Vestibular Rehabilitation: Review of Indications, Treatments, Advances, and Limitations
- 293 Downloads
Purpose of Review
Vestibular disorders result in symptoms that significantly impact an individual’s quality of life. Vestibular rehabilitation therapy (VRT) has, for many years, been used as an effective means of treating patients and their vestibular-related symptoms. For clinicians, it is crucial to stay up to date with the current best evidence in VRT in order to optimize patient management.
Current evidence is in support of VRT for treating patients with a variety of vestibular disorders, both central and peripheral. High level evidence studies support the use of treatment techniques of adaptation and substitution for gaze stabilization, habituation, balance and gait training, and canalith repositioning maneuvers. Recent evidence has also examined and found promising results with technological innovations that are targeted at those with bilateral vestibular hypofunction and insufficient gains with a standard exercise-based program. Nevertheless, factors such as anxiety overlay/depression, time when beginning therapy, and adherence may have an impact on how a patient will do with his/her VRT program and should be acknowledged.
Quantifiable and evidence-based literature supports the use of VRT for patients with a variety of vestibular disorders and their associated symptoms. The clinician needs to become familiar with each patient’s complaints and goals, as well as any potential barriers to positive outcomes with VRT, and combine this with their knowledge of current evidence-based literature in order to develop the optimal program for each unique patient.
KeywordsVestibular Dizziness Vertigo Rehabilitation Compensation Balance
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflicts of interest.
This article was made possible from funding through the Hertz Multidisciplinary Neurotology Clinic at UHN.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 1.Blackwell DL, Lucas JW, Clarke TC. Summary health statistics for U.S. adults: National Health Interview Survey, 2012. National Center for Health Statistics. Vital Health Stat. 2014;10(260). Contract No.: 260.Google Scholar
- 5.Cawthorne T. The physiological basis for head exercises. J Chartered Soc Physiother. 1944;3:106–7.Google Scholar
- 7.•• McDonnell MN, Hillier SL. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database Syst Rev. 2015;1. An updated Cochrane review (39 studies, 2,441 participants) demonstrated a statistically significant effect for VRT over control/ no intervention. High quality RCT’s demonstrated improvement in function and resolution of symptoms with VRT in the medium term. With one exception, treatment of BPPV did better in the short term with specific physical (repositioning) procedures than exercise based VRT. Google Scholar
- 8.Arnold SA, Stewart AM, Moore HM, Karl RC, Reneker JC. The effectiveness of vestibular rehabilitation interventions in treating unilateral peripheral vestibular disorders: a systematic review. Physiother Res Int. 2015.Google Scholar
- 9.•• 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. J Neurol Phys Ther. 2016;40(2):124–55. This systematic review identified strong evidence with a preponderance of benefit over harm that VRT should be offered to individuals with unilateral and bilateral vestibular impairments. Recommendations for therapists and clinicians were based on best available evidence. Treatment timetables for unilateral (acute and chronic) and bilateral peripheral vestibular impairments were noted. Google Scholar
- 14.Hunt WT, Zimmermann EF, Hilton MP. Modifications of the Epley (canalith repositioning) manoeuvre for posterior canal benign paroxysmal positional vertigo (BPPV). Cochrane Database Syst Rev. 2012;4:CD008675.Google Scholar
- 16.• Hilton M, Pinder D. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev. 2014;(12):CD003162. In a review of 11 RCT’s, the Epley manoeuvre demonstrated comparable treatment success with Semont and Gans manoeuvres but was superior to Brandt-Daroff exercises for BPPV. Despite short-term success, recurrence rates for BPPV were 36% overall. Google Scholar
