Practical Diagnosis and

Management of

VERTIGO

DR. PRAHLADA N. B
 Practical Guide to Diagnosis & Management of Vertigo

CHAPTER

Vestibular Rehabilitation
Therapy 11
Dr. Prahlada N. B
SECTIONS

Introduction
Mechanism and Rationale of VRT
Clinical Indications for VRT

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Assessment and Baseline Evaluation in VRT
Core Components of VRT INTRODUCTION
Individualized Treatment Planning in VRT
Duration, Frequency, and Monitoring of VRT
Vestibular Rehabilitation Therapy (VRT) is a special-
Barriers to Effectiveness & Strategies in VRT ized, exercise-driven therapeutic strategy designed to
Evidence Basis for VRT address the challenging symptoms that result from
vestibular disorders—namely dizziness, vertigo, un-
stable vision, and balance difficulties. These symp-
toms typically emerge when the vestibular system
ABBREVIATIONS
or its central pathways are compromised, disrupting
ABC - Activities-specific Balance Confidence Scale the harmonious integration of visual, vestibular, and
BBS - Berg Balance Scale proprioceptive cues that are essential for maintaining
BVH - Bilateral Vestibular Hypofunction balance and spatial awareness. VRT involves a tai-
CBT - Cognitive Behavioural Therapy lored set of exercise modules, each carefully select-
CDP - Computerized Dynamic Posturography ed based on the patient’s unique clinical profile and
DHI - Dizziness Handicap Inventory
DVA - Dynamic Visual Acuity
specific physiological deficits, especially within the
FGA - Functional Gait Assessment vestibulo-ocular, vestibulo-spinal, and somatosenso-
HEP - Home Exercise Program ry systems [1].
HIT - Head Impulse Test
Recognized as a conservative and non-invasive inter-
mHealth - Mobile Health
PPPD - Persistent Postural-Perceptual Dizziness vention, VRT has become a foundational treatment
RCT - Randomized Controlled Trial for a wide range of vestibular disorders. These in-
SOT - Sensory Organization Test clude unilateral and bilateral peripheral vestibular
TUG - Timed Up and Go hypofunction, recovery following episodes of benign
VOR - Vestibulo-Ocular Reflex paroxysmal positional vertigo (BPPV), persistent pos-
VR - Virtual Reality
VRT - Vestibular Rehabilitation Therapy Historical Insight:
VVAS - Visual Vertigo Analog Scale
X1 Viewing - Head movement while fixating on a The roots of VRT lie in the Cawthorne-Cooksey exercises,
stationary target developed in the mid-20th century (Table 1). These in-
X2 Viewing - Head and target move in opposite cluded simple head, eye, and postural movements aimed
directions at promoting central compensation after vestibular inju-
ry. While foundational, modern VRT is now individualized
based on assessment tools and grounded in neuroplastici-
ty science.

Vestibular Rehabilitation Therapy 1

Practical Guide to Diagnosis & Management of Vertigo

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tural-perceptual dizziness (PPPD), and balance dis- of sensory information critical for maintaining bal-
turbances resulting from central conditions such as ance, spatial orientation, and visual stability. It works
stroke or demyelinating diseases [2]. The core thera- in close collaboration with visual and propriocep-
peutic advantage of VRT lies in its ability to harness tive systems to sustain equilibrium, both at rest and
the brain’s natural neuroplasticity to reorganize sen- during movement. When the vestibular end-organs
sorimotor networks and support functional recovery. (e.g., semicircular canals, otoliths) or their neural
This chapter delves into the scientific rationale, es- connections are damaged, this sensory integration is
sential components, and clinical practices involved in disrupted, leading to conflicts in input, spatial dis-
VRT, with a particular focus on evidence-based exer- orientation, and unsteadiness (Fig. 21-1) [3]. In re-
cise regimens and personalized treatment strategies. sponse, the central nervous system initiates compen-
satory changes through neuroplastic mechanisms—a
process that VRT is specifically designed to stimulate.
MECHANISM AND RATIONALE OF VRT
Symptom Exacerbation ≠ Treatment VRT facilitates this adaptive process via three main
The vestibular system serves as a central integrator physiological mechanisms: adaptation, habituation,
Failure
and substitution.
Mild worsening of dizziness during VRT Adaptation involves recalibrating the vestibulo-ocu-
exercises (especially habituation and gaze
lar reflex (VOR), which is crucial for stabilizing vi-
stabilization) is expected and often indi-
sion during head movements. In cases like unilateral
cates activation of central compensatory
vestibular hypofunction, the VOR’s response becomes
mechanisms.
2 Vestibular Rehabilitation Therapy
 Practical Guide to Diagnosis & Management of Vertigo

Figure 21-1: Schematic representation of central compensation mechanisms in vestibular rehabilitation, illustrating how

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adaptation, habituation, and substitution integrate vestibular, visual, and proprioceptive inputs to restore balance and gaze
stability.

unbalanced—resulting in unstable vision. Exercises studies and clinical research have confirmed that ves-
aimed at gaze stabilization, such as head movements tibular plasticity is driven by sensory-driven activity
focused on fixed or moving targets (X1 and X2 view- in brainstem centers, cerebellar circuits, and cortical
ing), create retinal slip that serves as an error signal vestibular areas, offering a robust neurobiological
to gradually refine the VOR’s accuracy (Fig. 21-2) [4]. basis for the therapy [7].
Habituation works by reducing an abnormal re- In summary, VRT utilizes principles of neuroplasticity
sponse to a particular stimulus through repeated ex- to rebalance sensory inputs, recondition reflex path-
posure. Individuals with motion sensitivity or visually ways, and enhance postural control. The selection
induced dizziness often experience heightened reac- of exercises is grounded in thorough clinical evalu-
tions to certain movements or visual environments. ations, which help identify the specific sensory do-
Habituation exercises intentionally provoke mild mains—such as gaze stability, motion sensitivity, or
symptoms in a controlled manner, gradually desen- balance—that need to be addressed. Ultimately, the
sitizing the vestibular system and lessening symptom success of VRT depends not just on its solid scientific
severity over time [5]. This approach is particularly foundation, but also on careful individualization of
effective for patients with PPPD, vestibular migraines, therapy plans and patient commitment, establishing
or chronic BPPV. it as a vital component of modern vestibular care.
Substitution techniques are implemented when ad-
aptation or habituation alone is inadequate—as in CLINICAL INDICATIONS FOR VESTIBULAR
the case of bilateral vestibular loss. Here, the central REHABILITATION THERAPY (VRT)
nervous system is trained to rely more heavily on oth-
er senses, such as vision and proprioception, to com- Vestibular Rehabilitation Therapy (VRT) is an evi-
pensate for missing vestibular input. For example, dence-based, non-pharmacological approach used
patients may be asked to perform balance exercises
on firm versus soft surfaces to increase propriocep- Assessment Drives Intervention
tive input, or to practice maintaining visual fixation
during head movements to stabilize posture [6]. Use specific tools (e.g., DHI, HIT, DVA,
TUG, BBS) to classify deficits—such as
Through the strategic application of these mecha- gaze instability, motion sensitivity, or bal-
nisms, VRT fosters both cortical and subcortical reor- ance impairment—and tailor exercises
ganization that supports sustained recovery. Animal accordingly.
Vestibular Rehabilitation Therapy 3
Practical Guide to Diagnosis & Management of Vertigo

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Figure. 21-2: Illustration of gaze stabilization techniques.

Picture A (X1 Viewing): Patient rotates head side-to-side while maintaining gaze on a fixed target.
Picture B (X2 Viewing): Patient moves both head and target in opposite directions to enhance vestibulo-ocular reflex adap-
tation.

to manage a wide array of balance disorders involv- ance, and visual instability due to uneven signaling
ing the peripheral, central, and functional vestibular from the vestibular organs. VRT protocols—especial-
systems. Its clinical applications span both acute and ly those aimed at gaze stabilization and balance train-
chronic presentations, as well as post-treatment sce- ing—facilitate central compensation and support the
narios where recalibration of balance mechanisms is recovery process. Research consistently shows that
needed (Table 21-1). VRT yields the greatest benefit timely initiation of vestibular rehabilitation in such
when implemented after a comprehensive diagnostic cases leads to more substantial symptom reduction
workup, allowing for the formulation of exercise pro- and improved quality of life compared to pharmaco-
tocols that target each patient’s specific physiological logical treatment alone [8].
impairments and underlying mechanisms. Bilateral vestibular hypofunction also represents a
A major indication for VRT is unilateral vestibular key application for VRT, although its clinical manage-
hypofunction, frequently associated with conditions ment is inherently more complex. Unlike unilateral
such as vestibular neuritis and labyrinthitis. These loss, which allows for compensation through the un-
disorders typically cause sudden onset vertigo, imbal- affected labyrinth, bilateral dysfunction significantly
disrupts the vestibulo-ocular reflex (VOR) and pos-
Unilateral vs. Bilateral Hypofunction tural regulation. Affected individuals often report
Requires Distinct Strategies symptoms like oscillopsia during movement and per-
sistent disequilibrium. For these patients, VRT centers
Unilateral lesions benefit from VOR adap- on substitution strategies—enhancing the reliance on
tation; bilateral cases require substitution visual and proprioceptive cues and retraining postur-
and balance reliance on visual and pro- al control mechanisms to compensate for the lack of
prioceptive cues. vestibular input [9].
4 Vestibular Rehabilitation Therapy
 Practical Guide to Diagnosis & Management of Vertigo

Fig. 21-3: This illustration depicts the setup for the Dynamic
Although Benign Paroxysmal Positional Vertigo Visual Acuity (DVA) test, a clinical assessment tool used in
(BPPV) is often effectively treated using canalith Vestibular Rehabilitation Therapy (VRT) to evaluate vestibu-
repositioning techniques, a subset of patients—par- lo-ocular reflex (VOR) function during head movement. In
ticularly those with recurrent or long-standing cas- this test, patients attempt to read an eye chart while their
head is moved side-to-side at a set speed. A decline in visual
es—may continue to experience residual imbalance
acuity during motion suggests VOR impairment, guiding the
or motion sensitivity. In such instances, VRT is used need for gaze stabilization exercises and tracking rehabili-
after repositioning to manage lingering symptoms tation outcomes.
and support adaptation to head movement. This is
especially important for older adults and individuals conditions like MS, therapy also takes into account

