What is the protocol for performing vestibular rehabilitation therapy (VRT)?

Vestibular Rehabilitation Therapy Protocol

Vestibular rehabilitation therapy (VRT) is an exercise-based treatment program that should be implemented as a series of progressive exercises focusing on habituation, adaptation, and compensation for vestibular deficits to improve symptoms and quality of life in patients with vestibular disorders. 1, 2

Core Components of VRT Protocol

1. Initial Assessment and Exercise Selection

• VRT should begin with exercises based on the underlying vestibular disorder, with BPPV being the most common indication 3, 4
• For BPPV, determine canal involvement using the Dix-Hallpike maneuver (posterior canal) or supine roll test (lateral canal) before initiating appropriate rehabilitation 4
• Note that while repositioning maneuvers (Epley, Gufoni) are first-line treatments for BPPV with 90-98% success rates, VRT serves as complementary therapy or alternative when repositioning is contraindicated 3, 4

2. Habituation Exercises

• Implement Cawthorne-Cooksey exercises which consist of eye, head, and body movements in a hierarchy of increasing difficulty to provoke vestibular symptoms 1
• Begin with simple head movements in sitting or supine positions, then progress to more complex activities 1
• These exercises should be performed until symptoms fatigue, forcing the central nervous system to compensate through habituation 1
• For BPPV specifically, Brandt-Daroff exercises can be implemented, involving rapid lateral head/trunk tilts to promote debris dispersion toward the utricular cavity 1

3. Gaze Stabilization Training

• Implement exercises requiring head movement during visual fixation or visual target changes 5, 2
• Have patients focus on a target while moving their head horizontally and vertically at various speeds 2
• Progress to more challenging exercises by increasing speed, adding complex backgrounds, or performing in different positions 2, 6

4. Balance and Postural Control Training

• Include exercises with reduced support base in various head and trunk orientations 2
• Progress from standing on firm surfaces with feet apart to standing on foam with feet together 2, 6
• Add upper extremity tasks while maintaining balance 2
• Include walking exercises on various surfaces, slopes, and steps with eyes open and closed 1, 5

5. Exercise Frequency and Progression

• Exercises should be performed several times daily, even brief periods are sufficient to facilitate vestibular recovery 2
• Begin with 3-5 repetitions of each exercise, gradually increasing as tolerance improves 5, 2
• Progress to more challenging environments as symptoms improve 6
• Continue exercises for at least 2 weeks, with reassessment within 1 month 1, 4

Special Considerations

• VRT is safe with no serious adverse events reported in clinical trials 1
• Home-based therapy appears equally effective as clinician-supervised therapy, though initial instruction is important 1
• VRT may be particularly beneficial for elderly patients, potentially decreasing recurrence rates of symptoms 1
• Patients with certain comorbidities may require specialized, individually tailored protocols, including those with: cervical stenosis, Down syndrome, severe rheumatoid arthritis, cervical radiculopathies, Paget's disease, morbid obesity, ankylosing spondylitis, low back dysfunction, and spinal cord injuries 1, 3

Common Pitfalls to Avoid

• Relying solely on vestibular suppressant medications instead of exercise-based rehabilitation 3, 7
• Failing to reassess patients after initial treatment to confirm symptom resolution 3, 4
• Overlooking canal conversions or involvement of multiple canals in persistent symptoms 3, 4
• Discontinuing exercises prematurely when mild symptoms persist 2, 7
• Using inappropriate exercise intensity - exercises should provoke mild to moderate symptoms but not severe discomfort 2, 6

Expected Outcomes

• Patients with acute unilateral vestibular injury have the best prognosis for full recovery 5
• Those with bilateral lesions will show improvement but may have permanent deficits 5
• VRT demonstrates superior treatment outcomes compared to placebo for BPPV 1
• While initially less effective than repositioning maneuvers for BPPV, long-term effectiveness approaches that of repositioning procedures 1