REVIEW

CURRENT
OPINION Vestibular rehabilitation
Susan J. Herdman

Purpose of review
This review examines the research from 2011 through 2012 on treatment efficacy in two common
vestibular disorders – vestibular hypofunction and benign paroxysmal positional vertigo (BPPV).
Recent findings
Significant numbers of randomized controlled trials now support the use of specific exercises for the
treatment of patients with unilateral peripheral vestibular hypofunction. We do not know if some treatment
approaches are more effective than others. There is preliminary evidence that head movement may be
the component critical to recovered function and decreased symptoms. Some patient characteristics and
initial assessment results appear to predict treatment outcome but the evidence is incomplete. Treatment
of posterior canal BPPV canalithiasis is well established. New evidence supports certain treatments for
horizontal canal BPPV.
Summary
Treatments for unilateral vestibular hypofunction and for posterior canal BPPV are effective; however,
there are many as yet unanswered questions such as why some patients with vestibular hypofunction
do not improve with a course of vestibular exercises. We also do not know what would be the best
treatment for anterior canal BPPV or for multiple-canal involvement BPPV.
Keywords
benign paroxysmal positional vertigo, vestibular hypofunction, vestibular rehabilitation

INTRODUCTION movements. Different exercise approaches have

There is compelling evidence that specific exercises
are effective in ameliorating the symptomatic
and functional problems associated with certain
vestibular disorders. There is also evidence that
these exercises are not universally effective, some
patients do not benefit from these exercises,
and furthermore that there are several vestibular
disorders for which the use of exercise is not appro-
priate. This review will explore some of the evidence
published in 2011 and 2012 on the application
of vestibular rehabilitation therapy. New and
promising treatment approaches will also be dis-
cussed. Some research published prior to 2011 has
been included to provide the necessary background
for the review.
EXERCISES FOR PATIENTS WITH
VESTIBULAR HYPOFUNCTION
People with unilateral and bilateral vestibular
hypofunction typically have subjective complaints
of dizziness and dysequilibrium, motion sensitivity,
oscillopsia – visual blurring or jumping of the
environment during head movement, as well as
gait ataxia and imbalance, especially with head
been proposed to address these different problems.
Habituation exercises are designed to decrease
symptoms by systematically provoking those
symptoms [1–4]. Adaptation exercises are based
on inducing long-term changes in the neuronal
response of the vestibular system to a specific error
signal – retinal slip. The goals of these exercises are
to decrease visual blurring during head movement,
improve postural stability, and decrease symptoms.
The exercises consist of repeated head movements
while fixating a small stationary target or a target
moving in the opposite direction of the head
movements performed with progressively greater
challenges ([5], pp. 314–315). The third traditional
Departments of Rehabilitation Medicine and Otolaryngology–Head and
Neck Surgery, Emory University School of Medicine, Georgia, USA
Correspondence to Susan J. Herdman, PT, PhD, FAPTA, Professor,
Departments of Rehabilitation Medicine and Otolaryngology–Head
and Neck Surgery, Emory University School of Medicine, Center for
Rehabilitation Medicine, Rm 228, 1441 Clifton Rd, NE Atlanta, GA
30322, USA. Tel: +1 404 712 0612; fax: +1 404 712 5895; e-mail:
sherdma@emory.edu
Curr Opin Neurol 2013, 26:96–101
DOI:10.1097/WCO.0b013e32835c5ec4

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KEY POINTS

Vestibular rehabilitation is effective and well tolerated
for patients with unilateral vestibular hypofunction.

New treatments utilizing moving force platforms may
be effective adjuncts for the problems associated with
vestibular hypofunction.

Some patient characteristics and pretherapy
assessments contribute to poor subjective complaint,
slow gait speed and fall risk at discharge, and may
help therapists predict outcome of vestibular
rehabilitation exercises for patients with vestibular
hypofunction.

The canalith repositioning maneuver is considered to
be an effective treatment for posterior canal benign
paroxysmal positional vertigo (BPPV). Post-treatment
instructions are considered optional for treatment.

