What are the treatment options for a patient with vestibular insufficiency?

Treatment of Vestibular Insufficiency

Clinicians should offer vestibular rehabilitation/physical therapy as the primary treatment for patients with vestibular insufficiency presenting with chronic imbalance, as this intervention significantly improves symptom control, reduces fall risk, and enhances quality of life. 1

Core Treatment Approach

Vestibular Rehabilitation Therapy (VRT) - First-Line Treatment

VRT is strongly recommended for all patients with vestibular hypofunction based on Grade A evidence from systematic reviews and multiple RCTs. 1, 2 This recommendation applies to:

• Unilateral vestibular hypofunction with incomplete central compensation 1
• Bilateral vestibular hypofunction (based on 4 level 1 RCTs) 1
• Post-ablative therapy (following intratympanic gentamicin or labyrinthectomy) 1
• Chronic imbalance from Ménière's disease in the interictal period 1

What VRT Includes

VRT encompasses a range of physical exercises designed to promote central vestibular compensation 1:

• Gaze stabilization exercises (head-eye coordination during visual fixation) 1, 3, 4
• Habituation exercises (repeated exposure to symptom-provoking movements) 1, 3, 4
• Balance and postural control training (static and dynamic exercises) 1, 2, 4
• Walking exercises for endurance 1
• Adaptation exercises for vestibulospinal systems 5, 4

Specific Treatment Protocols

For Chronic Unilateral Vestibular Hypofunction

Prescribe gaze stabilization exercises 3-5 times daily for a total of at least 20 minutes daily for 4-6 weeks. 2

Add static and dynamic balance exercises for a minimum of 20 minutes daily for at least 4-6 weeks. 2

For Bilateral Vestibular Hypofunction

Prescribe gaze stabilization exercises 3-5 times daily for 20-40 minutes daily for approximately 5-7 weeks. 2

Continue balance exercises for a minimum of 6-9 weeks. 2

For Acute/Subacute Unilateral Hypofunction

Prescribe gaze stabilization exercises 3 times daily for at least 12 minutes total daily. 2

Critical Medication Management

Vestibular Suppressants - Avoid or Withdraw Quickly

Do NOT routinely prescribe vestibular suppressant medications (meclizine, antihistamines, benzodiazepines) for vestibular insufficiency. 6, 7 These medications:

• Interfere with central vestibular compensation and delay recovery 6, 7
• Cause significant adverse effects including drowsiness, cognitive deficits, and increased fall risk (especially in elderly) 6, 7
• Should be withdrawn as soon as possible if already prescribed 6, 7

If vestibular suppressants are necessary for severe acute symptoms, use them as needed rather than scheduled to minimize interference with compensation. 6, 7

Meclizine is FDA-approved for vertigo associated with vestibular system diseases at 25-100 mg daily in divided doses, but should be used with caution due to drowsiness and anticholinergic effects. 8

When VRT Should NOT Be Used

Do not recommend VRT for managing acute vertigo attacks. 1 VRT is contraindicated during:

• Acute vertiginous episodes 1, 6
• Active fluctuating vestibular function from conditions like active Ménière's disease 1

Stop VRT temporarily during acute exacerbations and resume once symptoms stabilize. 1

Supervised vs. Home-Based Therapy

Offer supervised vestibular rehabilitation based on strong evidence and patient preference. 2 The optimal approach combines:

• Weekly clinic visits with a trained physical therapist 2
• Daily home exercise program as prescribed above 2, 4
• Patient education about the recovery process 7, 3

Even brief periods of exercise performed several times daily are sufficient to facilitate vestibular recovery. 4

High-Risk Populations Requiring Special Attention

Elderly Patients

Patients with unilateral vestibular hypofunction are at significantly higher risk of falls. 1

Patients with bilateral vestibular insufficiency have limited ability to compensate and are at even higher risk of falls and fall-related injuries. 1

Assess all patients before treatment for fall risk factors including impaired mobility, CNS disorders, and lack of home support. 9, 7

Post-Ablative Therapy Patients

Patients who receive ablative treatments (intratympanic gentamicin, labyrinthectomy) are candidates for post-treatment VR if central compensation is incomplete. 1

Level 1 RCT evidence shows that postoperative VR improves motion sensitivity and subjective symptoms compared to controls. 1

Expected Outcomes and Duration

Benefits of VRT include: 1

• Improved symptom control
• Reduced risk of falls
• Improved confidence
• Enhanced quality of life
• Better gaze and postural stability 2

Stop therapy when: 2

• Primary goals are achieved
• Symptoms resolve
• Balance and vestibular function normalize
• Progress plateaus

Factors that may prolong recovery include time from symptom onset, comorbidities, cognitive dysfunction, concurrent central lesions, and use of vestibular suppressant medications. 2, 4

Common Pitfalls to Avoid

• Do not prescribe long-term vestibular suppressants - they impede compensation and prolong recovery 6, 7
• Do not attempt VRT during acute attacks - this worsens symptoms 1, 6
• Do not use voluntary saccadic or smooth-pursuit eye movements in isolation (without head movement) - strong evidence shows no benefit 2
• Do not delay VRT initiation - early application hastens compensation 3
• Do not forget to reassess within 1 month to document resolution or persistence of symptoms 7