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with coexisting medical conditions [10]. fatigue and cognitive demands, ensuring a more tai-
lored approach [13].
Persistent Postural-Perceptual Dizziness (PPPD)
is a functional disorder marked by ongoing dizziness Age-related vestibular decline, or presbyvestibu-
and unsteadiness, worsened by upright posture, mo- lopathy, is becoming an increasingly common indi-
tion, or visually busy environments. Its pathophysi- cation for VRT, particularly as the population ages.
ology, while not completely understood, is believed Older adults frequently suffer from a gradual loss of
to involve maladaptive sensory and behavioral pro- vestibular hair cells and slower central sensory pro-
cessing. VRT protocols for PPPD typically incorporate cessing, leading to increased unsteadiness, fear of
habituation techniques and visual desensitization ex- falling, and a higher risk of falls. VRT strategies in
ercises to gradually reduce patients’ reliance on vi- this group focus on safety, muscle strengthening, and
sual cues and help them re-adapt to motion-related enhancing proprioceptive input. Clinical evidence
environments. Cognitive behavioral therapy is fre- supports its effectiveness in reducing fall incidence
quently used as a complementary approach in these and improving functional mobility in older individ-
cases [11]. uals [14].
Menière’s disease, a chronic inner ear disorder Another important application of VRT is in post-con-
characterized by episodic vertigo, fluctuating hearing cussive dizziness, often observed in individuals with
loss, tinnitus, and aural pressure, is another condi- mild traumatic brain injuries (mTBI) or sports-relat-
tion where VRT is often utilized—particularly during ed concussions. These patients commonly present
periods between acute attacks. While medication with a combination of gaze instability, sensitivity to
is the mainstay of acute management, patients fre- visual motion, and impaired balance. When VRT is
quently experience residual imbalance and sensitivi- initiated early and customized to the patient’s spe-
ty to motion during stable phases. VRT during these cific deficits, it can become a critical component of
inter-ictal periods can improve dynamic balance and a comprehensive concussion management plan [15].
gaze stabilization [12]. Despite its broad utility, VRT is not one-size-fits-
Patients with central vestibular disorders—result-
ing from conditions such as cerebellar infarcts, multi- Gaze Stabilization is the Foundation
ple sclerosis (MS), traumatic brain injuries, or brain- for Dynamic Visual Recovery
stem strokes—may also derive functional benefit
from VRT. Although outcomes in central lesions are X1 and X2 viewing exercises should be
less predictable than in peripheral disorders, studies prescribed early and progressed gradual-
have shown that targeted rehabilitation can improve ly; improvements in dynamic visual acu-
balance, coordination, and dual-task performance. In ity often correlate with functional gains.
Vestibular Rehabilitation Therapy 5
Practical Guide to Diagnosis & Management of Vertigo

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Figure 21-4: This illustration shows the performance of the Head Impulse Test (HIT), a key bedside assessment tool in Ves-
tibular Rehabilitation Therapy (VRT). The clinician quickly rotates the patient’s head to one side while the patient maintains
gaze on a fixed target. A corrective saccade indicates vestibulo-ocular reflex (VOR) dysfunction, helping to identify unilateral
or bilateral vestibular hypofunction. This test guides diagnosis, therapy selection, and monitoring of VRT progress.

all. Certain populations may require customized or needs. As vestibular science advances, VRT continues
phased treatment plans. For instance, individuals with to stand at the forefront of treatment, offering sub-
fluctuating vestibular symptoms—such as those with stantial benefits in restoring balance, enhancing daily
active Menière’s disease or vestibular migraine—may functioning, and improving quality of life
benefit more from episodic or staged interventions.
Likewise, patients with significant psychiatric comor-
bidities, such as anxiety or depression, may find that ASSESSMENT AND BASELINE EVALUATION
VRT exacerbates symptoms unless supported by con- IN VESTIBULAR REHABILITATION THERAPY
current psychological care or pharmacotherapy. For Thorough and accurate assessment is the foundation
such complex cases, a multidisciplinary approach in- of effective Vestibular Rehabilitation Therapy (VRT)
volving neurologists, physiotherapists, audiologists, (Table 21-3). A detailed baseline evaluation not only
and mental health professionals is often essential to clarifies the nature and severity of the vestibular dys-
achieving optimal outcomes [16]. function but also informs the design of a treatment
In summary, VRT is indicated across a diverse range plan tailored to the patient’s specific impairments.
of vestibular disorders—spanning peripheral, cen- This evaluation typically integrates subjective self-re-
tral, and functional categories. Its success hinges on port tools, objective clinical testing of vestibular and
accurate diagnosis, clinical staging, and the ability to postural systems, and standardized assessments of
personalize exercise protocols to suit each patient’s functional mobility and fall risk. By synthesizing find-
ings from these methods, clinicians can classify the
Habituation is Crucial for Motion Sen- type of vestibular dysfunction—such as gaze insta-
sitivity and PPPD bility, motion-provoked dizziness, or postural imbal-
ance—each of which calls for a distinct therapeutic
Identify provocative movements and strategy.
create customized exposure plans; track
symptom reduction weekly.

6 Vestibular Rehabilitation Therapy

 Practical Guide to Diagnosis & Management of Vertigo

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Fig. 21-5: This illustration depicts the setup for Computer-
ized Dynamic Posturography (CDP), a vestibular assessment
tool used to evaluate a patient’s postural control under
varying sensory conditions. It measures balance responses
to visual, proprioceptive, and vestibular challenges, aiding in
both baseline assessment and outcome monitoring during
Vestibular Rehabilitation Therapy (VRT).

Subjective Evaluation
The subjective component of assessment uses vali-
dated questionnaires and rating scales to quantify In addition, the Visual Vertigo Analog Scale (VVAS) is
how dizziness affects the patient’s daily life, mobility, used to assess the intensity of dizziness triggered by
and self-confidence. One of the most widely utilized visual stimuli (Appendix -3). This tool is particularly
tools is the Dizziness Handicap Inventory (DHI)—a relevant for individuals with Persistent Postural-Per-
25-item self-report measure that evaluates the phys- ceptual Dizziness (PPPD) and other motion sensitivi-
ical, functional, and emotional consequences of ves- ty syndromes. By identifying the degree of visual de-
tibular disorders (Appendix-1). The DHI generates pendence, the VVAS can guide the inclusion of visual
a numerical score reflecting the patient’s perceived desensitization exercises within the VRT protocol
level of handicap and is sensitive to clinical changes [19].
over time, making it particularly useful for monitor-
ing progress throughout the course of VRT [17].
Objective Vestibular and Balance Testing
Another valuable instrument is the Activities-specific
Balance Confidence Scale (ABC), which gauges a pa- Objective clinical tests provide direct insight into the
tient’s confidence in their ability to perform various function of the vestibulo-ocular and vestibulo-spinal
Progression is Key in Balance Training
activities without falling (Appendix-2). This measure
is especially helpful for older adults and individuals Challenge the vestibular system by alter-
at high risk of falls, as it captures both the physical ing surface, stance, visual input, and add-
and psychological dimensions of balance confidence ing dual tasks. Use safety precautions in
[18]. elderly and high fall-risk patients.
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Practical Guide to Diagnosis & Management of Vertigo

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Fig. 21-6: This illustration demonstrates the Clinical Test of Sensory Interaction in Balance (CTSIB), a key vestibular assess-
ment used in VRT. The patient stands on both firm and foam surfaces with eyes open and closed across six conditions. By
systematically altering visual and somatosensory input, the CTSIB helps clinicians determine the patient’s reliance on vision,
proprioception, or vestibular function for balance, thereby guiding targeted rehabilitation strategies.Therapy (VRT).

reflexes. The Head Impulse Test (HIT)—and its more tailor gaze stabilization exercises within the VRT pro-
advanced counterpart, the video Head Impulse Test gram [21].
(vHIT)—assesses the functionality of the semicircu- Computerized Dynamic Posturography (CDP)—spe-
lar canals and the integrity of the vestibulo-ocular re- cifically the Sensory Organization Test (SOT)—of-
flex (VOR) (Fig. 21-4). In individuals with peripheral fers a quantitative assessment of how vestibular, vi-
vestibular hypofunction, a corrective eye movement sual, and proprioceptive systems work together to
(saccade) often follows a quick head thrust toward maintain balance (Fig. 21-5). This test analyzes the
the impaired side. The vHIT offers quantitative mea- patient’s sway under different sensory conditions,
surements of VOR gain and is especially useful for de- helping to uncover patterns of sensory dependence
tecting covert saccades and asymmetries in vestibular or compensatory strategies. Notably, CDP can reveal
response[20]. subtle postural deficits that may not be detected
The Dynamic Visual Acuity (DVA) test is another im- during a standard clinical exam [22].
portant tool for evaluating gaze stability during head In addition to instrumented assessments, bedside
movements (Fig. 21-3). It assesses a patient’s ability balance tests offer valuable insights into vestibu-
to maintain clear vision while the head is actively or lo-spinal function. Tests such as the Romberg test,
passively rotated. A reduction in visual acuity during tandem gait, and the Clinical Test of Sensory Interac-
movement suggests a VOR deficit and helps clinicians tion in Balance (CTSIB)evaluate the patient’s ability
to maintain postural stability under conditions that
Psychological Screening Should Be challenge visual and proprioceptive inputs. For exam-
Routine ple, the CTSIB involves standing on both firm and
foam surfaces with eyes open and closed, helping to
Anxiety, depression, and fear-avoidance identify whether balance deficits stem from visual re-
can significantly hinder VRT progress. liance or impaired vestibular input (Fig. 21-6)[23].
Refer for cognitive-behavioural therapy
when appropriate.
8 Vestibular Rehabilitation Therapy
 Practical Guide to Diagnosis & Management of Vertigo

Figure 21-7: This illustration demonstrates the Timed Up and Go (TUG) test, a functional assessment widely used in Vestib-
ular Rehabilitation Therapy (VRT) to evaluate mobility, balance, and fall risk. The patient is timed while rising from a seated
position, walking three meters, turning, returning, and sitting down. Prolonged completion time or instability during the task

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indicates impaired functional mobility and helps in both baseline assessment and monitoring of progress during rehabili-
tation.

