Rehabilitation Options for Patients With Dizziness and
Patients with peripheral vestibular dysfunction often present
with more than simply symptoms of dizziness. Patients may have an
array of physical and functional limitations that affect their
everyday activities. For instance, persons with a unilateral
vestibular hypofunction (unilateral weakness) may have difficulty
driving because of an inability to quickly check their blind
spot, and persons with benign paroxysmal positional vertigo
(BPPV) may subconsciously avoid fully checking their review
mirror for fear of provoking an episode of vertigo.
Often, patients who choose to limit their activities
dramatically reduce their mobility and, consequently, report
feelings of unsteadiness and imbalance when walking and
performing other daily activities. Some elderly patients find
that dizziness may be the symptom that prompts their entry into
the medical system. They may have additional balance issues and
be at a high risk of falling. With the near epidemic incidence
rate and complications of falls in the elderly (Centers for
Disease Control and Prevention, 2008a, 2008b; Lyons, 2004; Stuck,
1999), the identification and proper referral for care is a
professional duty and public health priority.
Audiologists conduct vestibular evaluations in patients with
balance and dizziness disorders. Audiologists may also provide
rehabilitation of patients with BPPV and serve as members of
multidisciplinary teams that manage patients with balance
disorders. It is important for audiologists to be knowledgeable
about the rehabilitation interventions that professionals such as
physical and occupational therapists utilize to minimize the
patients' symptoms and maximize their function. The evidence
supporting the effectiveness of vestibular rehabilitation is
quite strong (Hillier & Hollohan, 2007). A key ingredient to
successful rehabilitation is proper identification of the problem
and a systematic and progressive program of exercises. Exercises
prescribed depend directly on the underlying pathology and
Of the various rehabilitation interventions, the most
noteworthy is the effectiveness of canalith repositioning
treatment (CRT) for canalithiasis BPPV or liberatory maneuvers
for cupulolithiasis BPPV. The use of CRT for BPPV of the
posterior canal has been most widely studied. The recovery of
BPPV with correct application of CRT results in a resolution of
symptoms with a success rate of 65%-95% within one or two
treatments (Asawavichianginda, Isipradit, Snidvongs, &
Supiyaphun, 2000; Froehling et al., 1991; Lempert, Wolsley,
Davies, Gresty, & Bronstein, 1997; Lynn, Pool, Rose, Brey,
& Suman, 1995; Prokopakis et al., 2005; Richard, Bruintjes,
Oostenbrink, & van Leeuwen, 2005; Wolf, Hertanu, Novikov,
& Kroonenberg, 1999; Yimtae, Srirompotong, Srirompotong,
& Sae-seaw, 2003). The difference in success rate is unknown
but may depend on accurate diagnosis, individual patient factors,
and the skill of the professional performing the treatment. The
less well-known liberatory maneuvers have also been shown to have
success rates of 50%-93% after one to four treatments (Herdman,
Tusa, Zee, Proctor, & Mattox, 1993; Ireland, 1994; Levrat,
van Melle, Monnier, & Maire, 2003; Semont, Freyss, &
Vitte, 1988). CRT (also referred to as the Epley maneuver) is the
most well-known treatment for dizziness; however, there are
several other interventions performed by rehabilitation
specialists for the treatment of dizziness and imbalance.
Treatment for decreasing symptoms of dizziness can be
categorized as habituation exercises or adaptation exercises
(Herdman & Whitney, 2007). For a person with a unilateral
uncompensated hypofunction (UVH), prescribed exercises that focus
on adaptation of the vestibular-ocular reflex (VOR) are
indicated. The therapist must carefully instruct the patient in
proper performance of the exercises for successful
rehabilitation. Exercises consist of performing head movements
while keeping a target in focus. For example, a patient is asked
to look at a target in front of him and move his head side to
side while keeping the target in focus. The patient should
perform the exercise at a hertz (Hz) that results in subtle
feelings of nausea at the end of 1-2 minutes of performance
(Herdman & Whitney, 2007). The exercises are progressed in
difficulty and performed at an intensity that induces an error
signal. Therefore, the exercises should be progressed by pushing
the speed to a level just slower than when the target falls off
focus. Because adaptation is so precise, the exercise must be
performed in various positions (i.e., sitting, standing, lying,
walking) and at various distances and speeds. Adaptation of the
VOR can be complicated by moving the target in the opposite
direction of the head movement. Moving the arm and head in
opposite directions forces a doubling of the gain needed for the
eyes to stay on target. It also takes quite a bit of coordination
to perform this combination exercise, making the exercises
difficult to perform for many patients.