- 18.•• Bhattacharyya N, Gubbels SP, Schwartz SR, Edlow JA, El-Kashlan H, Fife T, et al. Clinical practice guideline: benign paroxysmal positional vertigo (update). Otolaryngol Head Neck Surg. 2017;156(3_suppl):S1–S47. This updated guideline endorsed by numerous societies provides 14 specific recommendations for management of BPPV including a well thought visual diagnostic algorithm for treatment. Google Scholar
- 19.Mandalà M, Santoro GP, Asprella Libonati G, Casani AP, Faralli M, Giannoni B, et al. Double-blind randomized trial on short-term efficacy of the Semont maneuver for the treatment of posterior canal benign paroxysmal positional vertigo. J Neurol. 2012;259(5):882–5.Google Scholar
- 20.Chen Y, Zhuang J, Zhang L, Li Y, Jin Z, Zhao Z, et al. Short-term efficacy of Semont maneuver for benign paroxysmal positional vertigo: a double-blind randomized trial. Otol Neurotol. 2012;33(7):1127–30.Google Scholar
- 23.• Ribeiro KM, Freitas RV, Ferreira LM, Deshpande N, Guerra RO. Effects of balance vestibular rehabilitation therapy in elderly with benign paroxysmal positional vertigo: a randomized controlled trial. Disabil Rehabil. 2016;24:1–9. Elderly patients receiving balance VRT and canolith repositioning procedures (CRP’s) had better dynamic balance than those only receiving CRP’s. Adverse events from falls can be further avoided with the addition of these 2 therapies. Google Scholar
- 24.• Bressi F, Vella P, Casale M, Moffa A, Sabatino L, Lopez MA, et al. Vestibular rehabilitation in benign paroxysmal positional vertigo: reality or fiction? Int J Immunopathol Pharmacol. 2017;30(2):113–22. This systematic review suggests that VRT and CRP’s have a synergistic effect when combined in the elderly (see above reference). While VRT does not reduce recurrence rates for BPPV it seems to reduce its unpleasantness. VRT can be used when spinal co-morbidities contraindicate CRP’s. Google Scholar
- 36.Matsugi A, Ueta Y, Oku K, Okuno K, Tamaru Y, Nomura S, et al. Effect of gaze-stabilization exercises on vestibular function during postural control. Neuroreport. 2017;28(8):439–43.Google Scholar
- 41.Bergeron M, Lortie CL, Guitton MJ. Use of virtual reality tools for vestibular disorders rehabilitation: a comprehensive analysis. Adv Med. 2015.Google Scholar
- 43.Meldrum D, Herdman S, Vance R, Murray D, Malone K, Duffy D, et al. Effectiveness of conventional versus virtual reality-based balance exercises in vestibular rehabilitation for unilateral peripheral vestibular loss: results of a randomized controlled trial. Arch Phys Med Rehabil. 2015;96(7):1319–28.Google Scholar
- 51.Tsukamoto HF, Costa Vde S, Silva RA Jr, Pelosi GG, Marchiori LL, Vaz CR, et al. Effectiveness of a vestibular rehabilitation protocol to improve the health-related quality of life and postural balance in patients with vertigo. Int Arch Otorhinolaryngol. 2015;19(3):238–47.Google Scholar
- 52.Karapolat H, Celebisoy N, Kirazli Y, et al. Is vestibular rehabilitation as effective in bilateral vestibular dysfunction as in unilateral vestibular dysfunction? Eur J Phys Rehabil Med. 2014.Google Scholar
- 59.Guinand N, van de Berg R, Cavuscens S, Stokroos RJ, Ranieri M, Pelizzone M, et al. Vestibular implants: 8 years of experience with electrical stimulation of the vestibular nerve in 11 patients with bilateral vestibular loss. ORL J Otorhinolaryngolody Relat Spec. 2015;77(4):227–40.Google Scholar
- 61.Wuehr M, Decker J, Schniepp R. Noisy galvanic vestibular stimulation: an emerging treatment option for bilateral vestibulopathy. J Neurol. 2017.Google Scholar
- 62.Iwasaki S, Yamamoto Y, Togo F, Kinoshita M, Yoshifuji Y, Fujimoto C, et al. Noisy vestibular stimulation improves body balance in bilateral vestibulopathy. Neurology. 2014;82:969–75.Google Scholar
- 63.Fujimoto C, Yamamoto Y, Kamogashira T, Kinoshita M, Egami N, Uemura Y, et al. Noisy galvanic vestibular stimulation induces a sustained improvement in body balance in elderly adults. Sci Rep. 2016;6:37575.Google Scholar
- 68.De Stefano A, Dispenza F, Citraro L, Petrucci AG, Di Giovanni P, Kulamarva G, et al. Are postural restrictions necessary for management of posterior canal benign paroxysmal positional vertigo? Ann Otol Rhinol Laryngol. 2011;120(7):460–4.Google Scholar