Functional Mobility and Fall Risk Assessment al structure for the baseline evaluation of patients
Evaluating functional mobility is essential for un- undergoing VRT. By categorizing impairments into
derstanding how vestibular dysfunction affects a pa- specific domains—such as gaze instability (assessed
tient’s ability to navigate daily life and for estimating through tools like HIT and DVA), motion-provoked
their risk of falling. One of the most commonly used dizziness (evaluated using the VVAS and habituation
tools for this purpose is the Timed Up and Go (TUG) testing), or postural imbalance (assessed via CDP,
test, a quick and reliable screening measure (Fif. 21- CTSIB, and functional mobility tests)—clinicians can
7). It assesses the time required for an individual to tailor the therapeutic approach accordingly. For in-
stand up from a chair, walk a distance of three me- stance, a patient showing low VOR gain and impaired
ters, turn around, return to the chair, and sit back dynamic visual acuity might benefit most from exer-
down. A completion time exceeding 13.5 seconds is cises focused on adaptation and gaze stabilization.
generally considered indicative of elevated fall risk, In contrast, a patient with high visual vertigo scores
particularly in older adults [24]. would be better suited to habituation training and
visual desensitization protocols.
The Berg Balance Scale (BBS) is another well-validat-
ed instrument used to assess balance (Appendix - 4). Beyond informing intervention strategies, this as-
Comprising 14 distinct tasks—including standing un- sessment process also carries prognostic significance.
supported, turning, and reaching—the BBS provides Patients presenting with more severe baseline im-
a robust measure of postural control. It is not only pairments may require longer courses of rehabilita-
predictive of fall risk but also responsive to changes tion or the inclusion of adjunctive therapies. Regular
over time, making it particularly useful in tracking re-evaluation using the same validated tools ensures
progress through VRT. Similarly, the Functional Gait objective tracking of outcomes, allowing clinicians to
Assessment (FGA) builds upon the earlier Dynamic refine the VRT program based on the patient’s prog-
Gait Index by evaluating gait under more challenging ress and evolving therapeutic needs.
conditions, such as walking while turning the head or
navigating obstacles (Fig. 21-8). Both tools offer crit- Cognitive Impairment Doesn’t Exclude
ical insights into mobility limitations and help clini- VRT
cians customize balance-focused interventions within
the VRT framework [25]. Simplify instructions, use visual aids, and
involve caregivers to ensure adherence
Taken together, these subjective and objective assess-
and safety.
ment tools form a comprehensive, multidimension-
Vestibular Rehabilitation Therapy 9
Practical Guide to Diagnosis & Management of Vertigo

CORE COMPONENTS OF VESTIBULAR REHA- designed to recalibrate this reflex by engaging visual
BILITATION THERAPY (VRT) targets during repeated head movements, harnessing

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Vestibular Rehabilitation Therapy (VRT) is systemati- the principles of neuroplasticity and motor learning
cally organized around specific categories of exercises to induce adaptive change [1].
that target distinct impairments in the vestibulo-oc- Two principal types of gaze stabilization exercises
ular, vestibulo-spinal, and sensorimotor integration are commonly used:
systems (Table 21-4). These exercises are designed • X1 Viewing Exercises (Fig. 21-2A): The patient
to promote central compensation by engaging mech- fixates on a stationary target, such as a letter on the
anisms such as adaptation, habituation, substitution, wall, while rhythmically moving the head side-to-
and sensory reweighting. A well-structured VRT pro- side or up-and-down. This movement creates a mis-
gram is highly individualized, with its progression match—called retinal slip—that serves as an error
guided by the patient’s unique clinical presentation, signal to drive adaptive changes in the VOR.
symptom severity, and functional goals. The four pri-
mary components of VRT include gaze stabilization, • X2 Viewing Exercises (Fig. 21-2B): This more ad-
habituation exercises, balance and gait training, and vanced variant involves simultaneous movement of
functional or endurance conditioning. both the target and the head in opposite directions,
thereby increasing the cognitive and sensorimotor
challenge. X2 is generally introduced once the pa-
A. Gaze Stabilization Exercises tient has gained proficiency with X1 tasks.
Gaze stabilization exercises form the cornerstone of The progression of these exercises follows a struc-
therapy for individuals with compromised vestibu- tured, incremental format. Patients typically be-
lo-ocular reflex (VOR), a condition frequently ob- gin in a seated position and advance to standing,
served in cases of unilateral vestibular hypofunction. walking, and finally to dynamic environments with
The VOR plays a vital role in maintaining clear vi- greater visual complexity. Key variables—including
sion during head movement. When impaired, it can the complexity of the visual background, the size
result in symptoms such as oscillopsia and blurred and distance of the visual target, and the speed of
vision with motion. Gaze stabilization exercises are head movements—can be manipulated to intensify
the difficulty. Research by Schubert and Migliaccio
Older Adults Respond Well with Proper confirmed that these exercises significantly enhance
Support dynamic visual acuity and alleviate oscillopsia in pa-
tients with vestibular hypofunction [4].
Even with multisensory decline, elderly
patients benefit from slow, structured VRT
focused on strength, stability, and fall pre- B. Habituation Exercises
vention. Habituation exercises are particularly beneficial for
10 Vestibular Rehabilitation Therapy
 Practical Guide to Diagnosis & Management of Vertigo

Fig. 21-8: This illustration depicts the Functional Gait As- Fig. 21-9: This illustration demonstrates the Dix-Hallpike
sessment (FGA), an advanced tool used in vestibular assess- position, a diagnostic and habituation maneuver commonly
ment to evaluate dynamic balance and gait performance used in Vestibular Rehabilitation Therapy. It involves tran-
under challenging conditions. The FGA includes tasks such sitioning the patient rapidly from a seated to a supine po-

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as walking while turning the head, changing speed, and sition with the head turned 45 degree to the affected side
stepping over obstacles. It is especially valuable in identify- and extended over the edge of the table. This movement
ing fall risk and guiding gait and dual-task training in Ves- provokes vertigo and nystagmus in cases like BPPV and can
tibular Rehabilitation Therapy (VRT). be used therapeutically by repeated exposure to desensitize
the vestibular system.
patients who experience dizziness in response to
specific motions or positions. Such symptoms often decreasing visual motion sensitivity and enhancing
result from an amplified response to otherwise nor- postural stability in patients with chronic dizziness
mal stimuli, as is common in disorders like persistent [5].
postural-perceptual dizziness (PPPD), chronic benign These exercises are especially valuable for reducing
paroxysmal positional vertigo (BPPV), and post-con- visual dependency and minimizing dizziness trig-
cussion syndrome. The goal of habituation therapy gered by movement, both of which are common and
is to desensitize the central nervous system through often disabling symptoms in vestibular dysfunction.
controlled, repeated exposure to the provocative
stimuli, thereby reducing symptom intensity over
time [26]. C. Balance and Gait Training
The habituation protocol begins with identifying the Balance and gait training are essential components of
movements or positions that trigger symptoms— Vestibular Rehabilitation Therapy (VRT), particularly
common examples include lying down, Dix-Hallpike for individuals experiencing postural instability and
position, rolling over in bed, or executing rapid head an elevated risk of falling. These exercises are de-
turns (Fig. 21-9 to 11). These provocative motions signed to engage the vestibulo-spinal pathways and
are then practiced deliberately, typically 3 to 5 repe- enhance the coordination of visual, vestibular, and
titions per session, two to three times daily, allowing proprioceptive inputs. The objective is to improve
short rest periods between sets. Over the course of 7 both static and dynamic postural control, targeting
to 10 days, the exercises are continued until the pa- deficits in anticipatory and reactive balance mecha-
tient experiences a noticeable reduction in dizziness. nisms that are commonly observed in vestibular dis-
Patients are educated to expect temporary worsen-
Older Adults Respond Well with Proper
ing of symptoms during the initial phases of habitua-
Support
tion and are encouraged to persist, as this temporary
discomfort is an anticipated part of the therapeutic Even with multisensory decline, elderly
process. Evidence from Pavlou and colleagues sup- patients benefit from slow, structured VRT
ports the effectiveness of habituation strategies, par- focused on strength, stability, and fall pre-
ticularly those involving simulator-based training, in vention.
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Practical Guide to Diagnosis & Management of Vertigo

Fig. 21-10: Habituation Exercise: Sit-to-supine transitions:

This illustration shows a habituation exercise example in-
volving sit-to-supine transitions. It is used in Vestibular Re-
habilitation Therapy (VRT) to repeatedly expose patients to Fig. 21-11: Habituation Exercise: Sit-to-supine transitions:
symptom-provoking movements, promoting central desen- This illustration shows a habituation exercise example in-
sitization and reducing dizziness over time through neural volving sit-to-supine transitions. It is used in Vestibular Re-
adaptation. habilitation Therapy (VRT) to repeatedly expose patients to
symptom-provoking movements, promoting central desen-
orders [27]. sitization and reducing dizziness over time through neural
adaptation.
Therapeutic progression typically begins with static
balance exercises, such as: al., targeted balance and gait exercises significantly
• Romberg stance (standing with feet together) (Fig. improved functional mobility and reduced fall risk in
21-12). older adults participating in vestibular rehabilitation

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[14].
• Single-leg stance (fig. 21-13).
• Tandem stance (heel-to-toe position) (Fig. 21-14).
D. Functional and Endurance Training
These exercises challenge the individual’s base of
support and are practiced on both stable (firm) and In addition to exercises aimed at specific vestibu-
unstable (foam or compliant) surfaces. To further in- lar impairments, functional and endurance training
crease the challenge, patients may be asked to close plays a vital role in restoring overall physical condi-
their eyes, thereby eliminating visual input and en- tioning and supporting neuroplastic recovery. Func-
couraging reliance on vestibular and somatosensory tional tasks are modelled after everyday activities
feedback. and are essential for enhancing independence and
safety within home and community environments.
As the patient progresses, dynamic balance exercises These tasks include:
are introduced. These may include:
• Stair navigation: Enhance coordination, rhythm,
• Walking while turning the head side-to-side (Fig. and postural alignment (Fig. 21-17).
21-8).
• Sit-to-stand drills: Improve lower extremity
• Navigating over or around obstacles (Fig. 21-15). strength and transitional movement control (fig. 21-
• Altering gait speed and direction (Fig. 21-16). 18).
• Walking on uneven or narrow pathways. • Reaching tasks: Train dynamic balance while en-
To replicate real-world demands and enhance the gaging the upper extremities fig. 21-19).
automaticity of postural control, dual-task training— • Turning and bending movements: Reinforce an-
such as walking while performing a cognitive task ticipatory postural adjustments during directional
like counting backward—is often incorporated. This changes fig. 21-20 to 21-23).
approach simulates multitasking conditions com- Endurance training is equally important, especially
monly encountered in daily life. In a study by Ricci et for patients who have become deconditioned due to
Objective Monitoring Ensures Account- prolonged inactivity or chronic vestibular symptoms.
ability Aerobic activities such as treadmill walking, station-
ary cycling, or brisk outdoor walking are used to en-
Reassess every 4–6 weeks using standard- hance cardiovascular fitness, reduce fatigue, and pro-
ized tools to quantify progress and adjust mote psychological well-being. These exercises have
the program. also been shown to increase cerebral blood flow, fa-
cilitate neural recovery, and build tolerance for more
12 Vestibular Rehabilitation Therapy
 Practical Guide to Diagnosis & Management of Vertigo

Fig. 21-13: This illustration demonstrates the Single Leg

Stance exercise, a core component of static balance train-
Fig. 21-12: Romberg Stance: This illustration shows the ing in Vestibular Rehabilitation Therapy. It shows a patient
Romberg stance, a foundational static balance assessment standing on one leg with arms positioned for stability, per-
and training posture used in Vestibular Rehabilitation Ther- formed on both firm and foam surfaces with eyes open or
apy (VRT). By standing with feet together, eyes open and closed. This exercise is designed to challenge postural con-
then closed, patients challenge their reliance on visual and trol by engaging the vestibular and proprioceptive systems,
proprioceptive inputs, helping to assess and improve vestib- and it can be progressively intensified by altering the sur-
ular compensation and postural control. face or visual input.

support compensation for the imbalance in vestibular

demanding elements of the VRT program [15].