Evidence now supports the use of the Roll treatment and
the Gufoni maneuver as treatment for horizontal canal
BPPV canalithiasis.
exercise approach, substitution, has patients per-
form exercises that foster the substitution of alterna-
tive strategies to replace the lost or compromised
vestibular function. The goal of these exercises, such
as performing eye and head movements between
two or more targets and the remembered target
exercises in which visual fixation is maintained
during a head movement performed with eyes
closed, is to improve gaze stability during head
movement ([5], pp. 311, 315–316). Finally, most
vestibular rehabilitation programs include balance
and gait exercises, especially while walking or
performing other activities.
Evidence supporting the use of vestibular
rehabilitation exercises in the treatment of
patients with vestibular hypofunction
A Cochrane Review in 2011 on vestibular rehabili-
tation added six studies to the 21 identified in the
2007 review [6]. Exercises used in these articles
include habituation, adaptation, and substitution.
These studies compared vestibular rehabilitation
therapy for patients with unilateral peripheral ves-
tibular hypofunction to sham treatments, no treat-
ment, and other forms of vestibular rehabilitation
therapy. The patients in all studies were either com-
munity dwelling or in-patients following surgery
who had been community dwelling prior to admis-
sion to the hospital. The authors concluded:
(1) There is moderate to strong evidence that
vestibular rehabilitation therapy is both well
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Vestibular rehabilitation Herdman
tolerated and effective for patients with unilat-
eral vestibular hypofunction (UVH) or loss.
(2) There is moderate evidence that vestibular
rehabilitation therapy is an effective treat-
ment of patients during the acute period after
resection of vestibular schwannoma or after
vestibular neuritis.
(3) Improvements have been reported in dizziness,
gait and balance, activities of daily living, vision
during head movements, and quality of life.
(4) There is moderate evidence that these improve-
ments are sustained for months after the reha-
bilitation process ends.
Moving force platform exercise approaches
in the treatment of patients with vestibular
hypofunction
Several studies have examined whether training
balance on force platforms has an added
benefit to the more traditional vestibular exercises.
Nardone et al. [7] compared postural control and
subjective scores of stability in patients perform-
ing Cawthorne–Cooksey habituation exercises
and patients performing balance training on an
oscillating force platform. Both forms of exercise
resulted in improved balance and in decreases
in the subjective rating of dysequilibrium. Winkler
and Esses [8] noted that the use of exercises incor-
porating platform perturbation with changes in foot
position and in visual cues and habituation and gaze
stabilization exercises resulted in greater improve-
ment than habituation and gaze stabilization
exercises alone. Another study compared the effect
of computerized dynamic posturography and treat-
ment using optokinetic stimulation in patients with
chronic UVH [9]. Both groups improved in the over-
all posturography score but there were differences
noted in the performance based on which sensory
cues were altered. Finally, a study by Marioni et al.
[10] demonstrated that gaze stability and weight
shifting exercises with biofeedback resulted in
improved stability compared to no treatment.
Are different treatment approaches equally
effective for vestibular hypofunction?
Only one study has compared habituation and gaze
stabilization exercises in the treatment of patients
with UVH [11]. This study had a small number
of participants (n ¼ 7) and therefore the results
should be considered as preliminary. Furthermore,
the study did not include gait and balance outcome
measures. Nevertheless, in this randomized com-
parison study patients were treated with either
habituation exercises or gaze stabilization exercises
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 Neuro-ophthalmology and neuro-otology

6.15–4.71
(adaptation and substitution exercises). Both groups

Table 1. Mean (SD) in outcome measures for patients with peripheral unilateral vestibular hypofunction at baseline and at discharge after a course of

Fall risk (DGI)

improved in measures of handicap, motion

19.8 (3.0)
14.2 (4.0)

<0.0001
sensitivity, and visual acuity during head movement

88%
183
127

119
[computerized dynamic visual acuity (DVA)]. These
findings were unanticipated because while habitu-
ation exercises are designed to reduce symptoms,
they theoretically should not result in an improved

