» Dizziness and Balance : Protocols For Successful Vestibular Rehabilitation

Dizziness and Balance

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Protocols For Successful Vestibular Rehabilitation

Protocols For Successful Vestibular Rehabilitation 

The process of prescribing systematic repetitive exercises and protocols to eliminate symptoms provoked by movement as well as enhancing the stability of posture and equilibrium is known as vestibular rehabilitation therapy (VRT).

Dating back to the 1940s, it began simply as a means of using active eye and head movement exercises to help patients with labyrinthine problems. By the 1980s, with the work of Brandt and Daroff, a higher degree of effective exercises were developed.

In modern times, the science of this therapy has greatly advanced the available treatment options. A VHT is generally delivered by physical therapists, physicians and audiologists and has received widespread endorsement from organizations such as The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS), the American Speech-Language Hearing Association (ASHA), and the American Academy of Audiology (AAA).

The science behind VRT

The plasticity of the central nervous system liest behind the physiological essence of VRT. But it does not work by actually regenerating or treating the damaged vestibular end organ alone; rather, it works by allowing the central nervous system and the brain to adapt to asymmetrical/conflicting input coming from the vestibular mechanisms.

In a best case scenario, VRT should begin within 90 days after dysfunction or loss of one of the vestibular systems. Having said that, many vestibular lesions, such as some of those which occur with rapid onset, do not necessarily benefit from this compensation protocol.

There is also a human factor to be considered. The patient’s reluctance to do any of the prescribed activities involving head motion that provoke systems of dizziness can retard the phenomenon of central compensation. In fact, this is a primary reason why it does not work in many people.

As Dr. David Zee of Johns Hopkins points out, the brain cannot fix what the brain cannot see.

There are other hindrances to VRT’s effectiveness, including the patient’s use of such medications as Meclizine, Antivert, Valium or other drugs which suppress CNS function or peripheral vestibular function. These pharmaceuticals also delay or prevent the central nervous system from relearning or adapting to asymmetrical sensory input.

Compounding this very real problem is that the patient, in their anxiety of avoiding becoming dizzy at work or while driving, comes to depend on those medications because they suppress their symptoms. It is not always a good idea for these patients to depend on these drugs as opposed to taking therapy for a long-term cure.

Advantages of VRT

Vestibular rehabilitation therapy is a cost-effective, non-invasive, user-friendly short course of therapy which is often the best and only way to manage symptoms of vestibular dysfunction and allows patients to return to their normal everyday ability to function.

Who benefits from VRT?

To be most effective, VRT should be used for patients who are outside of the acute phase of a condition. That means their symptoms no longer include the acute labyrinthine storm with debilitating vertigo and nausea, vomiting and diaphoresis.

In fact, patients in the midst of a labyrinthine storm secondary to labyrinthitis, vestibular neuritis or active Meniere’s Disease will receive little benefit.

But most patients, once they have reached a stabilized condition, can benefit greatly. That can also include any condition which causes a weakness of loss of vestibular function (vestibulopathy) such as a Meniere’s patient who is in the end-stage and not experiencing further attacks, and people whose fluctuating hearing loss has been stabilized.

Patients with labyrinthitis, vestibular neuronitis, vertebrobasilar and labyrinthine ischemias will also benefit.

All of these patients generally have symptoms that are brought on by active head movement, often at a particular frequency of motion and in a particular direction. Visual provocation may also be recorded, such as difficulty driving down a certain street if the patient is looking out the side window and there are a lot of telephone poles. While shopping for wallpaper or floor tiles, certain patterns can also provoke symptoms. Patients commonly complain that they have trouble walking down the aisles of a grocery store if they start to turn their head from side to side as they shop.


  1. Cawthorne, T: The Physiological Basics for Head Exercises. S Chartered Soc Physiother. 30:106, 1944.
  2. Cooksey, F.S.: Rehabilitation in Vestibular Injuries. Pro R Soc Med. 39:273, 1946.
  3. Brandt, T and Daroff, RB: Physical Therapy for Benign Paroxysmal Positional Vertigo. Arch Otolaryngology. 106:484, 1980.
  4. American Speech, Hearing, Language Association Supplement. Spring 1996. ASHA Volume 39 Number 2.
  5. American Academy of Audiology. Vestibular Issues. Task Force 1999.
  6. American Academy of Otolaryngology. Head and Neck Surgery Bulletin. Policy statements October 1998. Vol 17, No. 10.
  7. Gans, RE: Dizziness, Loss of Balance and Movement Therapy. Penn State Sports Medicine Newsletter. June 1997. Vol. 5, No. 10.
  8. Gans, RE: Vestibular Rehabilitation: Protocols and Programs. Singular Publishing Group 1996.
  9. Girardi, M and Konrad, HR: Vestibular Rehabilitation Therapy for the Patient with Dizziness and Balance Disorders. Head and Neck Nursing. Fall 1998. Vol. 16, No. V.


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