Vestibular rehabilitation

Vestibular rehabilitation is a programme of head, eye and neck movements, usually led by a physiotherapist, to assess balance function and re-educate the balance system so the person becomes more stable. The more customised this balance training is to the individual, the better the results.

The whole aim of vestibular rehabilitation is to improve balance and mobility, but it can also make marked improvements in someone’s quality of life.
Andrew Clements, Physiotherapist, Leicester Royal Infirmary

A customised exercise programme induces errors in the balance system (eyes, ears and body) and causes dizziness. It retrains the balance system to cope with the problems experienced. The exercises will not bring on an acute attack of vertigo but, initially, they will make generalised unsteady symptoms worse. Very specific tasks that make a person dizzy are identified and concentrated on and these form the basis of the exercise for each individual. People are given exercises to the limit of their ability. The exercises develop with the individual because as the patient improves, the exercises get easier. The physiotherapist will alter the exercises and work them harder until those particular movements no longer provoke dizziness for the patient. The outcome of a successful vestibular rehabilitation programme is that even though patients may still have an acute attack of vertigo, in between attacks they would no longer experience dizziness.

With non-rotational vertigo the patient feels as if they are not quite there and don’t quite catch up with their environment. In Ménière’s this occurs later in the disease and also after surgical and medical intervention which has been successful in controlling the rotational vertigo. The constant imbalance needs to be addressed, which is where vestibular rehabilitation comes in. The exercises are for general balance problems, not for attacks of severe rotational vertigo. It has been shown that people with a personally customised exercise programme do better than those undertaking generic exercises.

Patients are often taken off their medication as vestibular or centrally acting sedatives do not help vestibular rehabilitation. Although the medication is essential in treating acute episodes of vertigo, they are not for long term use.

There are several key points in successful vestibular rehabilitation:

• The patient needs to be motivated
• Effective communication between a multidisciplinary team is important. Physiotherapists, nurses, ENT doctors, hearing therapists, dieticians and sometimes neurologists need to work together. Patients’ symptoms change during treatment and the teams need to be able to react to this.
• The patient should have realistic expectations. It is common for people to get worse when they start to do the balance exercises however this is not a bad sign as it means that the exercises are having an effect. If the patient finds a certain movement makes them dizzy they will try and avoid it. Similarly if going out causes worry that people think they are drunk when they are more likely to shy away from the situation and stay at home. The less they do, the less they stimulate their semi-circular canals and the less they exercise the reflexes that control the eye movements the worse the balance gets and a downward spiral develops. The vestibular rehabilitation tries to reverse this, patients are encouraged to be positive and increase activity even though it may make them feel dizzy.