What is the best course of treatment for an adult patient with no significant medical history who is experiencing imbalance?

Treatment of Imbalance in Adults Without Significant Medical History

The best course of treatment for an adult patient with no significant medical history experiencing imbalance is vestibular rehabilitation therapy (VRT), which should be initiated promptly while avoiding vestibular suppressant medications that interfere with central compensation. 1, 2

Initial Diagnostic Approach

Before initiating treatment, determine the specific pattern and etiology of imbalance:

• Assess onset characteristics: Determine if symptoms are acute (sudden onset) versus chronic (persistent), episodic versus continuous, and whether triggered by specific head movements or positions 3, 4
• Identify red flags: Rule out central nervous system pathology, medication-induced ataxia, bilateral vestibular hypofunction, or autoimmune causes that may present with limited neurologic findings 4
• Evaluate fall risk: Use standardized tools such as the Timed Up-and-Go Test or Unipodal Stance Testing to quantify balance impairment and fall risk 5

Primary Treatment: Vestibular Rehabilitation Therapy

VRT should be offered as first-line treatment for chronic imbalance, as it significantly improves symptom control, reduces fall risk, enhances confidence, and improves quality of life. 1, 2

Evidence Base for VRT

• The American Academy of Otolaryngology-Head and Neck Surgery provides a strong recommendation (Grade A evidence) for VRT in patients with vestibular hypofunction presenting with impairments and activity limitations 2
• Multiple level 1 RCTs demonstrate efficacy across various vestibular conditions including unilateral and bilateral vestibular hypofunction 6, 2

VRT Components

The rehabilitation program should include: 1

• Gaze stabilization exercises to improve visual stability during head movements
• Habituation exercises to reduce motion-provoked symptoms
• Balance and postural control training to improve stability
• Walking exercises to build endurance and functional mobility

Treatment Duration and Monitoring

• Continue VRT until primary goals are achieved, symptoms resolve, balance normalizes, or progress plateaus 1
• For patients on bone loss-inducing medications or with borderline bone density, consider balance training combined with resistance exercises, flexibility training, and fall prevention strategies 6

Critical Medication Management

Avoid prescribing vestibular suppressant medications (antihistamines, benzodiazepines) for chronic imbalance, as they interfere with central vestibular compensation and delay recovery. 1, 2

• If vestibular suppressants were previously prescribed, withdraw them as soon as possible 2
• These medications cause drowsiness, cognitive deficits, and increase fall risk, particularly problematic in this population 2, 7

Contraindications and Timing Considerations

Do not initiate VRT during acute vertigo attacks, as this may worsen symptoms. 6, 8, 2

• VRT is specifically indicated for chronic imbalance and interictal instability, not acute episodic vertigo 6
• If the patient presents with acute vertigo, defer VRT until the acute episode resolves 2

Supervised vs. Home-Based Programs

• Current evidence does not favor formal outpatient therapy over independent home-based programs 2
• The choice should be based on patient preference, adherence likelihood, complexity of exercises needed, and availability of resources 6

Expected Outcomes

Patients undergoing VRT can expect: 1

• Improved symptom control and safety
• Reduced risk of falls and fall-related injuries
• Improved confidence in daily activities
• Enhanced quality of life

Common Pitfalls to Avoid

• Do not prescribe long-term vestibular suppressants, which impede compensation 1, 2
• Do not delay VRT initiation in patients with chronic symptoms 1
• Do not attempt VRT during acute attacks, which can worsen symptoms 6, 8
• Do not mistake different vestibular conditions (BPPV, Ménière's disease, visual vertigo) for each other, as treatment approaches differ 2

Additional Supportive Measures

For comprehensive management, also address: 6

• Dietary optimization: Ensure adequate calcium (1,000-1,200 mg/day) and vitamin D (800-1,000 IU/day) intake
• Lifestyle modifications: Encourage smoking cessation and limit alcohol consumption
• Exercise variety: Incorporate balance training, flexibility exercises, endurance activities, and progressive strengthening