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input between the two ears. Gaze stabilization exer-
By integrating functional tasks with gaze stabiliza- cises, especially the X1 and X2 viewing techniques,
tion, habituation, and balance exercises, VRT deliv- are central to treatment. These protocols stimulate
ers a holistic, multi-domain intervention. The ther- adaptation of the vestibulo-ocular reflex (VOR) and
apeutic plan is carefully progressed based on each improve dynamic visual clarity during head motion
patient’s tolerance, symptom response, and objective [4].
improvements, ensuring that both symptom resolu-
Patients are typically instructed to perform these ex-
tion and functional restoration are addressed effec-
ercises two to three times per day, with each session
tively.
lasting approximately 10–15 minutes, over a period
of four to six weeks. Alongside gaze stabilization,
INDIVIDUALIZED TREATMENT PLANNING IN balance retraining is critical, particularly in environ-
VESTIBULAR REHABILITATION THERAPY ments that are visually busy or unpredictable. Ex-
ercises such as tandem standing, standing on foam
A foundational concept in Vestibular Rehabilitation
surfaces, and walking while turning the head are
Therapy (VRT) is that treatment must be individu-
gradually introduced to challenge the sensory sys-
alized—there is no one-size-fits-all protocol (Table
tems, promote recalibration, and reinforce postural
21-5). Instead, therapy is tailored based on the pa-
stability [1].
tient’s specific diagnosis, functional impairments,
goals, and accompanying health conditions. This
personalized approach ensures that interventions are 2. Bilateral Vestibular Hypofunction
directly aligned with the patient’s symptom profile
Managing bilateral vestibular hypofunction (BVH)
and physical limitations, while also accounting for
presents additional complexities, as there is no intact
age, cognitive function, musculoskeletal comorbidi-
labyrinth to provide compensatory input. As a result,
ties, and psychological considerations. Customizing
gaze stabilization strategies in these patients rely
VRT enhances patient engagement, improves clinical
more on substitution mechanisms—including pre-
outcomes, and minimizes the likelihood of symptom
aggravation during the course of therapy [2]. Patient Education is as Important as Ex-
ercise
1. Unilateral Vestibular Hypofunction Explain the rationale for exercises, ex-
In patients with unilateral vestibular hypofunction— pected responses, and importance of
often arising from vestibular neuritis or following home practice to improve compliance and
surgical intervention—the central aim of VRT is to outcomes.

Vestibular Rehabilitation Therapy 13

Practical Guide to Diagnosis & Management of Vertigo

Fig. 21-14: Tandem stance on firm and foam surfaces: This

illustration depicts static and dynamic balance training set-
ups, specifically demonstrating tandem stance exercises
performed on both firm and foam surfaces. These tasks chal-

Sample copy
lenge postural control by progressively altering somatosen-
sory input, helping to improve stability and reduce fall risk
in individuals undergoing Vestibular Rehabilitation Therapy
(VRT).
Figure 21-15: This illustration depicts a patient navigating
dictive saccades, remembered target exercises, and around cones and walking over uneven terrain, representing
centrally preprogrammed eye movements. Saccadic dynamic gait training with dual-tasking in Vestibular Reha-
training involves instructing the patient to rapidly bilitation Therapy (VRT). These exercises enhance spatial
awareness, adaptability, and balance under varying sensory
alternate gaze between two visual targets with min-
and environmental demands. They are especially useful for
imal head movement, thereby compensating for the improving real-world mobility and reducing fall risk in pa-
absent VOR [9]. tients with vestibular and balance disorders.
Balance training is especially critical in BVH and
should be emphasized from the early stages of reha- These tasks help improve safety, mobility, and adapt-
bilitation. These patients often demonstrate signifi- ability in complex environments. Given the severity
cant unsteadiness, particularly in conditions of poor and persistence of symptoms in BVH, long-term re-
lighting or when somatosensory input is diminished. habilitation may be required. Many patients benefit
Therefore, therapy emphasizes enhancing the use of from assistive devices, such as canes or walkers, and
visual and proprioceptive inputs for balance. Exercis- home modifications aimed at reducing the risk of
es are introduced in a systematic progression—start- falls [28].
ing with a wide base of support on firm surfaces and
advancing to narrower stances on compliant (foam)
3. Central Vestibular Disorders
surfaces. Patients are also trained to maintain visual
fixation and use gaze anchoring techniques during Patients with central vestibular disorders—such as
balance activities. those arising from cerebellar stroke, multiple scle-
rosis, or traumatic brain injury—require a tailored
To bridge therapy with daily function, real-world task
rehabilitation approach distinct from peripheral ves-
training is incorporated. This includes walking while
tibular conditions. These individuals commonly ex-
turning, stepping over objects, and climbing stairs.
perience ataxia, unstable gaze, and deficits in sensory
integration. Such impairments often do not respond
Don’t Overlook Dual-Task Training well to traditional vestibulo-ocular reflex (VOR) ad-
aptation techniques. As a result, therapeutic strate-
Incorporating cognitive or motor tasks gies emphasize substitution—helping the brain rely
during balance and gait exercises mimics more on visual and proprioceptive information—and
real-life challenges and reduces fall risk.
compensatory methods that support safe and func-
14 Vestibular Rehabilitation Therapy
 Practical Guide to Diagnosis & Management of Vertigo

Figure 21-17: This illustration demonstrates stair negotia-

tion, a real-world functional task commonly used in Vestibu-
lar Rehabilitation Therapy (VRT). It challenges dynamic bal-
ance, depth perception, and vestibulo-motor coordination,
helping patients improve safety and confidence during daily
activities. This task is particularly valuable for those with
gait instability, post-vestibular loss, or age-related balance

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decline.

Figure 21-16: This illustration demonstrates a dual-task ten worsened by upright posture, visual motion, or
gait training activity used in Vestibular Rehabilitation Ther- exposure to visually complex environments. Patients
apy (VRT), where the patient walks while simultaneously frequently demonstrate heightened visual depen-
counting backwards. This exercise challenges both motor dence, with an amplified response to visual stimuli
and cognitive systems, improving dynamic balance, atten-
like moving crowds or traffic. In such cases, therapy
tion, and coordination. It reflects real-life scenarios requir-
ing multitasking, thereby enhancing safety and functional focuses on visual motion desensitization and gradual
mobility in complex environments. exposure to situations that provoke symptoms [11].
At the core of this approach are habituation exercis-
tional mobility [13]. es, in which patients are systematically introduced
Gait training is a key component of rehabilitation for to increasingly complex environments—such as gro-
this group, with particular attention to promoting cery store aisles, escalators, or city streets—until the
wide-based gait patterns that improve lateral stabil- dizziness diminishes through repeated exposure.
ity. To assist with movement symmetry and postur- In-clinic rehabilitation may be enhanced with the use
al awareness, therapists often use visual flow cues of video-based simulations or virtual reality systems,
and mirror feedback. Additionally, cognitive and du- offering a safe yet realistic way to confront visual
al-task training is essential, as individuals with cen- triggers.
tral lesions frequently experience challenges with at- Because psychological factors, including anxiety and
tention and multitasking. For example, walking while hypervigilance, often accompany PPPD, cognitive be-
reciting numbers or completing simple motor tasks havioural therapy (CBT) is commonly incorporated
mimics everyday cognitive demands and helps build into treatment. Studies have shown that integrating
more resilient gait control (Fig. 21-16). Research CBT with vestibular rehabilitation results in more
supports that these dual-task interventions enhance significant improvements in dizziness, emotional
gait performance and reduce the likelihood of falls well-being, and quality of life for these patients [30].
in patients with central vestibular dysfunction [29].
Severe BVH Demands Realistic Goal
Setting
4. Persistent Postural-Perceptual Dizziness (PPPD)
and Visually-Induced Dizziness
Focus on safety, functional compensation,
Persistent postural-perceptual dizziness (PPPD) is a and quality of life rather than full symp-
functional vestibular condition marked by chronic, tom resolution.
non-spinning dizziness and unsteadiness that is of-
Vestibular Rehabilitation Therapy 15
Practical Guide to Diagnosis & Management of Vertigo

Fig. 21-18: This illustration shows a patient performing sit-to-stand transitions, a functional task frequently incorporated
into Vestibular Rehabilitation Therapy (VRT). The movement enhances lower limb strength, postural control, and dynamic
balance—key components for reducing fall risk and improving daily function. It is particularly beneficial for older adults and
those with vestibular hypofunction or balance impairments.

