Vestibular Rehabilitation: Treating Vestibular Hypofunction - Key Concepts and Definitions

If someone has problems with gaze stability, they will often complain of ____.

blurry vision, objects jumping

If someone states they are feeling imbalanced, this is usually a _____ issue.

postural instability

The three ways in which we treat hypofunction are _____, _____, and ____.

adaptation, substitution, habituation

The three most common impacts of hypofunction are ____, ____, and ____.

motion sensitivity, gaze instability, postural instability

Vestibular compensation is when ____ and ____ respond to sensory conflict and then there is a readjustment of the ____ which balances ____.

cerebellum; brainstem; VOR; vestibular tone

True or False: Vestibular hypofunction is usually benign and are self-limiting.

TRUE

____ is an exercise-based treatment program designed to promote vestibular adaptation and substitution.

vestibular rehabilitation therapy (VRT)

The goals of VRT are to ____.

enhance gaze stability, enhance postural stability, improve symptoms of dizziness, and improve ADLs

Even though vestibular hypofunction is self-limiting and there is vestibular compensation, why might someone need PT?

because there may be poor compensation which cannot balance out their symptoms

Vestibular adaptation is ____.

readjusting the gain of the VOR or VSR

_____ is using alternative strategies or systems to replace lost vestibular function.

substitution

When VOR gain is not within 0.8-1.2, there is ____.

gaze instability

____ is using repetitive exposure to provocative motions.

habituation

The mechanisms of recovery for BVH are ____.

stabilize gaze in absence of vestibular input, postural stability

True or False: central reprogramming is effective when head movements are unpredictable.

FALSE; NOT effective when head movements are unpredictable

Progression of exercise protocols are designed to ____.

reset/return VOR

reduce exaggeration of motion or after motion

strengthen weakened system by decreasing dependency

strengthen remaining systems

In VRT, we want to improve or restore ____ and ____.

coordination of head and eye movement; balance and equilibrium function

____ is the cardinal indicator for uncompensation UVH.

oscillopsia

True or False: the CNS can adapt to oscillopsia and spontaneous nystagmus.

TRUE

VRT is indicated for ____.

stable, but poorly compensated vestibular lesions

VRT is NOT indicated for ____.

patients who have ongoing labyrinth pathology

Meniere's disease exacerbation

perilymphatic fistula

Adaptation is used for ____.

s/p acute vestibular neuritis or labyrinthitis, vestibular surgery, inactive Meniere's

_____ is used for stable bilateral deficits.

substitution

BVH is most commonly caused by ____

antibiotics or chemo

We have to make sure that VRT is ____ specific.

task

Intensity is based on ____, ____ and ____.

repetitions, level of difficulty, and patient's subjective experience

If your intensity is too little, you risk ____, and if your intensity is too much, you risk ____.

underdosing by failing to reach max potential for recovery; increasing vertigo which can lead to falls and being scared of PT

What does tolerance of errors mean?

some patients may not be psychologically okay after making errors, and we don't want them to be discouraged, so we need to keep that in mind when dosing

The goal with exercises are to ____.

allow the patient to struggle during SAFE practice and have enough symptoms so they see the need to change

With exercises, we want to take into consideration ____, ___, and ____.

patient awareness, personality, and current level of physical abilities

Gaze stabilization exercises are _____ or _____ exercises, whereas postural stability exercises are ____ exercises.

adaptation or substitution; substitution

Why would we want to work on exercises while walking or doing other aerobic activities?

because many patients with vestibular dysfunction limit activity to avoid symptoms

____ exercises are when a patient must maintain fixation while moving their head.

gaze stabilization

____ is the stimulus that increases the gain of vestibular response.

retinal slip (error signal)

With gaze exercises we induce ____ so that the brain tries to minimize blurring by increasing VOR.

retinal slip

When movements are anticipated, ____ is the most effective to maintain gaze.

central pre-programming

Other eye movements such as ____ and ____ can substitute for vestibular dysfunction.

saccade modification; enhancing smooth pursuit eye movements

Central pre-programming occurs more with (BVH/UVH).

BVH

We use (adaptation/substitution) for UVH and (adaptation/substitution) for BVH.

adaptation; substitution

A positive result on which two tests would indicate the use of gaze stabilization exercises?

HIT, DVA

VOR x 1 and VOR x 2 are (adaptation/substitution) exercises.

adaptation

What is the difference between VOR x 1 and VOR x 2?

VOR x 1 keeps target still and pt maintains fixation while moving head, VOR x 2 moves target in one direction that gaze is kept on while head moves in the other direction

We want to complete VOR x 1 for at least ____ min, ___ times per day and as ____ as possible without _____.

1; 2; fast; blurring

The goal of VOR x 1 and VOR x 2 is to increase ____.

speed

When pt can complete VOR x 1 for ___ minutes with ____ increase in symptoms, they can progress to ____.

