Vestibular Rehabilitation

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Vestibular Rehabilitation

Otology/Audiology
Author Credentials 

Marc Bennett, MD, MMHC, FACS
Associate Professor and Quality Officer
Otolaryngology
Vanderbilt University Medical Center
Nashville, TN

 

Nauman Manzoor, MD
Fellow
Otolaryngology
Vanderbilt University Medical Center
Nashville, TN

Module Summary

This module covers central basis of vestibular compensation and multidisciplinary utilization of a vestibular rehabilitative program.

Module Learning Objectives 
  1. Explain basics of vestibular recovery and compensation and predictors of outcomes.
  2. Discuss tenets of vestibular evaluation and components of a vestibular rehabilitation program.
  3. Describe methods to assess progress in vestibular rehabilitation.

 

Basic Science

Learning Objectives 
  1. Explain the basis of processes such as habituation, adaptation, and sensory substitution as it pertains to vestibular system.
  2. Discuss various negative and positive predictors of successful outcomes based on an understanding of neuroplasticity of vestibular and balance systems.

 

References 
  1. Herdman SJ. Role of vestibular adaptation in vestibular rehabilitation. Otolaryngol Head Neck Surg. 1998;119(1):49-54
  2. Herdman SJ, Hall CD, Delaune W. Variables associated with outcome in patients with unilateral vestibular hypofunction. Neurorehabil Neural Repair. 2012;26(2):151-162
  3. Schubert MC, Zee DS. Saccade and vestibular ocular motor adaptation. Restor Neurol Neurosci. 2010;28(1):9-18
  4. Hall CD, Meldrum D. The Aging Vestibular System: Implications for Rehabilitation (Chapter 32). In: Jacobson GP, Shepard NT. eds. Balance Function Assessment and Management. 2nd ed. San Diego (CA): Plural Publishing; 2016. 

Patient Evaluation

Learning Objectives 
  1. Identify based on history and intake forms, various neurological and systemic factors which will influence vestibular rehabilitation.
  2. Determine vestibular disorders which will likely not benefit substantially from vestibular rehabilitation (identify central or unstable vestibular disorders).
  3. Be facile with routine bedside vestibular evaluation including a thorough oculomotor assessment, cerebellar and coordination assessment, as well as evaluation of strength, range of movement, and peripheral sensation.

 

References 
  1. McCaslin DL, Dundas A, Jacobson GP. Bedside Assessment of the Vestibular System (Chapter 7). In: Jacobson GP, Shepard NT. eds. Balance Function Assessment and Management. 2nd ed. San Diego (CA): Plural Publishing; 2016. 
  2. Shepard NT, Telian SA. Programmatic vestibular rehabilitation. Otolaryngol Head Neck Surg. 1995;112(1):173-182

 

Measurement of Functional Status

Learning Objectives 
  1. Recognize various subjective measure of vestibular and balance dysfunction (dizziness handicap inventory, activities-specific balance confidence scores, visual and verbal analog scale and the vestibular activities of daily living scale).
  2. Describe components of standing measures of balance including Romberg and Tandem Romberg test.
  3. Recognize various forms of posturography testing including the sensory organization test (SOT) and modified clinical test of sensory organization and balance (mCTSIB).
  4. Describe various methods of gait assessment including gait speed and application of dynamic gait index (DGI).
References 
  1. Whitney SL, Furman JM. Vestibular Rehabilitation (Chapter 31). In: Jacobson GP, Shepard NT. eds. Balance Function Assessment and Management. 2nd ed. San Diego (CA): Plural Publishing; 2016. 

Treatment

Learning Objectives 
  1. Describe aspects of typical vestibular exercise program with goals of enhancing remaining vestibular and utilization of somatosensory and visual function.
  2. Describe treatment modifications based on definitive vestibular disorders and laboratory findings (such as bilateral vestibular hypofunction, complete loss of unilateral VOR etc.).
  3. Analyze role of multisensory integration and sensory substitution especially in settings of bilateral vestibular dysfunction.

 

References 
  1. Whitney SL, Furman JM. Vestibular Rehabilitation (Chapter 31). In: Jacobson GP, Shepard NT. eds. Balance Function Assessment and Management. 2nd ed. San Diego (CA): Plural Publishing; 2016. 
  2. Hall CD, Herdman SJ, Whitney SL, et al. Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Evidence-Based Clinical Practice Guideline: From the American Physical Therapy Association Neurology Section. J Neurol Phys Ther. 2016;40(2):124-155

 

Case Studies

  1. A middle-aged female with aural fullness, motion intolerance and dizziness with ambulation especially in visually challenging places. She has history of anxiety and panic disorders which is not controlled.
  • Her management included optimal control of migraine as well and anxiety component. Peripheral vestibular disorders were ruled out with clinical, audiometric and vestibular laboratory evaluation. Progressive improvement in dizziness was see with targeted VRT (vestibular rehabilitation therapy) aimed at reducing oscillopsia and confidence in ambulation. Migraine related vestibular disorder can confound VRT success in presence of other vestibular disorders and needs to be optimally managed in every patient.
  1. A previously active male has been referred for management of persistent dizziness and problems with ambulation especially on un-even surfaces after a recent bout of viral URI and ensuing vertigo. His neurotology evaluation revealed a diagnosis of vestibular neuritis including a positive head thrust test. 
  • His VRT management included strengthening of VOR with eye and head movement exercises and progressive difficulty with walking with head turns and on uneven surfaces from which he noted considerable benefit in ensuing weeks.
  1. An elderly female with multiple medical comorbidities (including diabetes) has noticed significant problems with ambulation and had frequent falls after a recent hospitalization for pyelonephritis (treated with gentamicin). Vestibular laboratory evaluation showed bilateral hypofunction.
  • Rehabilitation here is challenging in setting of bilateral vestibular loss. Sensory substitution was employed and strategies to prevent falls were implemented. 

 

 

 

References 
  1. Whitney SL, Furman JM. Vestibular Rehabilitation (Chapter 31). In: Jacobson GP, Shepard NT. eds. Balance Function Assessment and Management. 2nd ed. San Diego (CA): Plural Publishing; 2016.
  2. Martin-Sanz E, Rueda A, Esteban-Sanchez J, Yanes J, Rey-Martinez J, Sanz-Fernandez R. Vestibular Restoration and Adaptation in Vestibular Neuritis and Ramsay Hunt Syndrome With Vertigo. Otol Neurotol. 2017;38(7):e203-e208 

 

Review

Review Questions 
  1. What are the predictors of a successful outcome of vestibular rehabilitation program?
  2. Describe the differences in habituation, adaptation and substitution.
  3. Describe sensory organization test (SOT), VOR x 1 and VOR x 2 as it pertains to vestibular rehabilitation. 
  4. What kind of rehabilitation strategy should be used in patients with bilateral vestibular hypofunction?

 

Resources 

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  1. Annual Meeting Webcast (AMW):