Vestibular Rehabilitation

Sumaiyah Obaid
Assistant Professor
The University of Faisalabad
 Assessment
• Subjective
• Objective
– Vision
• Smooth persuit
• Saccades
• Visual field
– VOR
– Motor skills
– ROM
– Somato-sensation
 Assessment
• Positional/ Movement test
• Perception of upright
• Balance
• Functional ambulation measures
• High level skills
Motion Sensitivity
Quotient
Oculomotor & Vestibulo- Ocular Testing

• Eye follow/ head stationary

• Sacadic eye movement
• Head movement/ stationary object
• Head movement/ object movement in-phase
• Head movement/object movement out-of-phase
• Passive head shaking
 Principles to Guide Management
• Decrease overactivity/ tension
– Positioning and active inhibition
• Side lying vs supine
• Encourage flexion/rotation from supine and
extension/rotation from prone
• Correct sitting and standing
– Rocking/ swaying in supported position
– Positioning and handling skills to attain length for
active holding and during displacement
 Principles to Guide Management
• Establish gaze stabilisation and progressively challenge this
function during re-training to restore both static and
dynamic component of the VOR
• Decreased dizziness and develop tolerance to motion of the
head and body in space
– Specific positioning protocols

– Habituate the vestibular system with repetitive eye, head, body

motion
 Principles to Guide Management

• Establish postural control and mobility on firm

surface with minimal handling
– Practice postural holding with eyes closed
– Initially use slower paced activities that involves head
displacement that occurs with normal movement
– Progress to faster displacements that are externally
paced
 Principles to Guide Management

• Practice in conditions of visual/ proprioceptive

conflict
– EC on compliant surface
– Wobble board/ trampoline
– Use uneven surfaces, terrain
– Vary the lighting
– Work in busy crowded enviornments
 Principles to Guide Management

• Restore general conditioning and endurance

• Educate about residual deficits/ safety

awareness
 Exercise to Improve Gaze Stability

• Acute stage
– Business card on wall with head moving horizontally
for 1 minute
– Vertical movement for 1 minute
– Repeat exercise then on large pattern
• Checkerboard vertically and horizontally depending on
nausea
 Exercise to Improve Gaze Stability

• Sub-acute stage
– Move card and head in opposite direction horizontally/
vertically for 1 min
– Increase duration

• Chronic stage
– Patient fixates on visual target placed on wall in front
while bouncing up and down on trampoline
 Exercises to Increase Postural Stability

• Feet together
– Eyes on target in front and head moving right/ left for 1 minute;
increase time

• Walk with assistance

• Walk with head turning to right/ left
• Eye open- feet together and standing heel-toe-arms
– First stretched then across chest and holding for 5-15 minutes
– Practice above with eyes closed
 Exercises to Increase Postural Stability

• Standing on foam

• Walk backwards

• Count backwards as walking

• Walk on different surfaces

• Walk with tandem stance and then braiding

• Walk and turning first in large circles and then small to both sides

• Walk on ramps
 Exercises to Increase Postural Stability

• Maintain balance sitting on swedish ball and

then bouncing or when bouncing on trampoline
• Doing above with visual fixation on stationary
target facilitating otolith-ocular reflex
• Walk in crowded area with flow of traffic and
against it
 BPPV
• Diagnosis is based on:
– Latency of 1 or more seconds after head is moved in to provoking

position

– Gradual reduction in vertigo and nystagmus <60 seconds

– Characteristic nystagmus

– Reversal of the nystagmus and recurrence of vertigo when person

returns to sitting

– Decreased intensity of vertigo with repeated movement in provoking

position
 BPPV
• Other symptoms related with BPPV
– Postural instability
– Disequilibrium
– Unsteady gait
– Sensitivity to head movement

• Capulolithiasis
– Brandt-Daroff habituation exercises
– Liberatory maneuver
 BPPV

• Canalithiasis
– Hallpike-Dix test
• Posterior canal

• Horizontal canal