Vestibular Rehabilitation
Vestibular rehabilitation (VR) is a
specialized form of therapy intended to alleviate both the primary and
secondary problems due to vestibular disorders. It is an exercise-based program
primarily designed to reduce vertigo and dizziness, reduce gaze instability,
and/or reduce imbalance and fall risk as well as address any secondary
impairments that are a consequence of the vestibular disorder.
For most people who have a vestibular
disorder, the deficit is permanent because the amount of restoration of
vestibular function is very small. However, after vestibular system damage,
symptoms can reduce, and function can improve because of compensation. This
occurs because the brain learns to use other senses (vision and somatosensory body sense) to substitute for the deficient vestibular system. For many,
compensation occurs naturally over time, but for patients whose symptoms do not
reduce and who continue to have difficulty returning to daily activities, VR
can assist in recovery by promoting compensation.
The goal of VR is to use a
problem-oriented approach to promote compensation. This is achieved by
customizing exercises to address the specific problem(s) of everyone.
Therefore, before an exercise program can be designed, a comprehensive clinical
examination is needed to identify problems related to a vestibular disorder.
Depending on the vestibular-related problem.
Procedure
VRT is usually performed on an
outpatient basis, although in some cases, the treatment can be initiated in the
hospital. Patients are seen by a licensed physical or occupational therapist
with advanced post-graduate training.
VRT begins with a comprehensive
clinical assessment that should include collecting a detailed history of the
patient’s symptoms and how these symptoms affect their daily activities. The
therapist will document the type and intensity of symptoms and discuss the
precipitating circumstances.
Additionally, information about
medications, hearing or vision problems, other medical issues, history of
falls, previous and current activity level, and the patient’s living situation
will be gathered.
The assessment also includes administering different tests to evaluate the patient’s problems more objectively. The therapist will screen the visual and vestibular systems to observe how well eye movements are being controlled. Testing assesses sensation (which includes gathering information about pain), muscle strength, extremity and spine range of motion, coordination, posture, balance, and walking ability.
A customized exercise plan is
developed from the findings of the clinical assessment, results from laboratory
testing and imaging studies, and input from patients about their goals for
rehabilitation. For example, a person with BPPV may undergo a canal
repositioning exercise for the spinning s/he experiences, whereas someone with
gaze instability and dizziness due to vestibular neuritis (a deficit from a
weakened inner ear) may be prescribed gaze stability and habituation exercises,
and if the dizziness affects their balance this may also include balance
exercises.
An important part of the VRT is to
establish an exercise program that can be performed regularly at home.
Compliance with the home exercise program is essential to help achieve rehabilitation
and patient goals.
Along with exercise, patient and
caregiver education is an integral part of VRT. Many patients find it useful to
understand the science behind their vestibular problems, as well as how it
relates to the difficulties they may have with functioning in everyday life. A
therapist can also provide information about how to deal with these
difficulties and discuss what can be expected from VRT. Education is important
for patients because it takes away much of the mystery of what they are
experiencing, which can help reduce the anxiety that may occur because of
their vestibular disorder.
Benefits
- Balance and/or leg strength/flexibility
- Gait (how you walk)
- Visual stability and mobility
- Neck mobility and neck and arm strength
- Positional testing, including an inner ear exam
- Common symptoms that can be helped with vestibular rehabilitation include:
- Dizziness or blurry vision with head movements
- Neck tightness, stiffness, and/or pain
- Imbalance or the need to hold onto objects when walking
- Headaches
- Frequent falls
- Generalized “dizziness, wooziness, and foggy head” feelings
- Vertigo/spinning
Now we will
consider the "generic" type of vestibular rehabilitation in which
ataxic or vertiginous individuals are provided with a series of tasks to
perform that require them to use their eyes while their head is moving, and
possibly when their body is also moving. Many processes might be usefully
influenced by experience and motion (see Hain, 2011 for more details):
Plasticity
-- changes in central connections to compensate for peripheral disturbances. It
would be nice if plasticity could handle everything. Unfortunately, there
appear to be limits on how much the brain can compensate. Although conventional
wisdom holds that older persons adapt less well than younger, a recent study
suggests that there is no difference in the benefit of vestibular
rehabilitation according to age (Wriseley et al, 2002)
Formation of
internal models -- a cognitive process where one learns what to
expect from one’s actions. Internal models are critical for predictive motor
control, which is essential when one is controlling systems that have delays.
