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Vestibular Rehabilitation: Review of Indications, Treatments, Advances, and Limitations

  • Otology: Vestibular Disorders (J Rutka, Section Editor)
  • Published:
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Abstract

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.

Recent Findings

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.

Summary

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.

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References

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  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.

  2. Ward BK, Agrawal Y, Hoffman HJ, Carey JP, Della Santina CC. Prevalence and impact of bilateral vestibular hypofunction: results from the 2008 US National Health Interview Survey. JAMA Otolaryngol Head Neck Surg. 2013;139(8):803–10.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Agrawal Y, Carey JP, Della Santina CC, Schubert MC, Minor LB. Disorders of balance and vestibular function in US adults: data from the National Health and Nutrition Examination Survey, 2001–2004. Arch Intern Med. 2009;169:938–44.

    Article  PubMed  Google Scholar 

  4. Stevens JA, Corso PS, Finkelstein EA, Miller TR. The costs of fatal and non-fatal falls among older adults. Inj Prev. 2006;12(5):290–5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Cawthorne T. The physiological basis for head exercises. J Chartered Soc Physiother. 1944;3:106–7.

    Google Scholar 

  6. Cooksey FS. Rehabilitation in vestibular injuries. Proc R Soc Med. 1946;39(5):273–8.

    PubMed  PubMed Central  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.

  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.

  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.

  10. Herdman SJ, Hall CD, Maloney B, Knight S, Ebert M, Lowe J. Variables associated with outcome in patients with bilateral vestibular hypofunction: preliminary study. J Vestib Res. 2015;25(3–4):185–94.

    Article  PubMed  Google Scholar 

  11. Porciuncula F, Johnson CC, Glickman LB. The effect of vestibular rehabilitation on adults with bilateral vestibular hypofunction: a systematic review. J Vestib Res. 2012;22:283–98.

    PubMed  Google Scholar 

  12. Helminski JO, Zee DS, Janssen I, Hain TC. Effectiveness of particle repositioning maneuvers in the treatment of benign paroxysmal positional vertigo: a systematic review. Phys Ther. 2010;90(5):663–78.

    Article  PubMed  Google Scholar 

  13. Prokopakis E, Vlastos IM, Tsagournisakis M, Christodoulou P, Kawauchi H, Velegrakis G. Canalith repositioning procedures among 965 patients with benign paroxysmal positional vertigo. Audiol Neurootol. 2013;18(2):83–8.

    Article  CAS  PubMed  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 

  15. Bruintjes TD, Companjen J, van der Zaag-Loonen HJ, van Benthem PP. A randomised sham-controlled trial to assess the long-term effect of the Epley manoeuvre for treatment of posterior canal benign paroxysmal positional vertigo. Clin Otolaryngol. 2014;39(1):39–44.

    Article  PubMed  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.

  17. Liu Y, Wang W, Zhang AB, Bai X, Zhang S. Epley and Semont maneuvers for posterior canal benign paroxysmal positional vertigo: a network meta-analysis. Laryngoscope. 2016;126(4):951–5.

    Article  PubMed  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.

  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.

  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.

  21. Casani AP, Nacci A, Dallan I, Panicucci E, Gufoni M, Sellari-Franceschini S. Horizontal semicircular canal benign paroxysmal positional vertigo: effectiveness of two different methods of treatment. Audiol Neurotol. 2011;16:175–84.

    Article  Google Scholar 

  22. Mandala M, Pepponi E, Santoro GP, et al. Double-blind randomized trial on the efficacy of the Gufoni maneuver for treatment of lateral canal BPPV. Laryngoscope. 2013;123:1782–6.

    Article  PubMed  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.

  25. Alsalaheen BA, Mucha A, Morris LO, et al. Vestibular rehabilitation for dizziness and balance disorders after concussion. J Neurol Phys Ther. 2010;34:87–93.

    Article  PubMed  Google Scholar 

  26. Marshall S, Bayley M, McCullagh S, et al. Updated clinical practice guidelines for concussion/mild traumatic brain injury and persistent symptoms. Brain Inj. 2015;29:688–700.

    Article  PubMed  Google Scholar 

  27. Moore BM, Adams JT, Barakatt E. Outcomes following a vestibular rehabilitation and aerobic training program to address persistent post-concussion symptoms. J Allied Health. 2016;45(4):e59–68.

    PubMed  Google Scholar 

  28. Schneider KJ, Meeuwisse WH, Nettel-Aguirre A, et al. Cervicovestivular rehabilitation in sport-related concussion: a randomized controlled trial. Br J Sports Med. 2014;48:1294–8.

    Article  PubMed  Google Scholar 

  29. Balci BD, Akdal G, Yaka E, et al. Vestibular rehabilitation in acute central vestibulopathy: a randomized controlled trial. J Vestib Res. 2013;23:259–67.

    PubMed  Google Scholar 

  30. Dai CY, Huang YH, Chou LW, et al. Effects of primary caregiver participation in vestibular rehabilitation for unilateral neglect patients with right hemispheric stroke: a randomized controlled trial. Neuropsychiatr Dis Treat. 2013;9:477–84.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Alghadir AH, Iqbal ZA, Whitney SL. An update on vestibular physical therapy. J Chin Med Assoc. 2013;76:1–8.