0.80–0.54
0.80 (0.15)
DVA. Similarly, gaze stabilization exercises are

1.01(0.17)
Gait speed

<0.0001
expected to improve DVA but not necessarily reduce

(m/s)
symptoms, although this has been shown in at

85%
132
89

59
least one previous study [12]. The author suggests
that the important factor for successful outcome for
patients with UVH may be the inclusion of head

0.327 (0.134)
0.210 (0.138)

0.095–0.139
movements in the exercises.

ipsilesional

<0.0001
It is possible that treatment efficacy is not only
dependent on matching the exercise appropriately

78%
DVA

153
70

67
to the patient’s problems but also is dependent on
the characteristics of the individual patient.

1.39 (1.4)
2.9 (0.95)

<0.0001
Disability

1.1–1.8
Are there factors that can be identified that

score

75%
140
136
are associated with who will and who will

68
not show improvement?
&&
Herdman et al. [13 ] examined data from

59 (29.8)
24 (30.1)
<0.0001
symptoms
209 patients with UVH, all of whom had been % of time

interfere
treated with similar courses of vestibular adaptation,

80%
79
76

20
substitution, and balance and gait exercises. As with

–
numerous other studies, the results documented
that whereas most patients improve with a course

31.7–22.3
51.5 (16.9)
78.5 (16.0)
of vestibular exercises, some patients do not improve
confidence

<0.0001
Balance

or improve in only certain areas (Table 1). This

(ABC)

78%
108

prognostic study examined the relationship between

82

69
vestibular adaptation, substitution and balance and gait exercises

patient characteristics, pretreatment measures of

subjective complaints, and physical function and
treatment outcome. The strength of the relation-
visual analogue
Dysequilibrium

ships between patient characteristics, initial sub-

3.97 (2.54)
1.58 (1.91)

0.11–0.15
<0.0001

].
jective complaints, and initial physical function

&&
DGI, Dynamic Gait Index; DVA, dynamic visual acuity. Adapted from [13
with outcome measures was determined using
scale

81%
180
149

113

bivariate correlation analysis. Factors or groups of

factors that influenced recovery were determined
using regression analysis. The primary findings of
Oscillopsia visual

the study were:

analogue scale

3.05 (2.66)
0.79 (1.65)

1.58–2.94
<0.0001

(1) In agreement with previous studies, age did

78%

not affect which patients would improve [14].

182
88

65

However, the current study showed that older

patients walked more slowly and had poorer
visual acuity during head movement than did
Prepost comparison: P value
No. of prepost comparisons

% of patients significantly

younger patients at discharge. This was expected

No. of patients abnormal

95% Confidence interval

because there is a naturally occurring decrement

No. of patients tested

in gait speed and in DVA with age. Older patients

Outcome measures

were also more likely to remain at risk for falls

at baseline

At discharge

than were younger patients. This may reflect slow

improved
At baseline

gait speed as that is a component of scoring in the

Dynamic Gait Index (DGI) test or it may indicate
a lesser degree of recovery in older patients.

