Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Updated Clinical Practice Guideline From the Academy of Neurologic Physical Therapy of the American Physical Therapy Association

Abstract

Background: Uncompensated vestibular hypofunction can result in symptoms of dizziness, imbalance, and/or oscillopsia, gaze and gait instability, and impaired navigation and spatial orientation; thus, may negatively impact an individual's quality of life, ability to perform activities of daily living, drive, and work. It is estimated that one-third of adults in the United States have vestibular dysfunction and the incidence increases with age. There is strong evidence supporting vestibular physical therapy for reducing symptoms, improving gaze and postural stability, and improving function in individuals with vestibular hypofunction. The purpose of this revised clinical practice guideline is to improve quality of care and outcomes for individuals with acute, subacute, and chronic unilateral and bilateral vestibular hypofunction by providing evidence-based recommendations regarding appropriate exercises. Methods: These guidelines are a revision of the 2016 guidelines and involved a systematic review of the literature published since 2015 through June 2020 across 6 databases. Article types included meta-analyses, systematic reviews, randomized controlled trials, cohort studies, case-control series, and case series for human subjects, published in English. Sixty-seven articles were identified as relevant to this clinical practice guideline and critically appraised for level of evidence. Results: Based on strong evidence, clinicians should offer vestibular rehabilitation to adults with unilateral and bilateral vestibular hypofunction who present with impairments, activity limitations, and participation restrictions related to the vestibular deficit. Based on strong evidence and a preponderance of harm over benefit, clinicians should not include voluntary saccadic or smooth-pursuit eye movements in isolation (ie, without head movement) to promote gaze stability. Based on moderate to strong evidence, clinicians may offer specific exercise techniques to target identified activity limitations and participation restrictions, including virtual reality or augmented sensory feedback. Based on strong evidence and in consideration of patient preference, clinicians should offer supervised vestibular rehabilitation. Based on moderate to weak evidence, clinicians may prescribe weekly clinic visits plus a home exercise program of gaze stabilization exercises consisting of a minimum of: (1) 3 times per day for a total of at least 12 minutes daily for individuals with acute/subacute unilateral vestibular hypofunction; (2) 3 to 5 times per day for a total of at least 20 minutes daily for 4 to 6 weeks for individuals with chronic unilateral vestibular hypofunction; (3) 3 to 5 times per day for a total of 20 to 40 minutes daily for approximately 5 to 7 weeks for individuals with bilateral vestibular hypofunction. Based on moderate evidence, clinicians may prescribe static and dynamic balance exercises for a minimum of 20 minutes daily for at least 4 to 6 weeks for individuals with chronic unilateral vestibular hypofunction and, bas...

Longitudinal [18]UCB-H/[18F]FDG imaging depicts complex patterns of structural and functional neuroplasticity following bilateral vestibular loss in the rat

“…Multimodal physical training is the mainstay of therapy in patients with bilateral vestibular loss 23 , 68 . The applied principles are based on neurophysiological considerations and tailored to training of the vestibular-ocular reflex (habituation training), the interplay of multisensory sources to control posture (sensory pertubation training), and dynamic balance (locomotor training) 69 , 70 .…”

“…Structural changes such as altered receptor expressions, synaptic morphology and cell proliferation were reported in vitro in the brainstem, striatum, hippocampus, and frontal cortex after bilateral vestibular deafferentation in the rat 17 , 20 – 22 . In clinical practice, multimodal physical training of eye-head-coordination, postural balance, and locomotion are established and evidence-based treatment principles for patients with bilateral vestibular loss 23 . While these exercises are effective at improving mobility and reducing the risk of falls, their mode of action on cerebral structure and function is barely understood.…”

Vestibular Deficits in Deafness: Clinical Presentation, Animal Modeling, and Treatment Solutions

“…Vestibular rehabilitation is a physiotherapy program that accelerate compensation phenomena that are effective but slow and helps to correct inappropriate balance strategies. It is designed to promote vestibular compensation through adaptation, substitution, and habituation ( 225 – 227 ). Rehabilitation is often proposed in cases of acute unilateral vestibular deficits, inappropriate spontaneous compensation, or bilateral vestibular loss.…”

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“…One of the obvious benefits of digital health is to improve access, which is a challenge in VR ( 3 ). It is estimated that between 53 and 95 million adults have peripheral vestibular hypofunction across Europe and the US ( 4 ), and VR is a first-line, evidence-based treatment for these adults ( 5 , 6 ). In a recent European Survey of VR in 22 countries, almost 50% of therapists reported that VR was difficult to access ( 2 ).…”