From the Guidelines
The most common treatment modality for vestibular rehabilitation is vestibular habituation exercises, particularly the Cawthorne-Cooksey exercises, as supported by the most recent and highest quality study 1. These exercises involve a progressive program of head and eye movements, balance activities, and positional changes designed to promote neuroplasticity and central compensation for vestibular deficits.
Key Components of Vestibular Rehabilitation
- A typical regimen includes starting with simple head movements while sitting, progressing to standing balance exercises, and eventually incorporating more complex movements like walking with head turns.
- Patients should perform these exercises 2-3 times daily for 10-15 minutes per session, continuing for 6-8 weeks, though some patients may require longer treatment periods.
- Symptoms may temporarily worsen during initial sessions, which is normal and patients should be encouraged to continue.
Mechanism of Action
These exercises are effective because they stimulate the vestibular system, forcing the brain to adapt to conflicting sensory information and develop compensatory strategies.
- The exercises work by promoting neural adaptation, substitution of alternative strategies, and habituation to provocative movements.
- For optimal results, exercises should be tailored to each patient's specific deficits and gradually increased in difficulty as tolerance improves, as recommended by recent clinical practice guidelines 1.
Clinical Evidence
The use of vestibular rehabilitation has been supported by various studies, including a 2020 clinical practice guideline on Ménière's disease 1, which recommends offering vestibular rehabilitation/physical therapy for patients with chronic imbalance.
- Additionally, a 2017 clinical practice guideline on benign paroxysmal positional vertigo also supports the use of vestibular rehabilitation, including habituation exercises and canalith repositioning maneuvers 1.
- While earlier studies, such as the 2008 clinical practice guideline on benign paroxysmal positional vertigo, also discussed the use of vestibular rehabilitation 1, the most recent and highest quality study 1 provides the strongest evidence for its effectiveness.
From the FDA Drug Label
Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults (1). The most common treatment modality for vestibular rehabilitation is not explicitly stated in the FDA drug label.
- The label only mentions the treatment of vertigo associated with diseases affecting the vestibular system.
- Vestibular rehabilitation is not directly addressed in the label. 2
From the Research
Treatment Modalities for Vestibular Rehabilitation
The most common treatment modality for vestibular rehabilitation is an exercise-based program. This program is designed to promote vestibular adaptation and substitution, with the goals of:
- Enhancing gaze stability
- Enhancing postural stability
- Improving vertigo
- Improving activities of daily living 3 This exercise-based program has been in existence for over 70 years and has a growing body of evidence to support its use in patients with vestibular disorders 4.
Key Exercises and Mechanisms
The key exercises for vestibular rehabilitation include:
- Head-eye movements with various body postures and activities
- Maintaining balance with a reduced support base with various orientations of the head and trunk
- Repeating movements that provoke vertigo
- Exposing patients to various sensory and motor environments 3 These exercises facilitate vestibular recovery mechanisms, including vestibular adaptation, substitution by other eye-movement systems, and habituation.
Effectiveness of Vestibular Rehabilitation
Studies have shown that exercise-based vestibular rehabilitation is effective in improving symptoms of imbalance, falls, fear of falling, oscillopsia, dizziness, vertigo, motion sensitivity, and secondary symptoms such as nausea and anxiety 4, 5. Vestibular rehabilitation has also been shown to be effective in reducing dizziness and improving balance ability in patients with vestibular neuritis 6.
Indications and Outcomes
Vestibular rehabilitation is indicated for any stable but poorly compensated vestibular lesion, regardless of the patient's age, cause, and symptom duration and intensity 3. The outcomes of vestibular rehabilitation can be measured using various scales, including the Vertigo Symptom Scale, the Dizziness Handicap Inventory, and the Berg's Balance Scale 5, 6.