Vestibular Rehabilitation: Vertigo and Balance

Introduction to Vestibular Rehabilitation

Vestibular rehabilitation constitutes a physiotherapy specialty dedicated to evaluating and treating balance disorders and vestibular-origin vertigo. This discipline, developed since the 1940s with Cawthorne and Cooksey's pioneering work rehabilitating soldiers with post-traumatic vertigo during World War II, relies on the central nervous system's remarkable ability to compensate for peripheral vestibular deficits through neuronal plasticity mechanisms called vestibular compensation.

The vestibular system, located in the inner ear, is one of three sensory systems maintaining balance and gaze stabilization during head movements. It comprises five receptor organs per ear: three semicircular canals (horizontal, anterior, posterior) detecting angular accelerations, and two otolith organs (utricle, saccule) detecting linear accelerations and head position relative to gravity. Vestibular information is integrated in brainstem vestibular nuclei with visual and proprioceptive information to generate vestibulo-ocular reflexes (gaze stabilization) and vestibulo-spinal reflexes (postural maintenance).

Vestibular vertigo and balance disorders affect approximately 35% of adults over 40. Benign paroxysmal positional vertigo (BPPV) is the most frequent cause, representing 20-30% of all vertigo cases. Vestibular rehabilitation is recommended as first-line treatment by international societies for most peripheral vestibular disorders and as therapeutic complement for central vestibular pathologies.

Neurophysiological Principles

Vestibular rehabilitation exploits three fundamental neurophysiological mechanisms: adaptation, substitution, and habituation. Vestibular adaptation refers to the vestibulo-ocular reflex (VOR) capacity to modify its gain to compensate for unilateral vestibular deficit. Gaze stabilization exercises exploit VOR adaptation by requiring the patient to maintain visual fixation during head movements of increasing frequency and amplitude.

Sensory substitution intervenes when the vestibular deficit is too severe for adaptation alone. The CNS learns to rely more on visual and proprioceptive information. Visual substitution exercises train compensatory ocular strategies, while proprioceptive substitution reinforces somatosensory information use.

Vestibular habituation, developed by Norre and De Weerdt in the 1980s, involves repetitive exposure to movements and positions provoking vertigo, progressively reducing the vertiginous response through synaptic plasticity. This mechanism is particularly relevant for residual vertigo and persistent postural-perceptual dizziness (PPPD).

Central vestibular compensation requires favorable conditions: immobility, movement avoidance, and prolonged vestibuloplective medication use delay compensation. Rehabilitation provides necessary sensory stimulations, encourages movement, and helps manage anxiety and fear of falling.

Techniques and Maneuvers

The Epley maneuver (canalith repositioning maneuver) is the reference treatment for posterior semicircular canal BPPV (85-95% of cases). It uses a five-position head sequence guided by gravity to progress otoliths along the posterior canal and reposition them in the utricle. Success rate is 80-95% after one to three maneuvers.

The Semont maneuver (liberatory maneuver) is an alternative using rapid lateral tilting. The Lempert maneuver (barbecue or log roll) treats horizontal canal BPPV (5-15% of cases) through 360-degree patient rotation in supine position by 90-degree increments.

Gaze stabilization exercises (VOR adaptation) are the pillar of unilateral vestibular deficit rehabilitation. VORx1 requires fixating a stationary target during increasingly rapid head movements. VORx2 increases difficulty by moving the target opposite to head movement. Progression involves increasing speed, duration, and visual environment complexity.

Balance and proprioception exercises follow progressive difficulty: standing with feet together (eyes open/closed), tandem stance, single-leg stance, unstable surfaces (foam, balance board), dynamic exercises (walking with head rotations, obstacle courses, dual cognitive-motor tasks). Optokinetic stimulation is used for visual dependence habituation and PPPD treatment.

Indications and Pathologies

BPPV is the most frequent and best-codified indication. Diagnosis relies on Dix-Hallpike test (posterior canal) or roll test (horizontal canal). Treatment by repositioning maneuver is curative in most cases. For recurrent BPPV (15-50% recurrence at one year), habituation exercises and self-repositioning maneuvers (Brandt-Daroff, modified Epley) are taught.

Vestibular neuritis causes acute unilateral vestibular deficit. After the acute phase (3-5 days), early vestibular rehabilitation is essential. The program combines gaze stabilization, progressive balance exercises, and head movement habituation. Recovery is achieved in 80-90% of cases after 4-8 weeks.

Meniere's disease benefits from inter-crisis vestibular rehabilitation for balance improvement and functional disability reduction. The program emphasizes vestibular habituation, balance training, anxiety management, and fall prevention.

Presbyvestibulopathy (age-related vestibular decline) affects approximately 35% of people over 65 and significantly contributes to fall risk. An adapted rehabilitation program reduces fall risk and improves mobility confidence. PPPD, characterized by chronic dizziness exceeding three months, is treated with progressive habituation, visual dependence desensitization, and cognitive behavioral therapy.

Course of a Treatment Program

The vestibular physiotherapy assessment includes structured interview, clinical evaluation (head impulse test, nystagmus search, Romberg test, Fukuda test, Berg Balance Scale, Dynamic Gait Index), and handicap perception tests (Dizziness Handicap Inventory).

The first rehabilitation session focuses on therapeutic education: explaining vertigo mechanisms, vestibular compensation principles, and why movement avoidance delays recovery. Subsequent sessions (typically 8-12 over 4-8 weeks) include progressive gaze stabilization, increasing balance complexity, specific habituation exercises, and a daily home exercise program (15-20 minutes).

The home program is essential, comprising 4-6 targeted exercises performed two to three times daily. The physiotherapist provides illustrated instructions and adapts the program at each consultation based on progress and difficulties.

Variants and Technological Innovations

Virtual reality represents a major innovation, creating controlled sensory conflict situations for visual dependence habituation and PPPD treatment, with results equivalent or superior to conventional rehabilitation. Force platform posturography enables objective balance assessment and biofeedback rehabilitation. Optokinetic stimulation is experiencing renewed interest with modern immersive projection technologies.

Vibrotactile biofeedback uses wearable devices providing tactile vibrations signaling postural oscillations. AI-assisted vestibular rehabilitation analyzes posturographic data to optimize program personalization and predict clinical evolution.

Contraindications and Precautions

Absolute contraindications are limited. Undiagnosed central vestibular pathology (brainstem or cerebellar stroke, cerebellopontine angle tumor) must be excluded before rehabilitation. Sudden-onset vertigo with focal neurological signs requires urgent brain imaging. Unstable cervical pathologies contraindicate repositioning maneuvers and rapid cervical movements.

Patients on vestibuloplective medication (benzodiazepines, first-generation antihistamines) have reduced compensation potential. Progressive withdrawal, in collaboration with the prescribing physician, is recommended. The anxiety component (30-50% of vestibular patients) may limit adherence and delay compensation; its identification and management are essential.

Fall risk must be assessed, particularly in elderly patients. Balance exercises are performed in a safe environment with nearby support, progressively adapted to patient capabilities. Closed non-slip footwear is recommended. Home exercises should be performed near a wall or stable furniture.