Much of the benefit of vestibular therapy may depend on internal models. An
example of this is a recent study by Herdman et al (2007) showing recovery of
better vision in persons with bilateral vestibular loss was attributed to
"centrally programmed eye movements".
Learning of
limits -- another cognitive process involved with learning
what is safe and what is not. Someone who does not know their limits may be
overly cautious and avoid dangerous situations. Someone who does not realize
that, for example, they can't figure out which way is up, may drown in a
swimming pool.
Sensory
weighting -- a cognitive process in which one of several
redundant senses is selected and favored over another. Classically, selection
occurs between vision, vestibular, and somatosensation inputs when one is
attempting to balance. People with unreliable vestibular systems, such as those
with Meniere's disease, sometimes seem unable to switch off their visual
reliance, causing them distress in certain situations where vision is an
incorrect reflection of body movement (i.e., in the movies). (Lacour et al,
1997)
Habituation
-- helpful in motion sickness.
Patients
typically referred for Vestibular Rehabilitation have been diagnosed with a
vestibular condition including:
- Benign Paroxysmal Positional Vertigo (BPPV)
- Vestibular Neuritis/Labyrinthitis
- Unilateral Vestibular Hypofunction (UVH)
- Vestibular Migraine
- Persistent Postural Perceptual Dizziness (PPPD)
- Mal de Debarquement (MdDS)
- Cervicogenic Dizziness
- Post-Concussion Syndrome (PCS)
- Meniere’s Disease
- Neurological conditions (i.e., stroke, traumatic brain injury)
- Vestibular deconditioning from aging or inactivity and many other vestibular conditions.
If you have
not yet been assessed or diagnosed with a vestibular condition, common symptoms
that can be helped with vestibular rehabilitation include:
- Vertigo (sense of spinning)
- General dizziness or lightheadedness
- Nausea, vomiting, fatigue
- Neck tightness, stiffness, and/or pain
- Imbalance and difficulty walking
- Headaches
- Frequent falls
- Vision issues (double vision, shaky vision with head movement, difficulty focusing, poor tolerance to screens)
- Brain fog, difficulty concentrating, mild memory issues.
How to do
Vestibular Rehabilitation Therapy?
Vestibular
rehabilitation exercises are not difficult to learn but require a high degree
of consistency by the patient to achieve success. We often recommend the exercises be performed
a minimum of 2-3 times a day, which can be tedious or difficult to
incorporate into a busy schedule. We suggest that our patients set up a regular
schedule so that the exercises can be more easily incorporated into their daily
routines.
In most
cases, patients will notice that the vestibular rehabilitation exercises will
somewhat increase their symptoms. Generally, this means that you’re doing the
exercises properly and stimulating your vestibular system appropriately. But
with time and consistent work, your symptoms should decrease until they are
more manageable and, in many cases, completely resolved. We often use a
weightlifting analogy: when you first start lifting a certain amount of weight,
it is difficult, and your muscles are sore after your workout. But, over time,
the weights become easier to lift and your muscles hurt less overall. It is
then that you are ready to progress by lifting heavier weights, or in the case
of vestibular rehabilitation, performing more complex vestibular exercises.
NOTE: If you have a diagnosis of Benign Paroxysmal Positional Vertigo (BPPV) then treatment primarily involves maneuvers to reposition the dislocated inner ear crystals. In some cases, vestibular rehabilitation home exercises are required as a part of the manual treatments required to improve BPPV. Learn more about BPPV here.
Outcome From
Vestibular Rehabilitation
Expected
vestibular rehabilitation outcomes include:
- Decreased risk of falling
- A decrease in dizziness symptoms
- Improved balance
- Improved ability to stabilize vision/gaze
- Increased body strength
- Return to a prior level of movement/function
- Increase in confidence in the ability to maintain balance
- Improved neck motion, reduced symptoms.
