Dizziness and Vertigo _________________________________________________________________________
Based on strong evidence and a preponderance of benefit over harm, patients with acute, subacute, or chronic unilateral or bilateral vestibular hypofunction should be offered vestibular rehabilitation [43]. Without head movements, saccadic or smooth-pursuit exercises should not be used alone as gaze stability exercises. Acute Peripheral Vertigo For cases of acute peripheral vertigo, vestibular rehabilitation begins with the patient focusing on an object with a blank background, then moving the head slowly (to avoid severe nausea) to the right and left, and then up/down. This is done two to three times per day for several minutes, and the patient is encouraged to increase the speed as tolerated [135]. Chronic Peripheral Vestibular Hypofunction The vestibular rehabilitation approach for chronic peripheral vestibular hypofunction is more aggressive, with increasingly more difficult tasks while keeping symptoms manageable. Tasks include eye and head movements while standing, walk- ing forward, walking backward, and standing or walking on compliant or uneven surfaces [135]. Bilateral Vestibular Loss Central adaptation is much less likely with bilateral vestibu- lar loss than in unilateral loss, but vestibular rehabilitation can promote strategic substitution through strengthening saccadic eye movements and optimizing the efficacy of neck stretch receptors. Vestibulo-ocular exercises are initiated when residual vestibular function is a possibility. Improved balance and gait speed help offset the bilateral loss [138]. Education on fall prevention is critical, because these patients have an especially high fall risk, compounded by darkness and uneven surfaces [135]. Central Vertigo Recovery of vestibular function in patients with central vertigo is limited because pathologic involvement of central vestibular structures restricts compensation, and improvement takes longer than with peripheral vestibular dysfunction [136]. For these patients, vestibular rehabilitation emphasizes gait and balance activities, along with eye and head movements. Adaptive methods to perform activities of daily function are often taught. If nausea is limiting, antiemetic medications used in conjunction with vestibular rehabilitation may improve participation and final outcomes [135].
The American Physical Therapy Association concludes that clinicians may prescribe a home exercise program of gaze stability exercises consisting of
a minimum of 3 times per day for a total of at least 12 minutes per day for patients with acute/subacute vestibular hypofunction and at least 20 minutes per day for patients with chronic vestibular hypofunction. (https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4795094. Last accessed September 30, 2024.) Strength of Recommendation : D (Expert opinion from the clinical experience of the guideline development team) General Components Vestibular rehabilitation uses several approaches to reduce symptoms and impairment and to promote function in patients with dizziness, postural instability, and gaze instability. Visual- vestibular interaction (adaptation) exercises strengthen the vestibulo-ocular reflex and gaze stability to promote central compensation for reduced vestibular input, improving gaze instability, balance, and dizziness [43; 135; 136]. Strategic substitution exercises promote the use of sensory stimuli and spatial cues from vision and proprioception to sub- stitute for loss of vestibular inputs. Cervico-ocular reflex input is strengthened to reduce spatial uncertainty, and alternative spatial cues can improve balance and walking [43; 135; 136]. Balance and gait training under challenging sensory and dynamic conditions facilitates visual and somatosensory cues to offset vestibular hypofunction. Equipment to augment training includes gaming technology, optokinetic drums, and virtual reality [43]. Habituation exercises reduce visual motion sensitivity (e.g., visual vertigo, space and motion discomfort) through system- atic exposure to noxious stimuli evoking mild, temporary symptoms. Approaches include optokinetic stimuli and virtual reality for immersion in repetitive moving and visually chal- lenging environments [43; 135; 136]. Vestibular rehabilitation can help counteract the negative effects of deconditioning, common in vestibular patients, to avoid symptom provocation [43]. Psychologic deconditioning can progress to PPPD (phobic postural vertigo) to become the greatest obstacle to recovery. After a vestibular event, elderly patients can develop fear of falling, avoidance behavior, and indefinite mobility limitation without vestibular rehabilita- tion [75].
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