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(2) Time from onset was not related to any out-
come, supporting the use of these exercises
in patients regardless of chronicity. Patients
in this study had a mean time from onset of
14.5 months (range 1 week to 12 years; median
5.0 months).
(3) The presence of different comorbidities did not
affect whether or not improvement occurred.
The exception was the presence of anxiety and/
or depression.
(4) Several patterns were identified in which
multiple factors accounted for significant
percentages of recovery of some of the outcome
measures.
(a) Poor subjective complaint outcome:
Patients with a high percentage of time
symptoms interfered with activities (%TSI)
at discharge were those who had anxiety
and/or depression and who had a high
%TSI at the time of the initial assessment.
These two factors together accounted for
83.7% (R2 ¼ 0.837) of the outcome.
Similarly, patients who rated their dis-
ability as high at discharge had higher
%TSI initially, worse disability scores
initially, and poor DVA score initially.
These three factors accounted for 47.8%
(R2 ¼ 0.478) of the disability score at
discharge.
(b) Slow gait speed at discharge: Patients
who walked more slowly at discharge
had slower gait speed initially and were
older. Approximately 55% of gait speed at
discharge was accounted for by those
two factors.
(c) Fall risk: Patients had lower (poorer) fall
risk scores at discharge, as measured
by the DGI test, if they had a history
of falls, had poor fall risk scores initially,
and were older. These three factors
accounted for 42.5% of DGI at discharge.
Interestingly, initial DVA score, which
has previously been show to predict fall
risk at discharge, was not a significant
factor [15].
The results of this study provide guidelines
that therapists and other clinicians can use to
develop expectations for recovery. More research
is needed, however, to determine other factors
that may explain treatment outcome such as
psychological factors including coping mechanisms
and personality traits that may affect recovery. The
identification of factors that influence recovery
should lead to different and more effective treat-
ment protocols.
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Vestibular rehabilitation Herdman
‘Vestibular rehabilitation’ for patients with
nonvestibular dizziness
The use of the some of the vestibular rehabilitation
exercises appears to have benefits in people with
nonvestibular imbalance and dizziness. A random-
ized placebo controlled trial studied older people
with nonvestibular dizziness who performed a
6-week course of either balance exercises or balance
exercises and gaze stabilization exercises [16].
They found that both groups improved in all out-
come measures; however, the group that performed
the gaze stabilization exercises had a significantly
greater improvement in fall risk compared to the
balance exercises only group.
The future
Although there is insufficient evidence at this
time to determine the benefits of the use of exercises
in the virtual reality environment, the possibilities
are promising. For example, virtual reality environ-
ments can be used to help patients who have
difficulty maintaining balance while walking in a
busy visual environment. Gaming paradigms are
also being used in the treatment of patients with
vestibular hypofunction [17]. Another anticipated
intervention for patients with vestibular loss is the
development of implantable vestibular prostheses
[18]. These prosthetic devices will require the thera-
pist to re-examine which vestibular exercises will be
most effective.
VESTIBULAR REHABILITATION OF
PATIENTS WITH BENIGN PAROXYSMAL
POSITIONAL VERTIGO
Benign paroxysmal positional vertigo (BPPV) is the
most common cause of vertigo due to a peripheral
vestibular disorder. It is especially common in
older persons, making it important that physicians
screen for this disorder considering our growing
older population.
Treatment of posterior semi-circular canal
benign paroxysmal positional vertigo
The effectiveness of exercises for the most common
form of BPPV, posterior semi-circular canal
canalithiasis, is supported by a Cochrane review
and other systematic reviews. A Cochrane review
noted that the canalith repositioning maneuver
(CRM) was both well tolerated and effective
as a treatment for posterior canal BPPV [19] and
a systematic review by Helminski et al. [20]
similarly concluded that the canalith repositioning
procedure is more effective than sham treatments
www.co-neurology.com 99
 Neuro-ophthalmology and neuro-otology
in managing posterior semi-circular canal canali-
thiasis. Furthermore, both the American Academy
of Neurology and the American Association of
Otolaryngology and Head and Neck Surgery
published practice guidelines and concluded that
the CRM was an effective treatment for posterior
canal BPPV [21,22].
The original canalith repositioning procedure
included detailed post-treatment instructions,
such as the patient was to remain upright for
48 h after the treatment. Numerous studies
