What is the best management for a patient with vestibular hypofunction?

Best Management for Vestibular Hypofunction

Vestibular rehabilitation therapy (VRT) is the primary treatment for vestibular hypofunction and should be offered to all patients with this condition, as it significantly improves symptom control, reduces fall risk, enhances gaze and postural stability, and improves quality of life based on Grade A evidence from systematic reviews and multiple randomized controlled trials. 1, 2

Core Treatment: Vestibular Rehabilitation Therapy

VRT should be prescribed as the first-line intervention for all forms of vestibular hypofunction, including unilateral vestibular hypofunction with incomplete central compensation, bilateral vestibular hypofunction, post-ablative therapy states, and chronic imbalance. 1, 2

Specific Exercise Components

VRT encompasses multiple evidence-based exercise types that must be included: 1, 2, 3

• Gaze stabilization exercises: Head movements during visual fixation to promote vestibulo-ocular reflex adaptation 2, 3
• Habituation exercises: Repeated exposure to movements that provoke symptoms 1, 3
• Balance and postural control training: Static and dynamic balance exercises with reduced support base 2, 3
• Walking exercises: For endurance and functional mobility 1, 3

Dosing and Duration Recommendations

The prescription must be tailored to chronicity and laterality: 2

• Acute/subacute unilateral hypofunction: Gaze stabilization exercises 3 times daily for minimum 12 minutes total daily 2
• Chronic unilateral hypofunction: Gaze stabilization 3-5 times daily for minimum 20 minutes total daily for 4-6 weeks, plus static/dynamic balance exercises minimum 20 minutes daily for at least 4-6 weeks 2
• Bilateral hypofunction: Gaze stabilization 3-5 times daily for 20-40 minutes total daily for 5-7 weeks, plus balance exercises minimum 6-9 weeks 2

Supervision Requirements

Supervised vestibular rehabilitation should be offered based on strong evidence and patient preference, combining weekly clinic visits with home exercise programs. 2

Critical Medication Management

Do NOT routinely prescribe vestibular suppressant medications (antihistamines like meclizine or benzodiazepines) for vestibular hypofunction, as these agents interfere with central vestibular compensation and delay recovery. 1, 4

While meclizine is FDA-approved for vertigo associated with vestibular system diseases 5, the American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against routine use because benzodiazepines and antihistamines impede the central compensation process that VRT aims to facilitate. 4, 1

If vestibular suppressants were previously prescribed, withdraw them as soon as possible to allow compensation to proceed. 1

The only acceptable exception is very short-term use (hours to days) for severe nausea/vomiting in acutely symptomatic patients who refuse other options or require prophylaxis immediately before/after repositioning procedures. 4

High-Risk Populations Requiring Urgent Intervention

Patients with bilateral vestibular hypofunction have severely limited compensation ability and face extremely high fall risk, requiring immediate VRT initiation and fall prevention strategies. 1

Elderly patients with vestibular hypofunction face compounded fall risk from multifactorial comorbid impairments and require assessment for additional risk factors including impaired mobility, CNS disorders, and lack of home support. 1

What NOT to Do During VRT

Do not include voluntary saccadic or smooth-pursuit eye movements in isolation (without head movement) to promote gaze stability, as strong evidence shows a preponderance of harm over benefit. 2

Do not recommend VRT during acute vertigo attacks, as this may worsen symptoms and is contraindicated. 4, 1, 6

Do not delay VRT initiation, as early application hastens compensation and reduces symptom duration. 7

Expected Outcomes and Stopping Criteria

VRT provides clear and substantial benefit with improvements in: 1, 2

• Symptom control and reduced dizziness 1, 2
• Fall risk reduction and improved safety 1, 2
• Enhanced confidence and quality of life 1, 2
• Normalized balance and vestibular function 2

Stop therapy when primary goals are achieved, symptoms resolve, balance and vestibular function normalize, or progress plateaus. 1, 2

Factors That May Modify Outcomes

Evaluate and address these factors that can affect rehabilitation success: 2

• Time from symptom onset (earlier intervention yields better outcomes) 2
• Comorbidities (visual, somatosensory, or CNS impairments prolong recovery) 2, 7
• Cognitive function 2
• Medication use (vestibular suppressants impede recovery) 2

Patients with progressive vestibular disorders, central involvement, or visual/somatosensory impairments require more prolonged treatment courses and may demonstrate incomplete recovery. 7