epley maneuver.
2. Based on the canalithiasis theory of free-floating otoconia in the semicircular canal.
3. The patient's head is moved into different positions in a sequence that will move the otoconia out of the involved semicircular canal and into the vestibule.
4. Once the otoconia are in the vestibule, the sign and symptoms should resolve.
5. The positions used in the treatment of posterior and anterior semicircular canal canalithiasis can be the same.
6. The procedure of CRM:
1. The patient's head is first rotated 45° toward the involved side. 
2. The patient is then moved into the Dix-hallpike position with the affected left ear toward the ground. 
3. Next, the head is rotated 90° to the right and maintains the 30° extension during this step. The head should now be positioned 45° to the right.
4. The patient is rolled onto the right shoulder and slowly brought up to the sitting position, head still rotated at 45° to the right.

5. Between each step, the therapist should wait for 1 to 2 minutes or until vertigo and nystagmus have stopped to ensure otoconia flow through the canal.

Liberatory (Semont) Maneuver

1. Treatment for posterior semicircular canal BPPV based on cupulolithiasis theory.
2. It involves rapidly moving the patient through positions designed to dislodge the otoconia from the cupula.
3. Liberatory Maneuver or right posterior SCC BPPV: 
1. The head is rotated 45° to the left side. 
2. With assistance, the patient is then moved from the setting to the right sideline and stays in this position for 1 minute. 
3. The patient is then rapidly moved 180°, from right side-lying to left side-lying. That should be in the original starting position, left rotated (nose down in the final position). 
4. After one minute in this position, the patient returned to sitting.

Brandt–Daroff Exercises

1. Exercises are designed to habituate the CNS to the provoking position.
2. They may also act to dislodge otoconia from the cupula or by causing otoconia to move out of the canal. 
3. Exercises for posterior SCC BPPV:
1. The patient starts in a sitting position and turns the head 45° to one side (left) then quickly lies down on the opposite shoulder (right). The patient should be instructed to remain in this position for 30 seconds or until the vertigo stops.
2. The patient then slowly returns to the starting position, maintaining the head rotation (left) until sitting upright.
3. The patient turns the head to the opposite direction (right) and nice down on the other shoulder (left), absorbing the similar 30 second time guidelines.
4. The exercise should be done 10 to 20 times, three times per day until the patient is without vertigo for two consecutive days.

Goals of BPPV Interventions:

1. The otoconia will be returned into the vestibule.
2. The patient will demonstrate reduced vertigo associated with head motion.
3. The patient will demonstrate improved balance.
4. The patient will demonstrate independence in a daily activity involving head motion.

Interventions of Unilateral Vestibular Hypofunction (UVH)

1. Gaze Stability Exercises

1. The purpose of these exercises is to improve the VOR and other systems that are used to assess the stability with head motion.
2. Vestibular adaptation exercises are designed to expose patients to retinal slip.
3. A retinal slip occurs when the image of an object moves off the fovea of the retina resulting in visual blurring.
4. The two primary exercises of vestibular adaptation are:
1. Exercise 1:
1. The patient is asked to move the head horizontally and vertically as quickly as possible while maintaining focus on a stable target.
2. A good target to use is a business card, asking the patient to focus on a word or a letter within a word.
2. Exercise 2
1. The patient is asked to move the head and target in opposite directions while focusing on the target.
5. Increasing the difficulty by the use of varying the distance from which the patient performs the exercises, moving the head more rapidly, and performing the exercise while standing or walking.
6. The computerized DVA test is useful to improve gaze stability for individuals with UVH and TBI.

2. Postural Stability Exercises

1. The purpose of postural stability exercises is to improve balance by encouraging the development of balanced strategies. 
2. The table shows Balance Exercises and Progression.

Table: Balance Exercises and Progression
Begin with	Progression	Purpose
1. Stand with feet shoulder-width apart, arm across the chest	Bring seat closer together Close eyes Stand on a sofa, cushion, or foam	Enhance the use of vestibular cues for balance by decreasing the base of support. Eyes closed increases reliance on vestibular cues for balance.
2. Practice ankle sways: medial-lateral and anterior-posterior	Doing circles sways. Close eyes.	Teaches the patient to use a correct ankle strategy.
3. Attempt to walk with the heel touching toes on a firm surface.	Do the same exercise on the carpet.	Enhance the use of vestibular cues or balance by decreasing the base of support. Doing the exercise on carpet alters proprioceptive input and increasing difficulty.
4. Practice walking 5 steps and turning 180°	Making smaller turns Close eyes	Turning provides a greater challenge to the vestibular system.
5. Walk and move the head side to side, up and down.	Counting backward from 100 by threes.	Use distracting cognitive or motor demands to challenge balance.

3. Habituation Exercises

1. Habituation Exercises are prescripted when a patient with a UVH has continual complaints of dizziness.
2. Habituation is defined as a deduction in response to a repeatedly performed movement.
3. To determine which habituation exercise to be prescribed, the physical therapist must determine the provoking positions first.
4. When a position elicits mild to moderate dizziness, the patient remains in the provoking position for 30 seconds or until symptoms are gone.
5. The patient is provided with the home exercise program based on the results of the positional test.
6. The exercises are designed to reduce dizziness and the patient should be encouraged that the symptoms normally decrease within two weeks.
7. If after two weeks the symptoms are no better, the habitation exercises should first be changed.
8. If this is not helpful then the patient should be referred to either a physical therapist with special training in vestibular rehabilitation or a physician for further evaluation.

Goals of Interventions:

1. The patient will demonstrate improved stability of gaze during head movement.
2. The patient will demonstrate diminished sensitivity to motion.
3. The patient will demonstrate improved static and dynamic postural stability.
4. The patient will be independent in the proper performance of a home exercise program that includes walking.

👉👉Patients with UVH should be informed that recovery time after initiating vestibular rehabilitation is 6 to 8 weeks.

Interventions for Bilateral Vestibular Hypofunction (BVH)

1. Gaze stability exercises 

1. Use of exercise 2, is not recommended for a patient with a BVH because this exercise may cause an excessive retinal slip.
2. But in patients with asymmetrical BVH, exercise 2 is useful.

Fig.1: Gaze stability exercises

2. Postural stability exercises.

3. Habituation exercises.

Goals of Interventions:

1. The patient will demonstrate improved stability of gaze during head movement.
2. The patient will demonstrate reduced subjective complaints of gaze instability.
3. The patient will demonstrate improved static and dynamic balance.
4. The patient will be independent in the proper performance of a home exercise program (HEP) that includes walking.
5. The patient will demonstrate enhanced decision-making skills regarding the performance of basic and instrumental activities of daily living.

Interventions for Abnormal Central Vestibular Function

1. Goals of intervention:
1. The patient will demonstrate enhanced decision-making skills regarding fall preventions and safety precautions to allow safe functioning within the home and community.
2. The patient will demonstrate enhanced decision-making skills regarding the use of compensatory strategies to assist in gaze stability.
2. The patient will be independent in the performance of a HEP that includes walking.
3. The physical therapy intervention for a central vestibular lesion at a level of brainstem likely will be similar to a UVH with the same expectations for recovery.
4. Gait and balance exercises
5. Habituation exercises

References:

• Physical Rehabilitation by Susan B. O'Sullivan

Related Topics:

• Vestibular Disorder
• Examination of a patient with vestibular disorder