suggested that these post-treatment instructions
are unnecessary. A 2012 Cochrane review, based
on nine papers, concluded that although there
was a statistically significant improvement in out-
come when the post-treatment instructions were
used, the difference was so small that the use of
these post-treatment restrictions was optional [23].
Although strong evidence supports the use of
the CRM for the treatment of posterior semi-circular
canal BPPV (PC-BPPV), there has been little evidence
supporting the use of an alternative treatment, the
Liberatory (Semont) maneuver. Fortunately, two
recent, randomized, placebo-controlled, double-
blinded studies reported a significantly greater per-
centage of remission following using the Liberatory
maneuver (86.8 and 84% remission, respectively)
compared to the sham treatment groups (0 and
&& &&
14% remission, respectively) [24 ,25 ].
Advances in the treatment of horizontal
semi-circular canal benign paroxysmal
positional vertigo
One of the difficulties of successfully treating
patients with horizontal semi-circular canal BPPV
(HC-BPPV) has been the determination of which
side is the affected side. Historically, in the canal-
ithiasis form the affected side is the most sympto-
matic side, and in the cupulolithiasis form the
affected side is the least symptomatic side. In
2006, the ‘bow and lean test’ (BLT) was proposed
as an addition to the roll test to identify the affected
side in HSC-BPPV [26]. In the BLT, the roll test
is performed first to determine whether the
BPPV is canalithiasis or cupulolithiasis based on
the duration of the nystagmus. The BLT is then
performed to determine the affected side by observ-
ing the direction of the nystagmus in the bow
and lean positions. Lee et al. [27] found that the
use of the BLT with the roll test increases treatment
efficacy from 67.4 to 83.1% for the canalithiasis
form of HC-BPPV and from 61.1 to 74.7% for the
cupulolithiasis form of HC-BPPV.
For the most part, evidence of treatment efficacy
for treatment of HC-BPPV canalithiasis has been
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weak, with no control groups or with control groups
consisting of patients who refused treatment or
who could not be treated. Recently a randomized
study examined 170 consecutive patients with HC-
BPPV canalithiasis [28]. The authors reported that
both the roll treatment and the Gufoni maneuver
resulted in a higher remission rate (69.1 and 60.9%,
respectively) than a sham treatment (35.4%) on the
initial day of treatment. At 1 month after treatment,
treatment efficacy for both the roll and the Gufoni
treatment group was still significantly better
than the sham treatment group. Another study
compared the Gufoni maneuver to a modification
of the Gufoni maneuver in which patients moved to
the sidelying position in stages rather than in a
single rapid movement [29]. Treatment of the
modified Gufoni resulted in a similar rate of
remission (93%) as treatment with the original
Gufoni maneuver (88%). However, the modified
Gufoni resulted in only a 2% conversion to PC-BPPV
compared to a 16% rate for the original Gufoni
maneuver [29].
A final note
For better or worse the treatment of BPPV has moved
&
into cyberspace. Kerber et al. [30 ] noted that in 2011
there were 33 videos on YouTube that demonstrated
the CRM. The ‘good’ news is that the video with the
most ‘hits’ (over 800 000) was one that accurately
demonstrated the CRM. The ‘bad’ news is that 36%
of the videos were considered by the authors to
inaccurately demonstrate the treatment. The ease
of access to videos on YouTube may enable patients
to review treatments that they perform at home.
However, access to inaccurate information may
delay appropriate treatment and recovery.
CONCLUSION
Although there is an increasing body of knowledge
supporting the use of vestibular exercises, there
are certain important questions that remain
unanswered. First, we do not understand the mech-
anisms underlying the improvement that occurs
with various treatment approaches for patients with
vestibular hypofunction. Identifying the underlying
mechanisms should lead to the development
of better treatment approaches. We do not know
why some patients with vestibular hypofunction do
not improve with a course of vestibular exercises.
Although we have strong evidence for treatments
for PC-BPPV, and some evidence that supports
certain treatments for HC-BPPV, we do not have
similar evidence for treatment of anterior canal
BPPV nor for multiple-canal BPPV.
Volume 26
Number 1
February 2013

Acknowledgements
None.
Conflicts of interest
The author has no financial conflict of interest with
material presented in this paper. The author is the
primary author on one of the studies discussed in this
paper. This work was not sponsored by any funding
agency, organization or person. The author is an inves-
tigator on a grant pending review through the Veterans
Administration that will study patients with vestibular
hypofunction.
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