VESTIBULAR REHABILITATION THERAPY (VRT)

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Vestibular rehabilitation can be effective in improving symptoms related to many vestibular (inner ear/balance) disorders. People with vestibular disorders often experience problems with vertigo, dizziness, visual disturbance, and/or imbalance. These are the problems that rehabilitation aims to address. Other problems can also arise that are secondary to vestibular disorders, such as nausea and/or vomiting, reduced ability to focus or concentrate, and fatigue.

Symptoms due to vestibular disorders can diminish quality of life and impact all aspects of daily living. They also contribute to emotional problems such as anxiety and depression. Additionally, one of the consequences of having a vestibular disorder is that symptoms frequently cause people to adopt a sedentary lifestyle in order to avoid bringing on, or worsening, dizziness and imbalance. As a result, decreased muscle strength and flexibility, increased joint stiffness, and reduced stamina can occur.

Treatment strategies used in rehabilitat1ion can also be beneficial for these secondary problems.

WHAT IS VESTIBULAR REHABILITATION?

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. It is an exercise-based program primarily designed to reduce vertigo and dizziness, gaze instability, and/or imbalance and falls. For most people with a vestibular disorder the deficit is permanent because the amount of restoration of vestibular function is very small. However, after vestibular system damage, people can feel better and function can return through compensation. This occurs because the brain learns to use other senses (vision and somatosensory, i.e. body sense) to substitute for the deficient vestibular system. The health of particular parts of the nervous system (brainstem and cerebellum, visual, and somatosensory sensations) is important in determining the extent of recovery that can be gained through compensation.

For many, compensation occurs naturally over time, but for people whose symptoms do not reduce and who continue to have difficulty returning to daily activities, VRT can help with recovery by promoting compensation.3 The goal of VRT is to use a problem-oriented approach to promote compensation. This is achieved by customizing exercises to address each person’s specific problem(s). Therefore, before an exercise program can be designed, a comprehensive clinical examination is needed to identify problems related to the vestibular disorder.

WHAT SHOULD PATIENTS EXPECT FROM VESTIBULAR REHABILITATION?

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 more objectively evaluate the patient’s problems. 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 anxiety that may occur as a result of their vestibular disorder.

ARE VESTIBULAR REHABILITATION EXERCISES DIFFICULT TO DO?

VRT exercises are not difficult to learn, but to achieve maximum success patients must be committed to doing them.

Since the exercises can sometimes be tedious, setting up a regular schedule so that the exercises can be incorporated into daily life is very important.

Exercises may, at first, make symptoms seem worse. But with time and consistent work, symptoms should steadily decrease, which means participation in activities of daily life will be easier for patients to do.

FACTORS THAT CAN IMPACT RECOVERY

When patients participate in VRT different factors can impact the potential for recovery. For example, the type of vestibular disorder affects recovery. Patients that have a stable vestibular disorder, such as vestibular neuritis or labyrinthitis, have the best opportunity to achieve a satisfactory resolution of their symptoms. When patients have a progressive vestibular disorder, like multiple sclerosis, or a fluctuating condition, like migraine and Meniere’s, which cause spontaneous attacks of dizziness or vertigo, compensation can be difficult to achieve, and therefore, success with VRT is more difficult.

To improve the chance for success with VRT for patients with progressive or fluctuating disorders it is important to manage these disorders medically. Patients with vestibular migraine may benefit more from VRT by implementing behavioral changes (reduction of migraine triggers and participation in cognitive behavioral treatment) and/or using pharmacological therapy to help reduce or eliminate the headache attacks. Although VRT does not treat the attacks of vertigo that patients with Meniere’s disease experience, if the frequency of these attacks is reduced with diet and medication, or if indicated, with a more aggressive chemical or surgical type of intervention, then VRT can possibly help reduce symptoms that occur between attacks. The goal of medical management is to help stabilize the disorder as best as possible to allow for compensation to occur. As a consequence, the exercise strategies used in VRT will have a better chance to promote compensation and reduce vestibular-related symptoms.

There are differences in potential recovery depending on the vestibular disorder. If patients have a unilateral lesion (only one ear affected by a vestibular disorder) they generally have a better chance of recovery as compared to those with bilateral lesions (both ears are affected). VRT does assist with recovery in patients with bilateral lesions, just not the same amount and not as quickly as in patients with unilateral lesions. For patients with central vestibular disorders, the structures of the brain that allow for compensation are affected. This limits the amount and speed of recovery. However, research has shown that patients with central vestibular disorders can make gains with VRT.

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