What is vestibular rehabilitation therapy for a healthy adult with acute vestibular neuritis, and how and when should it be initiated and performed?

What is Vestibular Rehabilitation Therapy?

Vestibular rehabilitation therapy (VRT) is an exercise-based physical therapy program designed to promote central nervous system compensation for vestibular dysfunction through repetitive head-eye movements, balance exercises, and habituation to provocative stimuli—it should be initiated as soon as the acute vertigo phase resolves in vestibular neuritis patients. 1, 2

Core Definition and Mechanisms

VRT refers to a structured program of physical exercises and maneuvers originally described by Cooksey and Cawthorne that promote:

• Gaze stability through head-eye coordination exercises during visual fixation 3, 2
• Postural stability by challenging balance with reduced support bases and various head/trunk orientations 3, 2
• Symptom habituation by repeatedly exposing patients to movements that provoke vertigo 3, 4
• Central vestibular compensation by activating neuroplastic mechanisms through repetition of specific exercises 5

The therapy works through three primary recovery mechanisms: vestibular adaptation at the level of vestibular nuclei, substitution by vision and proprioception for missing vestibular input, and behavioral strategies to manage residual deficits 4, 6.

Specific Indications for Vestibular Neuritis

For acute vestibular neuritis, VRT should be offered to all adults with unilateral vestibular hypofunction who have impairments, activity limitations, and participation restrictions. 1 This recommendation carries Grade A evidence from the American Academy of Otolaryngology-Head and Neck Surgery 1.

Critical Timing Considerations

• Do NOT initiate VRT during the acute vertigo attack—it is contraindicated and may worsen symptoms 3, 1
• Begin VRT as soon as the acute phase resolves (typically after 24-72 hours when severe spinning vertigo subsides) to facilitate faster compensation 4, 7
• Early application hastens compensation and reduces long-term disability 4, 6

Key Exercise Components

The essential exercises for vestibular neuritis include:

• Head-eye coordination exercises: Moving the head horizontally and vertically while maintaining visual fixation on a stationary target 2, 4
• Static and dynamic balance training: Standing and walking with progressively narrowed base of support, eyes open then closed 2, 4
• Habituation exercises: Repeating specific head movements that provoke residual dizziness until symptoms fatigue 3, 2
• Gait training: Walking with head turns, walking in various sensory environments (different surfaces, lighting conditions) 3, 2

Medication Management During VRT

Withdraw vestibular suppressants (antihistamines, benzodiazepines, meclizine) as soon as possible—these medications interfere with central vestibular compensation and delay recovery. 1 They also cause drowsiness, cognitive deficits, and increased fall risk, particularly in elderly patients 1.

Supervised vs. Home-Based Programs

Current evidence shows no significant difference between formal outpatient therapy and independent home therapy for final outcomes. 1 However, initial instruction by a trained therapist is important to ensure proper technique 8. As long as exercises are performed several times daily, even brief exercise periods are sufficient to facilitate vestibular recovery 2.

Expected Recovery Pattern

Recovery from vestibular neuritis occurs through:

• Peripheral restoration of labyrinthine function (usually incomplete, but improved by early corticosteroid treatment with 62% recovery within 12 months) 6
• Somatosensory and visual substitution for the impaired vestibular input 6
• Central compensation enhanced by vestibular exercise 6

Common Pitfalls to Avoid

• Starting VRT too early during acute vertigo attacks will exacerbate symptoms and is contraindicated 3, 1
• Continuing vestibular suppressants beyond the acute phase (first 2-3 days) delays compensation 1, 4
• Confusing vestibular neuritis with BPPV—these require completely different treatments (canalith repositioning for BPPV vs. VRT for vestibular neuritis) 1
• Inadequate exercise frequency—exercises must be performed multiple times daily for effectiveness 2

Safety Profile

VRT is safe with no serious adverse events reported in clinical trials. 8 The primary risks are transient exacerbation of symptoms during exercises and time/cost of therapy appointments 3.