Another method of coordinating eye and head movements is
accomplished by using two targets. The two targets are placed
approximately 3-4 feet apart on a wall in front of the patient.
First, the patient looks at one target with only her eyes then
moves her head to be in alignment with the target without the
eyes drifting off the target. Then without moving her head, the
patient looks at the other target with her eyes only and then
moves the head to be in alignment with the target. Again the eyes
should not drift off the target. As with any VOR exercise, the
adaptation is very specific, and the exercise should be performed
at different speeds and in the vertical plane as well as the
horizontal plane. Once various speeds are accomplished, the
exercises can be further maximized by performing them with a
complex background (Herdman & Whitney, 2007).
A typical adaptation program duration is between 6 and 8 weeks
and results in a return to not only the ability to go grocery
shopping without an increase in symptoms but to accomplish the
shopping within a reasonable time frame and without resulting in
excessive fatigue. Recently we had tremendous success with a
patient who had a 95% unilateral vestibular loss. She was able to
return to teaching fourth grade and was successful in the
classroom environment because she no longer had to worry about
her symptoms. She was able to walk backward down the hallway,
turn quickly, and ascend and descend stairs without symptoms or
loss of balance. This was remarkable considering that the entire
time she was performing these activities she was also constantly
moving her head to scan the children and keep them all in
A person with motion or visual field sensitivity may be
prescribed a similarly progressive exercise program; however, the
mechanism behind these exercises is considered habituation
(Herdman & Whitney, 2007). The phenomenon of habituation can
be likened to the phenomenon that allows you to tune out a
continuous repetitive tone. After a while of hearing it, your
brain simply ignores it. A therapist can determine which specific
movements or environments cause a moderate level of symptoms.
Then, through a progressive program of repetitive exposure, the
patient habituates to the sensation and as a result minimizes the
One mechanism used to determine specific motion sensitivity is
the Motion Sensitivity Quotient (Shepard & Telian, 1995). The
test has been shown to have good reliability and validity in a
study of 15 patients and is useful for determining the specific
activities to perform (Akin & Davenport, 2003). The Motion
Sensitivity test consists of a series of movements that the
patient performs. After each movement, the patient assesses the
level and duration of dizziness associated with the movement. The
therapist identifies and selects up to four movements that cause
moderate level symptoms for treatment. The patient is instructed
to perform the movements repeatedly, usually at a frequency of
two times per day with three repetitions per session (Herdman
& Whitney, 2007). Unlike the Cawthorne (Cawthorne, 1944) and
Cooksey (Cooksey, 1946) do-it-yourself exercises that were
advocated in the 1940s, selective exercises may be more efficient
for patients' recovery (Szturm, Ireland, &
Although success rates of complete recovery of symptoms
through rehabilitation of either adaptation or habituation
exercises are not as great as those for BPPV, they are still very
good. The vast majority of patients, 80%, will have at least a
decrease in symptoms. Anywhere from 10% to 30% of patients with
UVH will not have an improvement (Herdman & Whitney, 2007).
