When should vestibular rehabilitation therapy (VRT) be started in a patient with vestibular hypofunction?

When to Start Vestibular Rehabilitation Therapy (VRT)

Start VRT as soon as possible after diagnosis of vestibular hypofunction, ideally within the first 2 weeks of symptom onset, as earlier intervention produces superior outcomes in restoring vestibular function and preventing compensatory mechanisms that are harder to reverse. 1

Timing Based on Clinical Presentation

Acute Vestibular Hypofunction (First 2 Weeks)

• Begin VRT immediately within the first 2 weeks after onset of acute unilateral vestibular hypofunction for optimal recovery of dynamic visual acuity and angular vestibulo-ocular reflex (aVOR) gain 1
• Early intervention (mean 8.9 days after onset) significantly improves passive aVOR gain and reduces compensatory saccades compared to delayed treatment 1
• This early window represents a "sensitive period" where plastic reorganization in brain structures allows for optimal functional recovery rather than reliance on compensatory strategies 1
• Patients should perform gaze stabilization exercises at minimum 3 times daily for at least 12 minutes total for acute/subacute unilateral vestibular hypofunction 2

Subacute to Chronic Phase (Beyond 2 Weeks)

• VRT started between weeks 3-4 (mean 27.5 days) shows less improvement in aVOR gain and increased reliance on compensatory saccades rather than true vestibular recovery 1
• VRT initiated after 1 month (mean 82.5 days) demonstrates the least DVA improvement with minimal changes in aVOR gain 1
• For chronic unilateral vestibular hypofunction, prescribe exercises 3-5 times daily for 20+ minutes for 4-6 weeks minimum 2
• Despite delayed timing, VRT still provides significant benefit and should be offered, as strong evidence supports its effectiveness even in chronic cases 2

Clinical Scenarios Where VRT Should Be Offered

Unilateral Vestibular Hypofunction

• Offer VRT to all adults with unilateral vestibular hypofunction presenting with impairments, activity limitations, and participation restrictions (strong evidence, Grade A) 2
• This includes patients with vestibular neuritis, labyrinthitis, or unilateral Ménière's disease with incomplete central compensation 3

Bilateral Vestibular Hypofunction

• Strongly recommend VRT for bilateral vestibular hypofunction based on 4 level 1 RCTs (strong recommendation) 3
• Prescribe exercises 3-5 times daily for 20-40 minutes for approximately 5-7 weeks minimum 2
• Continue for minimum 6-9 weeks based on expert opinion 2

Post-Ablative Treatment

• Initiate VRT following ablative procedures (intratympanic gentamicin, labyrinthectomy) for patients with incomplete central vestibular compensation 3
• Level 1 RCT evidence shows postoperative VRT improves motion sensitivity and subjective symptoms on Dizziness Handicap Inventory 3

Chronic Imbalance from Ménière's Disease

• Offer VRT for chronic imbalance in Ménière's disease patients with unilateral peripheral vestibular hypofunction and incomplete central compensation 3
• VRT demonstrates preponderance of benefit over harm despite limitations in study quality 3

When NOT to Start VRT

Absolute Contraindications

• Do NOT recommend VRT during acute vertigo attacks in Ménière's disease or other conditions with active, fluctuating vestibular function 3, 4, 5
• Stop VRT immediately if patient develops acute vertigo with fluctuating vestibular function 3
• VRT during acute attacks may worsen symptoms and is contraindicated 4, 5

Relative Considerations for BPPV

• VRT may be offered as initial therapy for BPPV, though particle repositioning maneuvers (Epley) are more effective for rapid symptom resolution 3
• VRT shows superior outcomes to placebo but is less effective than repositioning maneuvers in short-term evaluation 3
• Consider VRT for BPPV when repositioning maneuvers are contraindicated or for reducing recurrence rates, particularly in elderly patients 3

Supervised vs. Home-Based Programs

Supervision Recommendations

• Offer supervised vestibular rehabilitation based on strong evidence and patient preference 2
• Current evidence is inadequate to favor formal outpatient therapy over independent home therapy 3
• Prescribe weekly clinic visits plus home exercise program for optimal outcomes 2

Exercise Prescription Specifics

• Combined adaptation and habituation exercises show faster improvement and better outcomes than single-exercise protocols 6
• Include gaze stabilization exercises emphasizing high-velocity head movements (240°/s) during short exercise bouts 7
• Avoid voluntary saccadic or smooth-pursuit eye movements in isolation without head movement (strong evidence of preponderance of harm over benefit) 2

Critical Pitfalls to Avoid

Medication Interference

• Withdraw vestibular suppressants (antihistamines, benzodiazepines) as soon as possible as they interfere with central vestibular compensation and delay recovery 4
• These medications cause drowsiness, cognitive deficits, and increased fall risk, particularly in elderly patients 4, 8
• Use medications as needed rather than scheduled if necessary for severe acute symptoms only 4

Timing Errors

• Delaying VRT beyond 2 weeks results in suboptimal aVOR recovery and increased reliance on compensatory saccades rather than true vestibular restoration 1
• Starting VRT during acute vertigo attacks worsens symptoms 3, 4, 5

Diagnostic Confusion

• Do not mistake visual vertigo, BPPV, or Ménière's disease for each other, as treatment approaches differ significantly 4, 5
• Ensure vestibular hypofunction is confirmed by objective vestibular function tests (video head impulse test, caloric testing) before initiating VRT 2, 1

Stopping Criteria

• Discontinue VRT when achieving primary goals, resolution of symptoms, normalized balance and vestibular function, or plateau in progress (moderate evidence) 2
• Evaluate factors that may modify outcomes including time from symptom onset, comorbidities, cognitive function, and medication use 2
• Most patients require 4-6 weeks minimum for chronic unilateral hypofunction, with bilateral cases requiring 6-9 weeks 2