    Article  PubMed  Google Scholar 

  32. Schubert MC, et al. Mechanism of dynamic visual acuity recovery with vestibular rehabilitation. Arch Phys Med Rehabil. 2008;89(3):500–7.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Schubert MC, Migliaccio AA, Della Santina CC. Modification of compensatory saccades after a VOR gain recovery. J Vestib Res. 2006;16(6):285–91.

    PubMed  PubMed Central  Google Scholar 

  34. Schubert MC, Hall CD, Das V, et al. Oculomotor strategies and their effect on reducing gaze position error. Otol Neurotol. 2010;31:228–31.

    Article  PubMed  Google Scholar 

  35. Whitney SL, Alghwiri A, Alghadir A. Physical therapy for persons with vestibular disorders. Curr Opin Neurol. 2015;28(1):61–8.

    Article  PubMed  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.

  37. Pavlou M, Bronstein AM, Davies RA. Randomized trial of supervised versus unsupervised optokinetic exercise in persons with peripheral vestibular disorders. Neurorehabil Neural Repair. 2013;27(3):208–18.

    Article  PubMed  Google Scholar 

  38. Thompson KJ, Goetting JC, Staab JP, Shepard NT. Retrospective review and telephone follow-up to evaluate a physical therapy protocol for treating persistent postural-perceptual dizziness: a pilot study. J Vestib Res. 2015;25(2):97–103.

    PubMed  Google Scholar 

  39. Pavlou M, Kanegaonkar RG, Swapp D, Bamiou DE, Slater M, Luxon LM. The effect of virtual reality on visual vertigo symptoms in patients with peripheral vestibular dysfunction: a pilot study. J Vestib Res. 2012;22:273–81.

    CAS  PubMed  Google Scholar 

  40. Alahmari KA, Sparto PJ, Marchetti GF, Redfern MS, Furman JM, Whitney SL. Comparison of virtual reality based therapy with customized vestibular physical therapy for the treatment of vestibular disorders. IEEE Trans Neural Syst Rehabil Eng. 2014;22(2):389–99.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Bergeron M, Lortie CL, Guitton MJ. Use of virtual reality tools for vestibular disorders rehabilitation: a comprehensive analysis. Adv Med. 2015.

  42. Garcia AP, Gananca MM, Cusin FS, et al. Vestibular rehabilitation with virtual reality in Meniere’s disease. Braz J Otorhinolaryngol. 2013;79:366–74.

    Article  PubMed  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.

  44. Szturm T, Reimer KM, Hochman J. Home-based computer gaming in vestibular rehabilitation of gaze and balance impairment. Games Health J. 2015;4(3):211–20.

    Article  PubMed  Google Scholar 

  45. Park MK, Kim KM, Jung J, Lee N, Hwang SJ, Chae SW. Evaluation of uncompensated unilateral vestibulopathy using the modified clinical test for sensory interaction and balance. Otol Neurotol. 2013;34(2):292–6.

    Article  PubMed  Google Scholar 

  46. Matsuda PN, Taylor CS, Shumway-Cook A. Evidence for the validity of the modified dynamic gait index across diagnostic groups. Phys Ther. 2014;94(7):996–1004.

    Article  PubMed  Google Scholar 

  47. Nilsagård Y, Kollén L, Axelsson H, Bjerlemo B, Forsberg A. Functional gait assessment: reliability and validity in people with peripheral vestibular disorders. Int J Ther Rehabil. 2014;21(8):367–73.

    Article  Google Scholar 

  48. Writer HS, Arora RD. Vestibular rehabilitation: an overview. Int J Otorhinolaryngol Clin. 2012;4(1):54–69.

    Article  Google Scholar 

  49. Wei SH, Chen PY, Chen HJ, Kao CL, Schubert MC. Visual afference mediates head and trunk stability in vestibular hypofunction. J Clin Neurosci. 2016;29:139–44.

    Article  PubMed  Google Scholar 

  50. Klatt BN, Carender WJ, Lin CC, Alsubaie SF, Kinnaird CR, et al. A conceptual framework for the progression of balance exercises in persons with balance and vestibular disorders. Phys Med Rehabil Int. 2015;2(4):1044.

    PubMed  PubMed Central  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.

  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.

  53. Ricci NA, Aratani MC, Caovilla HH, Gananca FF. Effects of vestibular rehabilitation on balance control in older people with chronic dizziness: a randomized clinical trial. Am J Phys Med Rehabil. 2016;95(4):256–69.

    Article  PubMed  Google Scholar 

  54. Verdecchia DH, Mendoza M, Sanguineti F, Binetti AC. Outcomes after vestibular rehabilitation and Wii(R) therapy in patients with chronic unilateral vestibular hypofunction. Acta Otorrinolaringol Esp. 2014;65(6):339–45.