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tion. Depending on a patient’s stability and progress,
5. Older Adults and Fall Risk Reduction assistive devices—like canes or walkers—may be pre-
scribed temporarily or permanently to enhance safe-
Older adults frequently experience age-related ves- ty.
tibular decline, which contributes to balance distur-
bances through multiple mechanisms—such as the Environmental modifications are another vital ele-
degeneration of vestibular hair cells, impaired vision, ment of fall prevention. These include improvements
reduced proprioceptive feedback, and muscle weak- like better lighting, removal of loose rugs or cords,
ness (sarcopenia). This combination greatly increas- and installation of handrails in high-risk areas. Regu-
es the risk of falls, making older patients a priority lar use of functional gait assessments, fall risk screen-
population for tailored, cautious, and progressive ing tools, and real-time feedback mechanisms allows
vestibular rehabilitation [31]. clinicians to track progress and adjust interventions
accordingly. Evidence from Ricci et al. and others
An effective VRT plan for this group typically in- confirms that individualized VRT significantly reduc-
cludes a combination of static and dynamic balance es fall frequency and boosts independence in older
exercises. Examples include tandem walking, sit-to- adults [14].
stand transitions, and turning drills, all designed to
improve postural control. These exercises are initial-
ly performed under supervision and advanced grad- Summary
ually as the patient’s confidence and tolerance grow. Designing customized VRT programs is essential for
Carefully introduced dual-task training helps re-es- effectively treating the wide spectrum of vestibular
tablish coordination between motor control and cog- disorders seen in clinical practice. By tailoring inter-
nitive processing. ventions to each patient’s diagnosis, symptom profile,
Strength training is also essential, especially exercis- cognitive function, and physical capabilities, clini-
es targeting the quadriceps and ankle dorsiflexors, cians can maximize vestibular compensation, mini-
which are crucial for gait stability and fall preven- mize functional limitations, and support sustained
recovery. This patient-centered approach not only
VRT is Dynamic—Not One Size Fits All improves rehabilitation outcomes but also increases
engagement, satisfaction, and long-term adherence
Customize the plan continuously based on to therapy
reassessment, functional needs, comor-
bidities, and lifestyle.
DURATION, FREQUENCY, AND MONITORING
16 Vestibular Rehabilitation Therapy
 Practical Guide to Diagnosis & Management of Vertigo

Sample copy
Figure 21-19: This illustration depicts reaching activities Figure 21-20: This illustration shows lifting activities incor-
used in Functional Task Training as part of Vestibular Reha- porated into Functional Task Training within Vestibular Re-
bilitation Therapy (VRT). These tasks involve controlled up- habilitation Therapy (VRT). Patients practice lifting objects
per body movements while maintaining balance, simulating from various heights and positions to simulate daily tasks
daily activities such as picking up objects or reaching over- such as handling groceries or lifting items at work. These
head. They enhance postural stability, coordination, and pro- exercises promote core stability, controlled weight shifting,
prioceptive feedback, and are especially useful in improving and balance under load, enhancing functional capacity and
functional independence and reducing fall risk. reducing the risk of falls or injury during real-world move-
ments.
OF VESTIBULAR REHABILITATION THERAPY 20 minutes, based on their symptom tolerance. Ex-
The timing and scheduling of Vestibular Rehabilita- ercises are divided strategically—such as gaze stabi-
tion Therapy (VRT) are critical elements in develop- lization (X1/X2 viewing), habituation activities, and
ing an effective and sustainable treatment plan. Rath- balance tasks—to prevent fatigue and minimize the
er than applying a uniform protocol, the duration risk of symptom flare-ups. As patients gain tolerance
and frequency of therapy are personalized according and experience symptom relief, both the frequency
to each patient’s diagnosis, the severity of symptoms, and intensity of the exercises are increased. Consis-
functional limitations, and how they respond to treat- tent and repetitive exposure to these stimuli is essen-
ment over time. Most VRT programs last between 4 tial to promote central vestibular compensation and
and 12 weeks, though individuals with long-standing lasting adaptation within the nervous system [1].
symptoms or concurrent neurological or musculo-
skeletal conditions may require longer-term care [2].
Cognitive Load Can Reveal Hidden
This time frame allows for meaningful neuroplastic
Deficits
changes and measurable functional improvement,
with regular opportunities for reassessment and ad- Dual-task training (e.g., walking while
justment. reciting numbers backward) can unmask
Patients are typically instructed to complete their subtle vestibular deficits and improve re-
home exercise program (HEP) two to three times al-world functional mobility and fall pre-
daily, with each session lasting approximately 10 to vention.
Vestibular Rehabilitation Therapy 17
Practical Guide to Diagnosis & Management of Vertigo

Fig. 21-22: This image sequence demonstrates a vestibular

habituation exercise involving forward and backward trunk
bending. The patient starts from a neutral standing position,
bends forward at the waist (first frame), returns to upright
(middle), and leans backward while maintaining balance
Fig. 21-21: This image depicts a trunk rotation exercise
(last frame). These movements help stimulate the vestibu-
commonly used in vestibular rehabilitation to promote
lar system, reduce motion sensitivity, and improve postural
habituation, postural control, and sensory integration. The
control. Repetitive performance of this task trains the brain
patient stands with feet shoulder-width apart and arms ex-
to adapt to provocative movements, making it especially ef-
tended forward, then rotates the upper body from one side
fective for patients with motion-provoked dizziness or im-
to the other while keeping the pelvis stable. This exercise
paired sensory integration.
engages the vestibulo-spinal pathways and helps reduce

Sample copy
motion-provoked dizziness. It is particularly beneficial for
provement. These assessments are typically conduct-
patients with impaired dynamic balance or visual-vestibu-
lar mismatch. Movements should be performed slowly and ed at baseline, mid-treatment (around 4–6 weeks),
smoothly, progressing to faster speeds as tolerated. and at the end of the program:
• Dizziness Handicap Inventory (DHI): Assesses the
Monitoring patient progress is an integral part of suc-
self-reported impact of dizziness on emotional, func-
cessful VRT implementation. Whether therapy is de-
tional, and physical well-being [17].
livered in-clinic or at home, continuous feedback and
monitoring systems help guide exercise progression, • Activities-specific Balance Confidence (ABC)
support adherence, and ensure safety. A combination Scale: Measures a patient’s confidence in maintain-
of subjective self-report tools and objective clinical ing balance during common daily activities [32].
assessments are used to track functional gains and • Timed Up and Go (TUG) test: A quick indicator of
inform modifications to the treatment plan. functional mobility and fall risk; longer times are as-
One of the most practical and widely used tools is sociated with greater impairment (Fig. 21-24) [24].
the weekly symptom diary. In this log, patients record • Berg Balance Scale (BBS): A comprehensive 14-
details such as the frequency, duration, and severi- item scale evaluating static and dynamic balance,
ty of dizziness or imbalance episodes, as well as any sensitive to progress during rehabilitation [33].
symptoms provoked by exercise. This diary not only
enables clinicians to detect symptom patterns and These tools collectively provide clinicians with quan-
therapy responses but also fosters patient account- tifiable data to justify therapy continuation, modifi-
ability and engagement. Research supports its value cation, or discharge, and they help to track real-time
in enhancing adherence and encouraging patients to progress.
actively participate in their recovery process [16]. Technological advances have further enhanced the
In conjunction with symptom diaries, clinicians rely ability to monitor patient adherence and outcomes—
on standardized outcome measures to quantify im- especially in home-based or remote settings. For ex-
ample, home video recordings and smartphone apps
now allow patients to capture their exercise sessions
Technology Can Enhance Engagement
for therapist review. These platforms often include
Virtual reality, mobile apps, and remote features such as automated reminders, symptom
monitoring can boost adherence and ex- tracking, and exercise progression algorithms, of-
tend access—especially for younger or fering a structured, interactive approach to VRT and
digitally literate patients. supporting communication between patients and
their care team [34].

18 Vestibular Rehabilitation Therapy

 Practical Guide to Diagnosis & Management of Vertigo

Fig. 21-23: This image sequence demonstrates a vestibular

habituation exercise involving forward and backward trunk
bending. The patient starts from a neutral standing position,
bends forward at the waist (first frame), returns to upright
(middle), and leans backward while maintaining balance Fig. 21-24: The illustration shows the Timed Up and Go
(last frame). These movements help stimulate the vestibu- (TUG) test, a rapid and reliable clinical assessment used to
lar system, reduce motion sensitivity, and improve postural evaluate functional mobility and fall risk. It depicts a patient
control. Repetitive performance of this task trains the brain rising from a chair, walking a distance of three meters, turn-
to adapt to provocative movements, making it especially ef- ing, returning, and sitting down—all timed with a stopwatch.
fective for patients with motion-provoked dizziness or im- Prolonged completion time suggests impaired mobility and
paired sensory integration. increased fall risk, making it a valuable baseline and out-

Sample copy
come measure in vestibular rehabilitation.
These digital tools proved particularly valuable
during the COVID-19 pandemic and continue to ben- introduction of purposeful interventions to overcome
efit patients in rural or underserved regions, where them is quite crucial in maximizing clinical outcomes,
regular in-person visits may be impractical. Impor- enhancing patient engagement, and preventing ther-
tantly, studies have shown that for certain vestibular apy drop out.
conditions, telerehabilitation can achieve outcomes
on par with traditional in-person therapy, indicating
A. Limited Exercise Program Adherence
a growing role for remote models in the future of
VRT delivery [35]. One of the frequent challenges faced in VRT is low
adherence to exercises prescribed. This is often due
to patient anxiety, misunderstanding of symptom
Summary provocation, or dissatisfaction with slow progress.
An effective VRT program must integrate well-de- Frustration is common when exercises result in tem-
fined recommendations for duration and frequency, porary dizziness as a consequence, mistaking such
along with comprehensive monitoring methods to symptoms as a bad outcome instead of a rehabilita-
track progress and optimize outcomes. By combining tion phase. Such fear results in avoidance behavior,
evidence-based assessment tools with modern digi- decreased adherence, and below-optimum outcome.
tal innovations, clinicians can adapt therapy to meet To offset this, clinicians need to give early education
individual patient needs, enhance safety and adher- in the rehabilitation program. Patients need to be ad-
ence, and support long-term recovery and function. vised that a short-term, mild flare-up of symptoms is
not only typical but predictable—meaning that the
central nervous system is not only being stimulated
BARRIERS TO EFFECTIVENESS AND STRAT-
but is actually adjusting and calibrating [2]. The
EGIES IN VESTIBULAR REHABILITATION
therapist is instrumental in reassuring patients that
THERAPY
Though Vestibular Rehabilitation Therapy (VRT) is
Technology Can Enhance Engagement
very successful in treating a vast majority of vestib-
ular disorders, its effectiveness is threatened by sev- Virtual reality, mobile apps, and remote
eral barriers. These are patient factors such as lack monitoring can boost adherence and ex-
of adherence, psychiatric comorbidity, and cognitive tend access—especially for younger or
deficits, as well as severity and intricacy of vestibular digitally literate patients.
disease per se. Early detection of these barriers and
Vestibular Rehabilitation Therapy 19
Practical Guide to Diagnosis & Management of Vertigo

these symptoms invariably fade with further practice ists. Cognitive Behavioral Therapy (CBT) is especially
and are actually a good sign of advancement. good as an adjunct to VRT when a patient presents
For further enhancement of drive, especially among with dizziness that is psychogenic or functionally mo-
those who become bored with exercise as such, new tivated. CBT involves reframing unhealthy thinking

