Vestibular Treament Approaches and Interventions

What are the three aspects of compensation?

Adaptation, substitution, and habituation

Describe adaptation

Modifying gain of the VOR

Describe substitution

Using non-vestibular strategies

Describe habituation

Reduction of symptoms through repeated performance/stimulation

Treatment theory for adaptation

Approximate/promote normal gaze stability

Treatment theory for substitution

Utilize alternative eye movements to make up for VOR deficits

Treatment theory for habituation

Reduce symptoms through the use of repeated postural changes/head movements

ADAPTATION of the VOR

Stimulus is the RETINAL SLIP (movement of image across
retina’s fovea, resulting in visual blurring)

• Image motion drives VOR adaptation

• Key elements = head movement and visual feedback

Where is the VOR primarily mediated?

Cerebellum and vestibular nuclei

What influences VOR Gain?

Synaptic plasticity in purkinjie cells

With what condition is adaptation of VOR primarily used?

Unilateral Hypofunction (neuritis/labyrinthitis)

Primary interventions for ADAPTATION of the VOR

VOR x 1 and VOR x 2

VOR x1 and VOR x2 dosage

Acute/subacute: Perform at least 3x per day, 12 minutes
Chronic: Perform at least 3x per day, 20 minutes

Some increased symptoms are expected – good rule of thumb – symptoms should not be increased for more than 15-20 minutes
after completion of exercises

VOR challenge is increased when

Visual targets are held closer to the eyes (15cm)

Cue the patient to perform as many reps as possible
within 30 or 60 seconds while keeping target mostly in
focus. Challenge them to complete more reps each day
in the same time period

Describe substitution

Applying and mastering alternative strategies (non-vestibular) to replace the lost or compromised VOR function

Especially useful for patients with bilateral peripheral
vestibular loss

• substituting gaze stability using smooth pursuits or saccades

• substitution postural stability using Focus on a target, close eyes, turn head but try to keep eyes on target. Then open eyes and check to see if you are still looking at the target

what is habituation

Repetitive exposure to provoking movements to improve patients’ tolerance to those movements
• Exact underlying mechanism is unknown,
however habituation to sensory input is a normal response in healthy individuals

What is the most thorough method to evaluate habituation

motion sensitivity quotient

How often should habituation exercises be prescribed

Perform repetitions (up to 5-10x) 2-3x a day

ex. Supine head turns, bend over in sitting, standing head turns, bending in standing with head turn

Treating BPPV

Treat with Canal Repositioning Maneuver as already covered
• If not responding to treatment the patient can be given
“Brandt-Daroff” exercises for home
• Typically perform 3-5 reps each direction, 2x/day

Treating oculomotor deficits

• Smooth pursuits

• Saccades

• Convergence

Treatment for neuritis

1. Adaptation Exercises - Seated horizontal and vertical VORx1 60x

2. Habituation exercises (if positionally sensitive) - Bend over in standing with visual focus 2×5

3. Balance integration - EC head turns on foam, static stand EC on foam

4. Dynamic balance - walking head and eye turns in hallway

Treatment for Bilateral hypofunction

• Seated eye-head movements 30x horizontal/vertical

• Remembered target 20x

• Balance integration - EC head turns on foam, static stand EC on foam

• Dynamic balance - standing toe taps to cones

Meniere’s Disease Tx

• Dietary education (decrease sodium/caffeine, increase water)

• Habituation exercises (MSQ)

• Balance integration

• Refer for medical management

Vestibular migraine Tx

Dietary education (decrease dairy alcohol, chocolate, MSG)

• MSQ

• Balance integration