However, indications of improvement in function as measured
through the Dizziness Handicap Inventory (Jacobson & Newman,
1990) or other disability or functional ability questionnaires
have been shown after participation in vestibular rehabilitation
(Cohen & Kimball, 2003, 2004; Hillier & Hollohan,
The problems of "dizziness" in the elderly can often
be a puzzle to solve. Dizziness is the term often used to
describe many symptoms besides vertigo. Often the exact
description is not fully investigated, and patients are referred
for an electronystagmography (ENG) or videonystagmography (VNG)
to determine whether vestibular weakness exists. Yet, when the
patient is asked to describe the dizziness without using the word
"dizzy," the true symptoms of imbalance or syncope may
be revealed. Many systems affect our sense of equilibrium, and
each has to be examined. In addition to vestibular dysfunction,
symptoms can arise from issues with circulation, breathing,
cervical dysfunction, muscular weakness, peripheral neuropathy,
and sensory processing dysfunction. The patient's subjective
reports of symptoms will tell much of the story; however,
dizziness is not always clearly described, and each patient has a
different perception. A good case history is crucial.
Symptoms described as "lightheaded," "passing
out," or "swooning" can indicate a cardiovascular
issue. Some patients referred to our balance clinic for
vestibular evaluation have had underlying pathologies such as a
pacemaker malfunction, vertebral artery occlusion, obstructive
pulmonary disease decompensation, orthostatic hypotension, and
cardiac arrhythmia as causes of the symptoms. All patients seen
in our balance clinic have their blood pressure, heart rate and
rhythm, and oxygen saturation measured during their evaluation.
Usually, cardiovascular and pulmonary conditions are treated
under the medical management by the physician. However, some
general conditioning or breathing exercises may be beneficial
once the physician clears the patient for exercise. A
rehabilitation professional with knowledge and skill in
cardiopulmonary rehabilitation would be able to monitor the
patient and modify the exercise program as needed.
When imbalance is a result of general vestibular hypofunction,
rehabilitation exercises that challenge balance without vision,
with disturbed vision, or on uneven surfaces are indicated. These
balance exercises can enhance the use of the vestibular input and
should be performed to challenge both static and dynamic balance.
A patient may be instructed to stand with his feet together on a
firm surface and then progress to a compliant surface. Then the
exercise can progress to being performed with the eyes closed or
while moving the arms or catching a ball. More dynamic balance
activities would include having a patient perform "sit to
stand" from various surfaces or walk while looking at
objects, or with eyes closed, or while catching a ball.
Imbalance can also be a result of general disuse. Various
exercise programs in the community or at home have been shown to
improve balance and decrease the risk of falls (Brown, 1999;
Davis, Donaldson, Ashe, & Khan, 2004; Marigold et al., 2005).
Specific physical impairments should be addressed in addition to
performing balance activities. If muscular weakness is
identified, traditional strengthening with progressive resistive
exercises is warranted. Likewise, if lack of flexibility is
noted, traditional stretching may be beneficial (Whaley,
Brubaker, & Otto, 2006). As with any rehabilitation program,
exercises that focus on specific physical impairments must be
combined with functional activities. As the patient's
physical performance improves (i.e., greater strength or
flexibility), the new ability has to be incorporated into
functional activities for long-term maintenance.
Balance issues can be identified and addressed after a
thorough examination and evaluation by a rehabilitation
professional. Testing for both static and dynamic balance,
strength, and flexibility, in addition to home safety,
depression, cognition, and medications, is recommended.
Accurate diagnosis leading to appropriate interventions by
skilled rehabilitation professionals can provide a great service
for patients with complaints of dizziness or imbalance. Knowing
and developing relationships with the rehabilitation
professionals in your community will provide you with an
excellent resource for yourself and your patients. The Vestibular
Disorders Association, an excellent resource for both patients
and professionals, maintains a database of vestibular
rehabilitation professionals. There are many resources and
methods for recovery currently available. The patient no longer
has to "live with" being dizzy.
Deanna Dye, PT, PhD
Idaho State University
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About the Author
Dr. Deanna Dye is an Assistant Professor of Physical Therapy
in the Kasiska College of Allied Health Professions at Idaho
State University. Dr. Dye operates the on-campus Dizziness and
Balance Clinic in conjunction with Dr. Jeff Brockett, who is an
Assistant Professor in the Audiology Department.
This article first appeared in the Vol. 7, No. 4, July/August
2008 issue of