Vestibular Rehabilitation

VRT Fundamentals - Dizzy No More!

• Vestibular Rehabilitation Therapy (VRT): Exercise-based program to improve symptoms of dizziness and imbalance from vestibular dysfunction.
• Goal: Promote central nervous system (CNS) compensation for vestibular deficits.
• Mechanisms:
  • Adaptation: Modifies Vestibulo-Ocular Reflex (VOR) gain.
  • Substitution: Enhances use of alternative sensory inputs (visual, somatosensory).
  • Habituation: Reduces sensitivity to provocative stimuli through repeated exposure.
• Indications: Stable peripheral or central vestibular lesions (e.g., BPPV after canalith repositioning, unilateral/bilateral vestibular hypofunction, post-acoustic neuroma surgery).
• Contraindications: Unstable/fluctuating vestibular lesions, acute severe vertigo requiring medical management.

⭐ Cawthorne-Cooksey exercises form the historical basis of many VRT programs and are often customized for individual patient needs_._

Brain's Balancing Act - How VRT Works

• Leverages neuroplasticity: brain's adaptive capacity.
• Key Mechanisms of Central Compensation:
  • Adaptation: Improves Vestibulo-Ocular Reflex (VOR) gain; crucial for gaze stability.
  • Habituation: Reduces response to dizziness-inducing stimuli through repeated, controlled exposure.
  • Substitution: Utilizes visual and somatosensory cues to replace lost vestibular function.
  • Sensory Re-weighting: Shifts reliance towards more accurate or available sensory inputs.

⭐ Central compensation, the core of VRT, can begin within days post-vestibular insult, highlighting the brain's rapid adaptive potential. oka

VRT Toolkit - Moves & Methods

• Gaze Stability Exercises: Enhance focus during head motion.
  • VOR x1: Head moves, target still.
  • VOR x2: Head & target move oppositely.
• Habituation Exercises: Desensitize to provoking stimuli.
  • Repeated exposure to dizziness triggers.
  • Example: Brandt-Daroff exercises.
• Balance Training (Postural Stability): Improve steadiness.
  • Static: Standing on varied surfaces, eyes open/closed.
  • Dynamic: Walking with head turns, tandem gait.
• Canalith Repositioning Maneuvers (CRMs): For BPPV.
  • Epley (posterior canal).
  • Semont (posterior canal).
  • Barbecue roll (horizontal canal).

⭐ Brandt-Daroff exercises are habituation exercises used for residual dizziness post-CRM or when CRMs are not tolerated by the patient for BPPV management.

Condition-Specific VRT - Tailored Tactics

• BPPV:
  • CRMs: Epley (post. canal), Semont; Gufoni, BBQ roll (horiz. canal).
  • Brandt-Daroff exercises for residual dizziness (habituation).

  ⭐ Epley maneuver is primary treatment for posterior canal BPPV.

• UVH (e.g., Vestibular Neuritis):
  • Gaze Stability: VOR x1, VOR x2 exercises improve VOR.
  • Balance & Gait Training: Static/dynamic. Adaptation exercises.
• BVH (e.g., Ototoxicity):
  • Substitution: Enhance visual & somatosensory cues.
  • Gaze Stability: Use remembered/imaginary targets.
  • Balance Training: Sensory augmentation; crucial fall prevention.
• Meniere's Disease (Inter-critical):
  • Balance training & habituation for motion sensitivity.
  • Avoid VRT during acute attacks.
• PPPD:
  • Habituation: To provocative visual stimuli & self-motion.
  • Sensory re-weighting, balance exercises, relaxation.

High‑Yield Points - ⚡ Biggest Takeaways

• VRT promotes gaze stability, postural control, and habituation via CNS plasticity.
• Includes Cawthorne-Cooksey exercises, gaze stabilization (VOR x1, x2), and balance training.
• Indicated for stable vestibular hypofunction (unilateral/bilateral), post-BPPV repositioning, and some central lesions.
• CRMs (Epley) are first-line for BPPV; VRT manages residual dizziness.
• Success depends on patient adherence, customized program, and early start.
• Significant improvement often seen in 4-8 weeks of consistent therapy.