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tools such as those of virtual reality (VR)-based train- patterns, minimizing avoidance behavior, and max-
ing systems might be used. These are interfaces that imizing emotional control. Many papers have indi-
convert the everyday balance tasks to exciting, in- cated that CBT used as a combination with VRT is
teractive activities that significantly boost drive. The superior as far as symptom control and functional
literature substantiates that VR-based VRT is highly improvement are concerned in those patients who
beneficial in younger, tech-savvy groups, as it best are symptomatically experiencing chronic dizziness
enhances visual-vestibular interaction and maintains and accompanying anxiety [37]. For these interven-
interest and adherence [36]. tions, clinicians should regularly screen at presenta-
tion and again as part of treatment for distress. Early
identification allows mental health professionals to
B. Psychological Comorbid intervene at a more opportune time, fostering a more
holistic and expeditious treatment course.
Many vestibular dysfunction patients also struggle
with psychiatric disorders like anxiety, depression,
panic disorders, and somatoform disorders. Psycho- C. Cognitive Impairment
logical issues very often exacerbate dizziness symp-
toms through hypervigilance, catastrophic thinking, Cognitive impairment presents a significant barrier to
and dysautonomic reactions. Persistent Postural-Per- effective vestibular rehabilitation, particularly among
ceptual Dizziness (PPPD) is a good illustration, older adults and individuals with neurological con-
whereby anxiety-associated maladaptive coping ditions such as stroke or dementia. Patients with
strategies compromise rehabilitation and result in cognitive deficits may have difficulty understanding
chronic symptoms [16]. complex instructions, recalling exercise routines, or
consistently engaging in their prescribed home pro-
Overcoming these challenges necessitates a team- grams. To accommodate these challenges, therapy
based, interdisciplinary effort that incorporates audi- should be simplified and highly structured—using
ologists, physiotherapists, and mental health special- short, clear commands, repetitive practice, and step-
by-step task breakdowns to facilitate learning and re-
Visual Dependency Must Be Addressed
tention [38].
Many patients with vestibular dysfunction Visual supports such as instructional diagrams,
overly rely on visual cues. Incorporating demonstration videos, and color-coded cues can fur-
exercises under reduced or altered visual ther assist comprehension and execution of exercis-
input (e.g., eyes closed or dynamic visual es. Moreover, caregiver involvement becomes crucial
surroundings) promotes vestibular com- in these cases. Caregivers can play an active role in
pensation. supervising daily exercises, ensuring that sessions
20 Vestibular Rehabilitation Therapy
 Practical Guide to Diagnosis & Management of Vertigo

Sample copy
Figure 21-25: Symptom Diary and Tracking Template: This illustration presents a Symptom Diary and Tracking Template de-
signed for patients undergoing Vestibular Rehabilitation Therapy (VRT). It enables daily documentation of dizziness episodes,
exercise adherence, symptom triggers, and comments—facilitating personalized progress tracking and therapist-guided ad-
justments.
are completed on schedule, and providing feedback ant aspects include guidance on selecting supportive
to the rehabilitation team during follow-up appoint- footwear, maintaining wide-based gait patterns, and
ments. Engaging the patient’s support system in this ensuring adequate lighting—all of which contribute
way promotes safety, consistency, and motivation to reducing fall risk.
throughout the course of therapy. Therapy should also include progressive exercises
that build confidence in movement, such as walking
D. Severe Bilateral Vestibular Loss with support from furniture, practicing safe turning
techniques, and performing sit-to-stand transitions.
Patients with severe bilateral vestibular hypofunc- While functional gains in BVH may be more modest
tion (BVH) often experience significant deficits in compared to other vestibular conditions, a struc-
gaze stabilization, balance, and mobility—especial- tured, compensation-focused rehabilitation program
ly in poorly lit environments or when walking over can still significantly improve independence and
uneven terrain. These individuals frequently lack overall quality of life [39].
sufficient vestibular input to benefit from traditional
VOR-based adaptation exercises and are at increased
risk of falls and injury during routine activities. In Summary
such cases, the therapeutic approach must shift from Barriers to effective Vestibular Rehabilitation Thera-
recovery of vestibular function to compensation and py are multifaceted and must be addressed through
safety [9]. individualized, evidence-based strategies. Poor ad-
Rehabilitation strategies emphasize the substitution
of visual and somatosensory cues for impaired ves- Consistent Home Exercise Logging Im-
tibular input. The use of assistive devices, such as proves Compliance
walkers or canes, is encouraged to enhance postural
Use of symptom diaries or mobile apps to
stability. In parallel, patients are educated in fall pre-
track dizziness episodes and exercise per-
vention techniques, including safe navigation strate-
formance empowers patients and enables
gies, modifications to their home environment, and
better therapist-patient collaboration.
techniques for recovering from a fall. Other import-
Vestibular Rehabilitation Therapy 21
Practical Guide to Diagnosis & Management of Vertigo

Sample copy
Fig. 21-26: This illustration depicts a patient using a virtual reality (VR) headset for balance training as part of techno-
logically integrated Vestibular Rehabilitation Therapy (VRT). VR environments simulate visually complex or motion-rich
settings, facilitating habituation, sensory integration, and neuroplasticity. This innovative approach enhances engagement,
customizability, and effectiveness of therapy for conditions such as PPPD, post-concussion dizziness, and chronic vestibular
hypofunction.

herence can be managed through clear education TECHNOLOGICAL INNOVATIONS IN VESTIB-

and engaging tools such as gamified technologies. ULAR REHABILITATION THERAPY
Psychological comorbidities require an interdisci-
plinary treatment model, often including Cognitive
Behavioural Therapy. Cognitive limitations necessi- The integration of new technologies with Vestibular
tate simplification of instructions and involvement of Rehabilitation Therapy (VRT) has significantly ex-
caregivers, while severe bilateral vestibular deficits panded clinicians’ treatment options and increased
demand a focus on compensation and safety. vestibular care accuracy, interaction, and accessibil-
ity. The new technologies attempt to maximize di-
By proactively identifying and addressing these chal- agnostic specificity, promote patient adherence, and
lenges, clinicians can broaden the accessibility and create more interactive and individualized rehabili-
effectiveness of VRT across diverse patient popula- tation programs. These technologies are particularly
tions—ultimately enhancing recovery outcomes and beneficial when used to bridge accessibility gaps and
minimizing long-term disability. treat complex or chronic vestibular disorders. Inno-
vative devices such as virtual reality (VR), comput-
er-based posturography, smartphone applications of
mobile health, and experimental vestibular implants
Multisensory Integration is Key to Bal- are at the frontline of technological advancement in
ance VRT.

Incorporating varied surfaces (foam, bal-

ance boards), visual challenges, and pro- Virtual Reality (VR) in VRT
prioceptive cues helps improve the central Virtual reality (VR) is a revolutionary device in ves-
nervous system’s integration of vestibular, tibular rehabilitation that presents immersive, con-
visual, and somatosensory inputs. trolled, and reproducible settings in which patients
22 Vestibular Rehabilitation Therapy
 Practical Guide to Diagnosis & Management of Vertigo

Fig. 21-27: This illustration displays a posturography feed-

back screen, representing advanced technology used in Ves-
tibular Rehabilitation Therapy (VRT) to assess and train bal-
ance control. The screen provides real-time visual feedback Fig. 21-28: This illustration shows a mobile app interface
on body sway, weight distribution, and stability under varied designed for logging home-based vestibular rehabilitation
sensory conditions. This data-driven approach enhances di- exercises. The app allows patients to record daily activi-
agnostic accuracy, tracks progress, and guides individualized ties, symptom severity, and exercise compliance, enhancing
balance training for patients with vestibular dysfunction. self-monitoring and clinician oversight. It supports adher-
ence, facilitates remote supervision, and promotes consis-
can perform exposure and habituation exercises. Vir- tent engagement with personalized VRT programs, especial-
tual reality mimics visually demanding settings—like ly in tele-rehabilitation settings.

Sample copy
shopping malls, busy streets, or moving cars—that contributing to the design of individual rehabilitation
are likely to evoke symptoms among patients with programs.
visual vertigo, motion sickness, or Persistent Postur-
al-Perceptual Dizziness (PPPD). Virtual reality allows The latest developments in posturography have al-
dose-controlled exposure to provocative stimuli, pro- lowed interactive balance training, whereby patients
moting central desensitization and better sensory in- are given visual or audio feedback to adjust sway or
tegration. center of pressure shifts. The closed-loop feedback
leads to motor learning and improves sensory re-
Differing from traditional rehabilitation environ- weighting, particularly in patients with balance insta-
ments, VR settings have attainable control over mo- bility and those who have experienced bilateral ves-
tion speed, visual flow, and task complexity. These tibular loss [40]. Therapy based on posturography is
factors can be modulated according to patient symp- not only used to evaluate fall risk in older adults but
tom threshold and advancement, thus customizing also used to quantify VRT treatment outcomes over a
the therapy experience. Some studies have indicated period of time.
that VR-based VRT significantly diminishes dizziness
symptoms, improves dynamic postural control, and
boosts treatment adherence through gamification Mobile Applications and Digital Platforms
and user engagement [36]. Furthermore, VR has
The growing availability of mobile health (mHealth)
been implemented effectively in telerehabilitation
applications has opened up a new era of accessibili-
programs and is thus a feasible alternative for remote
ty and self-directed care in vestibular rehabilitation.
or underserved groups.
These mobile tools are designed to deliver structured
exercise routines, monitor symptom progression, and
Posturography Platforms send reminders to help users adhere to prescribed
therapy schedules. Many applications also feature in-
The Computerized Dynamic Posturography (CDP) structional videos, interactive dashboards for track-
and related posturography systems have been em-
ployed as both diagnostic and rehabilitation devices
Personalization Drives Progress
in vestibular disorders for many years. The systems
give real-time quantitative measures of postural sway, VRT is most effective when exercises are
weight shifts, and sensory integration techniques. tailored to the patient’s specific deficits—
Based on measurement of balance under different such as gaze instability, motion sensitivity,
visual and proprioceptive conditions, posturography or postural imbalance—rather than apply-
is beneficial in pointing out individual deficits and ing a one-size-fits-all approach.

Vestibular Rehabilitation Therapy 23

Practical Guide to Diagnosis & Management of Vertigo

Sample copy
Fig. 21-29: This annotated medical illustration depicts the emerging concept of a vestibular implant, designed to restore
vestibular function in patients with bilateral vestibular loss. The image shows the precise placement of the device near
the semicircular canals, highlighting the internal electrode array inserted adjacent to the ampullae. An external processor
unit—similar to that used in cochlear implants—is also depicted, which transmits signals via telemetry. This illustration aids
in understanding the anatomical relationship of the implant components and their function in mimicking natural vestibular
input through direct stimulation of vestibular nerves.
F2g
i:.
ing progress, and digital symptom diaries. Together, attending in-person rehabilitation sessions [34]. Ad-
these elements empower patients to take an active ditionally, mobile apps can be paired with wearable
role in their recovery, while also allowing clinicians sensors or built-in smartphone accelerometers to
to monitor adherence remotely and adjust treatment objectively measure key metrics such as movement
plans as needed. quality, step counts, and postural sway during dai-
Several preliminary studies have shown that mHealth ly activities. These tools provide valuable, real-time
interventions can significantly improve patient com- data that inform both patient self-monitoring and cli-
pliance, engagement, and clinical outcomes—es- nician decision-making, contributing to a more per-
pecially among individuals who face barriers to sonalized and responsive rehabilitation process.