2; minimal; VOR x 2

(near/far) is more challenging than (near/far).

near; far

Active head-eye movements and imaginary targets are ____ exercises, and are usually used at week ____ of rehab.

substitution; 2

For patients with severe impairment that can't complete gaze stabilization exercises, we might prescribe them ____ before ____.

ocular exercises; VOR x 1

Patients should not complete ocular exercises for more than ___ minute(s) more than ___ time(s) per day.

1; 3

Optokinetic stimulation is _____ exercise for _____.

adaptation; visual motion sensitivity

Optokinetc stimulation is when _____.

there is sustained rotation of objects that encompass a large part of the visual field

Optokinetic stimulation promotes ____.

increased sensory stimulation to visual centers in brain

For optokinetic stimulation, we need to be able to _____.

grade parameters such as velocity, size, color, direction

For driving videos, we want the patient to watch for ____, ____ time(s) per day.

as long as they can tolerate; 1-2

We want the patient to stop watching the driving video if ____.

increased headache or dizziness to 5/10

For driving videos, symptoms should resolve to baseline within ____ minutes.

15

True or False: the target must always be seen clearly during gaze stabilization exercises.

TRUE

We often use (symmetrical/asymmetrical) ____ for gaze stabilization.

asymmetrical letters

We start the target (further away/closer).

further away

Head movements for gaze stabilization should be ___ degrees, ___, and ____.

20-30; smooth; continuous

For acute or subacute UVH, gaze stability exercises should be performed minimum ____ times per day at least ____ minutes per day.

3; 12

For chronic UVH, gaze stability exercises should be performed minimum ____ times per day at least ____ minutes per day for ____ weeks.

3-5; 20; 4-6

For BVH, gaze stability exercises should be performed minimum ____ times per day at least ____ minutes per day for ____ weeks.

3-5; 20-40; 5-7

____ is a great test to assess what sensory systems are involved in postural instability.

MCTSIB

Before giving postural stability exercises, we need to assess ____.

whether UVH or BVH, if any remaining vestib function, if overly reliant on other systems

The goals of postural stability exercises are _____.

learn to use stable visual references and surface somatosensory information

use remaining vestibular function

identify alternative postural movement strategies that are efficient and effective

recover normal postural strategies

If we put a patient on foam with their eyes closed we are fostering use of _____ system.

vestibular

Patients with UVH rely on ____ cues from LE acutely and ____ cues chronically.

somatosensory; visual

Patients with BVH rely on ____ cues from LE acutely and ____ cues chronically.

visual; somatosensory

If someone relies on vision, we want to use balance exercises that ____.

reduce or distort visual input but have good somatosensory input

If someone relies on somatosensation, we want to use balance exercises that ____.

have disrupted somatosensory input like carpet, foam, moving surfaces

If someone has vestibular loss, they will use (ankle/hip) strategy but not (ankle/hip) strategy.

ankle; hip

Hip strategy is required for ____ and ____, so we want to use these positions to work on hip strategy.

SLS; tandem stance

With BVH, there is increased risk for ____ and ____ should be considered for those with BVH age 65 and up.

falls; assistive devices

Habituation exercises are used to ____.

improve vertigo

We want to identify ____ before giving habituation exercises.

movements that provoke symptoms the worst

Cawthorne and Cooksey exercises are ____ exercises.

habituation

We want to select activities based on score of the ____.

MSQ

Habituation exercises are most commonly used for (UVH/BVH) or ____.

UVH; residual effects of BPPV after successful canal repositioning

True or False: habituation exercises are indicated for BVH.

FALSE

We want to use positions that were scored a ___ on the MSQ for ____ minutes ___ times per day.

3;3;3

There are ___ positions on the MSQ. You want to ____, then multiply by ____, then divide by ____.

16; total score; number of positions; 20.4

Ideally after 3-5 reps of a habituation exercise, symptoms will _____.

return to baseline or baseline number has decreased

We also want to select positions on the MSQ that relate to the patient's ____.

goals

True or False: we want to let symptoms resolve between each set of habituation exercises.

TRUE

Symptoms should not persist longer than ____ minutes.

20

We want to educate patients on ____ and _____.

benefit of performance of exercises and compliance with HEP

_____ is linked to fall risk.

dual task

____ is good to screen for need to work on dual tasking.

TUG-Cog

For vestibular hypofunction, acute is ____, subacute is ____, and chronic is ____.

days; weeks to months; greater than 3 months

For patients with no comorbidities that have acute or subacute UVH will likely be treated for ___ weeks, chronic UVH ___ weeks, and BVH ____ weeks... but depends on ____.

2-3; 4-6; 10; compliance with HEP

CPG recommends that static and dynamic balance exercises be performed for ____ minutes daily for at least ____ weeks for chronic UVH, and ____ minutes daily for at least ____ weeks for BVH.

4-6; 6-9

We may use ____ as reasons for stopping VRT.

achievement of primary goals

resolution of symptoms

normalized balance and vestib function

plateau in progress

_____ could modify rehab outcomes.

time from onset of symptoms

comorbidities

cognitive function

use of medication