    Article  PubMed  Google Scholar 

  55. Maciaszek J, Osinski W. Effect of Tai Chi on body balance: randomized controlled trial in elderly men with dizziness. Am J Chin Med. 2012;40(2):245–53.

    Article  PubMed  Google Scholar 

  56. Chen PY, Hsieh WL, Wei SH, Kao CL. Interactive wiimote gaze stabilization exercise training system for patients with vestibular hypofunction. J Neuroeng Rehabil. 2012;9:77.

    Article  PubMed  PubMed Central  Google Scholar 

  57. Sienko KH, Balkwill MD, Oddsson LI, et al. The effect of vibrotactile feedback on postural sway during locomotor activities. J Neuroeng Rehabil. 2013;10:93.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Goebel JA, Sinks BC, Parker BE Jr, Richardson NT, Olowin AB, Cholewiak RW. Effectiveness of head-mounted vibrotactile stimulation in subjects with bilateral vestibular loss: a phase 1 clinical trial. Otol Neurotol. 2009;30(2):210–6.

    Article  PubMed  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.

  60. Golub JS, Ling L, Nie K, et al. Prosthetic implantation of the human vestibular system. Otol Neurotol. 2014;35:136–47.

    Article  PubMed  PubMed Central  Google Scholar 

  61. Wuehr M, Decker J, Schniepp R. Noisy galvanic vestibular stimulation: an emerging treatment option for bilateral vestibulopathy. J Neurol. 2017.

  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.

  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.

  64. Bhattacharyya N, Baugh RF, Orvidas L, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2008;139:S47–81.

    Article  PubMed  Google Scholar 

  65. Herman SJ, Tusa RJ. Complications of the canalith repositioning procedure. Arch Otolaryngol Head Neck Surg. 1996;122(3):281–6.

    Article  Google Scholar 

  66. Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 1992;107:399–404.

    Article  CAS  PubMed  Google Scholar 

  67. Toupet M, Ferrary E, Bozorg Grayeli A. Effect of repositioning maneuver type and postmaneuver restrictions on vertigo and dizziness in benign positional paroxysmal vertigo. ScientificWorldJournal. 2012;2012:162123.

    Article  PubMed  PubMed Central  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.

  69. Mostafa BE, Youssef TA, Hamad AS. The necessity of post-maneuver postural restriction in treating benign paroxysmal positional vertigo: a meta-analytic study. Eur Arch Otorhinolaryngol. 2013;270(3):849–52.

    Article  PubMed  Google Scholar 

  70. Papacharalampous GX, Vlastarakos PV, Kotsis GP, Davilis D, Manolopoulos L. The role of postural restrictions after BPPV treatment: real effect on successful treatment and BPPV’s recurrence rates. Int J Otolaryngol. 2012;2012:932847.

    Article  PubMed  PubMed Central  Google Scholar 

  71. Tjernstrom F, Fransson PA, Holmberg J, Karlberg M, Magnusson M. Decreased postural adaptation in patients with phobic postural vertigo—an effect of an “anxious” control of posture? Neurosci Lett. 2009;454:198–202.

    Article  PubMed  Google Scholar 

  72. Odman M, Maire R. Chronic subjective dizziness. Acta Otolaryngol. 2008;128:1085–8.

    Article  PubMed  Google Scholar 

  73. Staab JP, Ruckenstein MJ, Solomon D, Shepard NT. Serotonin reuptake inhibitors for dizziness with psychiatric symptoms. Arch Otolaryngol Head Neck Surg. 2002;128:554–60.

    Article  PubMed  Google Scholar 

  74. Huppert D, Strupp M, Rettinger N, Hecht J, Brandt T. Phobic postural vertigo—a long-term follow-up (5 to 15 years) of 106 patients. J Neurol. 2005;252:564–9.

    Article  CAS  PubMed  Google Scholar 

  75. Vereeck L, et al. The effect of early customized vestibular rehabilitation on balance after acoustic neuroma resection. Clin Rehabil. 2008;22:698–713.

    Article  PubMed  Google Scholar 

  76. Whitney SL, Alghadir AH, Anwer S. Recent evidence about the effectiveness of vestibular rehabilitation. Curr Treat Options Neurol. 2016;18(3):12.

    Article  Google Scholar 

  77. Itani M, Koaik Y, Sabri A. The value of close monitoring in vestibular rehabilitation therapy. J Laryngol Otol. 2017;131(3):227–31.

    Article  CAS  PubMed  Google Scholar 

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  1. Department of Otolaryngology, Toronto General Hospital, University Health Network (UHN), 200 Elizabeth St, Toronto, ON, M5G 2C4, Canada

    Joanna Burzynski, Shaleen Sulway & John A. Rutka

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  1. Joanna Burzynski
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This article was made possible from funding through the Hertz Multidisciplinary Neurotology Clinic at UHN.

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This article is part of the Topical Collection on Otology: Vestibular Disorders

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Burzynski, J., Sulway, S. & Rutka, J.A. Vestibular Rehabilitation: Review of Indications, Treatments, Advances, and Limitations. Curr Otorhinolaryngol Rep 5, 160–166 (2017). https://doi.org/10.1007/s40136-017-0157-1

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