Vestibular Adaptation Takes Time—Set Vestibular Implants: A Future Frontier

Expectations Among the most exciting developments in vestibular
rehabilitation is the emergence of the vestibular im-
Reinforce to patients that VRT benefits
plant, a device conceptually similar to the cochlear
may take weeks to months. Managing ex-
pectations early increases adherence and implant. These experimental systems are being de-
reduces frustration. veloped to restore vestibular function in individuals

24 Vestibular Rehabilitation Therapy

 Practical Guide to Diagnosis & Management of Vertigo
with severe bilateral vestibular loss—a condition for vestibular medicine.
which current therapeutic options remain limited. Among the most rigorous investigations of VRT effec-
Vestibular implants work by delivering targeted elec- tiveness was that of Hall et al. (2016) in preparing
trical stimulation to the semicircular canals or vestib- an evidence-based clinical practice guideline for the
ular nerve, thereby mimicking the effects of natural American Physical Therapy Association. The authors,
vestibular input. in a 2016 systematic review of 39 good-quality RCTs,
Initial clinical trials have indicated that vestibular determined that VRT significantly reduces symptoms
implants may partially restore vestibulo-ocular reflex of dizziness, gaze instability, balance dysfunction,
(VOR) function, enhance dynamic visual acuity, and and health-related quality of life in patients who have
improve balance and postural control in individuals unilateral peripheral vestibular hypofunction. The
with profound vestibular impairment [41]. Although guideline recommended strongly that individualized
this technology is still in the research phase, its poten- VRT programs be used in place of general physical
tial to transform care for patients with otherwise un- activity or observation alone, due to a pattern of con-
treatable vestibular loss is substantial. Key challenges sistently favorable findings across a broad range of
ahead include minimizing surgical risks, optimizing patient groups and clinical settings [2].
neural signal encoding, and supporting long-term In addition to its benefits in unilateral dysfunction,
adaptation by the central nervous system. Neverthe- VRT has also proven valuable in the management
less, the vestibular implant represents a compelling of bilateral vestibular hypofunction (BVH)—a more
vision for the future of VRT—one that moves toward complex condition characterized by severe gaze in-
biologically integrated and sensorimotor-enhancing stability and postural imbalance. Herdman et al.
solutions. demonstrated that even in the absence of function-

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al input from both labyrinths, patients could expe-
Summary rience meaningful improvements in dynamic visual
acuity and postural control through targeted exer-
Technological advancements are continuously re- cises aimed at adaptation and substitution. In their
shaping the scope and potential of vestibular rehabili- prospective studies, patients undergoing gaze stabi-
tation. Virtual reality introduces engaging, immersive lization and balance training reported reductions in
environments for habituation and balance training; oscillopsia and improved ambulation under various
computerized posturography offers objective, precise sensory conditions, supporting the neuroplastic po-
measurements to assess and guide postural control tential of central pathways to compensate for pro-
strategies; and mobile applications extend the reach found peripheral loss [9].
of VRT, improving adherence and outcomes in home-
based and underserved settings. Looking ahead, ves- The older population is also a priority demographic
tibular implants hold promise for restoring function for VRT due to heightened vulnerability to age-relat-
in patients with otherwise intractable bilateral ves- ed vestibular decline and fall injuries. Several clini-
tibular deficits. Collectively, these innovations reflect cal trials and systematic reviews have indicated that
the dynamic evolution of VRT into a more personal- personalized VRT programs in older adults result in a
ized, technology-driven discipline that unites clinical substantial fall risk decrement, improved functional
expertise with digital precision. gait performance, and increased balance confidence.
As an example, a systematic review conducted by Ric-
ci et al. (2010) determined that vestibular rehabilita-
EVIDENCE BASIS FOR VESTIBULAR REHABIL- tion is both safe and highly effective in middle-aged
ITATION THERAPY and older adults, enhancing not only postural stabil-
ity but activity level and social participation as well
[14]. These results are especially relevant consider-
The clinical efficacy of Vestibular Rehabilitation Ther- ing the worldwide aged population and rising preva-
apy (VRT) is well supported by a robust body of sci- lence of vestibular disorders among them.
entific literature, including randomized controlled
trials (RCTs), systematic reviews, and meta-analyses. Gradual Exposure Prevents Symptom
These studies consistently demonstrate that VRT is a Exacerbation
highly effective intervention for improving function,
reducing symptoms, and enhancing the quality of life Habituation exercises should begin with
in patients with a wide range of vestibular disorders. mild symptom provocation. Overloading
The strength of this evidence underscores the impor- the patient too early can cause discour-
tance of VRT as a first-line conservative therapy in agement and non-compliance.
Vestibular Rehabilitation Therapy 25
Practical Guide to Diagnosis & Management of Vertigo
Further, there is support for VRT’s use in a wide range As vestibular science continues to evolve and pa-
of clinical disorders, such as Persistent Postural-Per- tient-based care is further emphasized, VRT will con-
ceptual Dizziness (PPPD), post-concussional dizzi- tinue to be a dynamic and essential tool in promot-
ness, and central vestibular disorders. Individualized ing balance, decreasing disability, and enhancing the
protocols involving habituation, visual desensitiza- autonomy and quality of life of those who live with
tion, and balance training have been successful in vestibular dysfunction.
diminishing symptom duration and restoring func-
tion even in more difficult presentations. Notably, in-
vestigations highlight that VRT results are optimized GLOSSARY
when programs are individualized, supervised, and Activities-specific Balance Confidence Scale
feature repeated outcome assessment through stan- (ABC): A self-reported measure assessing an individ-
dardized measures like the Dizziness Handicap In- ual’s confidence in performing daily activities with-
ventory (DHI), Functional Gait Assessment (FGA), out losing balance.
and Computerized Dynamic Posturography (CDP).
Adaptation: A vestibular rehabilitation mechanism
that promotes recalibration of the vestibulo-ocular
Summary reflex (VOR) to improve gaze stability during head
movement.
Vestibular Rehabilitation Therapy has emerged as
an essential, evidence-based cornerstone in the con- Balance Training: A category of VRT exercises de-
servative management of vestibular dysfunction. signed to improve static and dynamic postural con-
Grounded in the principles of neuroplasticity, central trol by integrating visual, vestibular, and propriocep-
compensation, and sensorimotor integration, VRT tive inputs.

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provides a comprehensive framework for addressing Bilateral Vestibular Hypofunction (BVH): A
a wide range of vestibular impairments—whether pe- condition characterized by reduced or absent func-
ripheral, central, age-related, or functional. tion in both vestibular systems, leading to imbalance,
The treatment advantage is created through judicious oscillopsia, and high fall risk.
use of gaze stabilization, habituation exercises, bal-
Cognitive Behavioral Therapy (CBT): A psy-
ance training, and functional retraining, specifically
chotherapeutic approach that addresses maladaptive
tailored to deal with the patient’s unique situation.
thoughts and behaviors, often used adjunctively in
The individualization of VRT guarantees that treat-
patients with dizziness and anxiety.
ment is relevant and timely in response to changes in
symptoms, comorbidity, and practical functional re- Computerized Dynamic Posturography
quirements. This reactiveness, plus growing amounts (CDP): A diagnostic and rehabilitative tool that eval-
of good-quality evidence, secures VRT’s place as more uates postural control under various sensory condi-
than a treatment adjunct but as a central treatment tions using force platform technology.
resource in vestibular disorders. Dizziness Handicap Inventory (DHI): A vali-
The progressive incorporation of technological devel- dated questionnaire used to assess the physical, emo-
opments, like systems of virtual reality, applications tional, and functional impact of dizziness on daily
via cell phone, and sensor-based feedback systems, life.
continues to improve the accuracy, motivation, and Dynamic Visual Acuity (DVA): A clinical test that
accessibility of VRT. Additionally, growth in inter- evaluates the ability to maintain visual clarity during
disciplinary practice—including the involvement of head movement, reflecting VOR function.
audiologists, neurologists, physiotherapists, psychol-
ogists, and general care professionals—has further Fall Recovery Strategies: Techniques taught
reinforced the context in which VRT is provided. during VRT to help patients safely respond to or re-
cover from a fall, particularly in those with severe
Early Initiation of VRT Enhances Out- balance deficits.
comes
Functional Gait Assessment (FGA): A perfor-
Initiating vestibular rehabilitation within mance-based measure that evaluates gait under dif-
days to weeks after symptom onset—es- ferent conditions to assess fall risk and mobility.
pecially in cases like vestibular neuritis—
Gaze Stabilization Exercises: Exercises aimed
can accelerate central compensation, re-
at improving VOR function by training the eyes to
duce chronicity, and improve long-term
remain fixed on a target during head motion (e.g., X1
functional recovery.
26 Vestibular Rehabilitation Therapy
 Practical Guide to Diagnosis & Management of Vertigo
and X2 viewing). and opposite to head movement.
Habituation: A form of vestibular rehabilitation Virtual Reality (VR): Computer-generated envi-
that reduces symptom sensitivity through repeated ronments used in VRT to simulate motion-rich set-
exposure to provocative stimuli. tings for habituation and balance training.
Head Impulse Test (HIT): A clinical test of semi- Visual Vertigo Analog Scale (VVAS): A self-re-
circular canal function that assesses the vestibulo-oc- ported measure of dizziness intensity triggered by vi-
ular reflex via rapid head movements. sual motion or complex visual environments.
Home Exercise Program (HEP): A structured X1 Viewing: A gaze stabilization exercise where the
set of vestibular rehabilitation exercises prescribed head moves while maintaining focus on a stationary
for independent performance outside of clinical set- target.
tings.
X2 Viewing: A more advanced gaze stabilization
Mobile Health (mHealth): The use of mobile de- exercise where both the head and the target move in
vices and apps to deliver health care services, includ- opposite directions.
ing remote vestibular rehabilitation protocols.
Oscillopsia: A visual symptom characterized by the
REFERENCES
perception that the environment is moving or bounc-
ing, typically caused by impaired VOR.
Persistent Postural-Perceptual Dizziness 1. Herdman SJ, Whitney SL. Physical therapy treat-
(PPPD): A chronic functional vestibular disorder ment of vestibular hypofunction. In: Herdman SJ,
Clendaniel RA, editors. Vestibular Rehabilitation. 4th

