What is the recommended treatment for vestibular disorders using vestibular rehabilitation therapy (VRT)?

Vestibular Rehabilitation Therapy for Vestibular Disorders

Vestibular rehabilitation therapy (VRT) should be offered to patients with chronic vestibular disorders, particularly those with chronic imbalance, but should not be used during acute vertigo attacks. 1, 2

Indications for VRT

Recommended for:

• Patients with chronic imbalance from vestibular disorders 1
• Following ablative therapy for vestibular disorders 1
• Bilateral vestibular hypofunction 1
• Poorly compensated stable vestibular lesions 3
• Residual dizziness after resolution of acute vestibular conditions 2

Not Recommended for:

• Acute vertigo attacks in Ménière's disease 1
• During active vertigo episodes 1

Components of Effective VRT

VRT programs should include exercises targeting:

1. Gaze stability exercises:

   • Head-eye coordination exercises
   • Visual fixation during head movement
   • Visual target changes with head movement 3

2. Balance and postural stability training:

   • Standing with reduced support base
   • Various head and trunk orientations
   • Walking and turning exercises 3, 4

3. Habituation exercises:

   • Repetition of movements that provoke mild to moderate symptoms
   • Gradual exposure to various sensory environments 2, 3

4. Substitution training:

   • Visual substitution exercises
   • Somatosensory cue utilization
   • Alternative postural strategies 3, 4

Implementation Protocol

Exercise Prescription:

• Begin with exercises producing mild to moderate symptoms
• Perform exercises 3-5 times daily for 3-5 minutes per session
• Progress by increasing difficulty as tolerance improves 2
• Even brief periods of exercise are sufficient if performed several times daily 3

Medication Considerations:

• Vestibular suppressant medications should NOT be used during VRT
• These medications interfere with central compensation
• Can delay recovery and cause unwanted side effects 2

Expected Outcomes

VRT provides significant benefits:

• Improved symptom control
• Reduced risk of falls, especially in elderly patients
• Improved confidence and quality of life
• Enhanced safety during daily activities 1, 2

Contraindications and Special Considerations

VRT may require modification or may not be appropriate for patients with:

• Cervical stenosis
• Severe rheumatoid arthritis
• Cervical radiculopathies
• Paget's disease
• Morbid obesity
• Ankylosing spondylitis
• Low back dysfunction
• Spinal cord injuries 1, 2

Common Pitfalls to Avoid

1. Using vestibular suppressant medications long-term
2. Discontinuing exercises when symptoms temporarily increase
3. Inadequate exercise frequency
4. Failure to progress exercise difficulty
5. Not addressing psychological components 2
6. Stopping VRT during fluctuating vestibular function 1

Evidence Quality and Recommendations

The American Academy of Otolaryngology-Head and Neck Surgery provides a strong recommendation (Grade A evidence) for VRT in chronic imbalance, particularly following ablative therapy or in bilateral vestibular disorders 1. The evidence shows a preponderance of benefit over harm, with improved symptom control, reduced fall risk, and enhanced quality of life 1.

For acute vertigo attacks, particularly in Ménière's disease, VRT is not recommended as there is insufficient evidence supporting its use in this context 1.