Sample copy
characterized by non-spinning dizziness and un-
steadiness triggered by upright posture and visual ed. Philadelphia: F.A. Davis; 2014. p. 356–81.
motion. 2. Hall CD, Herdman SJ, Whitney SL, Cass SP,
Posturography: A technique used to quantify bal- Clendaniel RA, Fife TD, et al. Vestibular rehabilita-
ance and postural control, often providing visual or tion for peripheral vestibular hypofunction: an evi-
auditory feedback for therapeutic purposes. dence-based clinical practice guideline. J Neurol Phys
Ther. 2016;40(2):124–55.
Saccades: Rapid eye movements used in substitu-
tion strategies to maintain gaze in patients with im- 3. Bamiou DE, Luxon LM, Davies RA. Audiovestibu-
paired vestibular function. lar medicine related balance disorders: management
strategies. Curr Opin Neurol. 2005;18(1):5–9.
Sensory Organization Test (SOT): A compo-
nent of CDP that evaluates a patient’s ability to main- 4. Schubert MC, Migliaccio AA, Clendaniel RA. Ves-
tain balance under various sensory conditions. tibulo-ocular reflex adaptation exercises improve
gaze stability in patients with unilateral vestibular
Substitution: A compensatory strategy in VRT
hypofunction. J Neurol Phys Ther. 2008;32(2):74–
where alternative sensory systems (e.g., vision or
81.
proprioception) are used to maintain function when
vestibular input is deficient. 5. Pavlou M, Lingeswaran A, Davies RA, Gresty MA,
Bronstein AM. Simulator based rehabilitation in visu-
Timed Up and Go (TUG): A simple clinical test
ally induced dizziness. J Neurol. 2004;251(5):525–
measuring the time taken to stand up from a chair,
31.
walk three meters, turn, return, and sit down; used
to assess mobility and fall risk. 6. Badke MB, Miedaner JA, Grove CR, Shea TA,
Pyle GM. Outcomes after rehabilitation for adults
Vestibular Implant: An emerging device designed
with balance dysfunction. Arch Phys Med Rehabil.
to electrically stimulate the vestibular nerve, mimick-
2004;85(2):227–33.
ing natural vestibular input in patients with bilateral
vestibular loss. 7. Smith PF, Darlington CL. Neuroplasticity following
unilateral vestibular deafferentation. Prog Neurobiol.
Vestibular Rehabilitation Therapy (VRT): A
2013;111:1–17.
specialized exercise-based therapy aimed at improv-
ing symptoms of dizziness, imbalance, and gaze in- 8. Herdman SJ, Schubert MC, Das VE, Tusa RJ. Re-
stability by enhancing central compensation. covery of dynamic visual acuity in unilateral vestibu-
lar hypofunction. Arch Otolaryngol Head Neck Surg.
Vestibulo-Ocular Reflex (VOR): A reflex that
2003;129(8):819–24.
stabilizes vision by producing eye movements equal
Vestibular Rehabilitation Therapy 27
Practical Guide to Diagnosis & Management of Vertigo
9. Herdman SJ, Hall CD, Schubert MC, Das VE, Tusa ty recovery with vestibular rehabilitation. Arch Phys
RJ. Recovery of dynamic visual acuity in bilateral ves- Med Rehabil. 2008;89(3):500–7.
tibular hypofunction. Arch Otolaryngol Head Neck
22. Nashner LM. Computerized dynamic posturogra-
Surg. 2007;133(4):383–9.
phy. In: Jacobson GP, Shepard NT, editors. Balance
10. Bhattacharyya N, Gubbels SP, Schwartz SR, Ed- Function Assessment and Management. San Diego:
low JA, El-Kashlan H, Fife TD, et al. Clinical prac- Plural Publishing; 2008. p. 371–400.
tice guideline: benign paroxysmal positional vertigo
23. Cohen H, Blatchly CA, Gombash LL. A study of
(update). Otolaryngol Head Neck Surg. 2017;156(3_
the clinical test of sensory interaction and balance.
suppl):S1–S47.
Phys Ther. 1993;73(6):346–54.
11. Popkirov S, Staab JP, Stone J. Persistent postur-
24. Podsiadlo D, Richardson S. The timed “Up & Go”:
al-perceptual dizziness (PPPD): a common, charac-
a test of basic functional mobility for frail elderly per-
teristic and treatable cause of chronic dizziness. Pract
sons. J Am Geriatr Soc. 1991;39(2):142–8.
Neurol. 2018;18(1):5–13.
25. Wrisley DM, Marchetti GF, Kuharsky DK, Whitney
12. Yardley L, Burgneay J, Nazareth I, Luxon L. Neu-
SL. Reliability, internal consistency, and validity of
ro-otological and psychiatric abnormalities in a com-
data obtained with the Functional Gait Assessment.
munity sample of people with dizziness: a blind, con-
Phys Ther. 2004;84(10):906–18.
trolled investigation. J Neurol Neurosurg Psychiatry.
1998;65(5):679–84. 26. Staab JP, Eckhardt-Henn A, Horii A, Jacob R,
Strupp M, Brandt T, et al. Diagnostic criteria for per-
13. Alahmari KA, Sparto PJ, Marchetti GF, Furman
sistent postural-perceptual dizziness (PPPD): Con-
JM, Whitney SL. Comparison of physical therapy out-
sensus document of the committee for the classifica-

Sample copy
comes for vestibular rehabilitation based on etiology
tion of vestibular disorders of the Bárány Society. J
of dizziness. Otol Neurotol. 2014;35(10):1745–51.
Vestib Res. 2017;27(4):191–208.
14. Ricci NA, Aratani MC, Doná F, Macedo C, Cao-
27. Whitney SL, Wrisley DM, Marchetti GF, Gee MA,
villa HH, Ganança FF. A systematic review about the
Redfern MS, Furman JM. Clinical measurement of sit-
effects of the vestibular rehabilitation in middle-age
to-stand performance in people with balance disor-
and older adults. Rev Bras Fisioter. 2010;14(5):361–
ders: validity of data for the Five-Times-Sit-to-Stand
71.
Test. Phys Ther. 2005;85(10):1034–45.
15. Alsalaheen BA, Mucha A, Morris LO, Whitney SL,
28. Agrawal Y, Carey JP, Della Santina CC, Schubert
Furman JM, Sparto PJ. Vestibular rehabilitation for
MC, Minor LB. Disorders of balance and vestibular
dizziness and balance disorders after concussion. J
function in US adults: data from the National Health
Neurol Phys Ther. 2010;34(2):87–93.
and Nutrition Examination Survey, 2001–2004. Arch
16. Staab JP, Ruckenstein MJ. Expanding the differ- Intern Med. 2009;169(10):938–44.
ential diagnosis of chronic dizziness. Arch Otolaryn-
29. Hebert JR, Corboy JR, Manago MM, Schenk-
gol Head Neck Surg. 2007;133(2):170–6.
man M. Effects of vestibular rehabilitation on mul-
17. Jacobson GP, Newman CW. The development of tiple sclerosis–related fatigue and upright postural
the Dizziness Handicap Inventory. Arch Otolaryngol control: a randomized controlled trial. Phys Ther.
Head Neck Surg. 1990;116(4):424–7. 2011;91(8):1166–83.
18. Powell LE, Myers AM. The Activities-specific Bal- 30. Staab JP. Chronic subjective dizziness. Continuum
ance Confidence (ABC) Scale. J Gerontol A Biol Sci (Minneap Minn). 2012;18(5):1118–41.
Med Sci. 1995;50A(1):M28–M34.
31. Bigelow RT, Semenov YR, Trevino C, Ferruc-
19. Pavlou M, Davies RA, Bronstein AM. The assess- ci L, Resnick SM, Simonsick EM, et al. Association
ment of increased sensitivity to visual stimuli in pa- between visuospatial ability and vestibular function
tients with chronic dizziness. J Vestib Res. 2006;16(4- in the Baltimore Longitudinal Study of Aging. J Am
5):223–31. Geriatr Soc. 2015;63(9):1837–44.
20. MacDougall HG, Weber KP, McGarvie LA, Hal- 32. Powell LE, Myers AM. The Activities-specific Bal-
magyi GM, Curthoys IS. The video Head Impulse ance Confidence (ABC) Scale. J Gerontol A Biol Sci
Test: diagnostic accuracy in peripheral vestibulopa- Med Sci. 1995;50A(1):M28–34.
thy. Neurology. 2009;73(14):1134–41.
33. Berg KO, Wood-Dauphinee SL, Williams JI, Maki
21. Schubert MC, Migliaccio AA, Clendaniel RA, Al- B. Measuring balance in the elderly: validation of
lak A, Carey JP. Mechanism of dynamic visual acui- an instrument. Can J Public Health. 1992;83 Suppl
28 Vestibular Rehabilitation Therapy
 Practical Guide to Diagnosis & Management of Vertigo
2:S7–11.
34. Meldrum D, Glennon A, Herdman S, Murray
D, McConn-Walsh R. Virtual reality rehabilitation
of balance: assessment of the usability of the Nin-
tendo Wii Fit Plus. Disabil Rehabil Assist Technol.
2012;7(3):205–10.
35. Micarelli A, Viziano A, Augimeri I, Alessandrini
M. Tele-rehabilitation in vestibular disorders: need
for a balance between clinical efficacy and health
technology assessment. Eur Arch Otorhinolaryngol.
2020;277(12):3287–9.
36. Micarelli A, Viziano A, Augimeri I, Alessandrini
M. Three-dimensional head-mounted gaming task
procedure maximizes effects of vestibular rehabilita-
tion in unilateral vestibular hypofunction. Int J Reha-
bil Res. 2017;40(4):325–32.
37. Holmberg J, Karlberg M, Harlacher U, Riva-
no-Fischer M, Magnusson M. Treatment of phobic
postural vertigo: a controlled study of cognitive–be-
havioural therapy and self-controlled desensitization.

Sample copy
J Neurol. 2006;253(4):500–6.
38. Whitney SL, Marchetti GF, Schade A, Wrisley DM.
The sensitivity and specificity of the Timed “Up & Go”
and the Dynamic Gait Index for self-reported falls in
older adults. J Geriatr Phys Ther. 2004;27(2):52–9.
39. Dobbels B, Mertens G, Gilles A, Claes AJ, van de
Berg R, Fransen E, et al. Rehabilitation after bilateral
vestibulopathy: predictors of rehabilitation success.
Acta Otorhinolaryngol Ital. 2019;39(4):294–301.
40. Whitney SL, Wrisley DM, Brown KE, Furman
JM. Is perception of vertical impaired in individ-
uals with vestibular dysfunction? Otol Neurotol.
2009;30(4):545–52.
41. van de Berg R, Guinand N, Guyot JP, Kingma H,
Stokroos R. The vestibular implant: Hearing and bal-
ance restoration for patients with bilateral vestibu-
lopathy. Acta Otolaryngol. 2012;132(6):710–5.

Vestibular Rehabilitation Therapy 29