Vestibular Rehabilitation Therapy (VRT): A Physio’s Guide to Dizziness & Balance

Vestibular Rehabilitation Therapy (VRT) is an exercise-based program designed to promote central nervous system compensation for inner ear deficits. Whether the patient has Vestibular Neuritis, Labyrinthitis, or BPPV, VRT is the gold standard for reducing vertigo, improving gaze stability, and preventing falls. This guide breaks down the three mechanisms of recovery and the specific exercises used in clinical practice.

1. Signs & Symptoms of Vestibular Dysfunction

• Vertigo: An illusion of movement (spinning/rotatory) of self or environment.
• Dizziness: A non-specific feeling of unsteadiness or lightheadedness.
• Oscillopsia: Visual blurring during head movement (the world "bounces" when walking).
• Imbalance: Veering to one side while walking (usually towards the lesion side).

The "Red Flags" (Central vs Peripheral):
If a dizzy patient presents with the 5 D's, suspect a Central Lesion (Stroke/Brainstem) and refer immediately:
1. Diplopia (Double vision)
2. Dysphagia (Swallowing difficulty)
3. Dysarthria (Slurred speech)
4. Drop attacks
5. Dysmetria (Coordination loss)

2. The 3 Mechanisms of Recovery

VRT works by retraining the brain to compensate for the lost signal from the ear. It relies on neuroplasticity through three main mechanisms:

Mechanism	Definition	Exercise Example
1. Adaptation	Resetting the gain of the Vestibulo-Ocular Reflex (VOR). The brain learns to adjust eye movements to match head speed.	Gaze Stability Exercises (VOR x1)
2. Habituation	Repeated exposure to specific movements that provoke dizziness to desensitize the system.	Brandt-Daroff exercises; Motion Sensitivity training.
3. Substitution	Using alternative strategies (Vision + Somatosensory) to replace lost vestibular function.	Balance training on foam; Wide-based gait.

3. Adaptation Exercises (Gaze Stability)

These are crucial for patients complaining of blurry vision when moving or driving.

A. VOR x1 Viewing

• Setup: Hold a target (e.g., a business card with a letter 'A') at arm's length.
• Action: Keep eyes fixed on the target while rotating the head side-to-side (NO-NO motion).
• Rule: The target must remain clear. If it blurs, slow down.
• Progression: Increase speed -> Checkered background -> Standing -> Walking.

B. VOR x2 Viewing (Advanced)

• Setup: Hold the target at arm's length.
• Action: Move the target to the right while moving the head to the left (Opposite directions). Eyes stay glued to the target.
• Difficulty: Much harder; requires high-level coordination.

4. Habituation Exercises

Used when patients are sensitive to motion (e.g., looking up, bending down). The goal is to provoke mild symptoms until the brain ignores the error signal.

The "10-Minute Rule": Habituation exercises will make the patient dizzy. This is normal. The dizziness should settle within 15-20 minutes after stopping. If it lasts hours, the dose was too high.

• Brandt-Daroff Exercises: Often used for residual BPPV or general motion sensitivity. Involves moving from sitting to lying on one side, sitting up, then lying on the other side.
• Cawthorne-Cooksey Exercises: A graduated protocol moving from eye movements in bed -> head movements sitting -> standing -> walking with turns.

5. Substitution & Balance Training

For patients with bilateral vestibular loss (both ears damaged), adaptation is impossible. We must substitute.

• Visual Fixation: Teach patients to fixate on a distant object while walking.
• Sensory Integration: Reducing reliance on vision (eyes closed balance) to force the use of proprioception (feet).
• Environment: Night lights to prevent falls in the dark (when vision is removed).

6. Revision Notes

VOR (Vestibulo-Ocular Reflex): Stabilizes gaze during head movement.
Nystagmus: Involuntary eye movement. Direction is named by the fast phase.
BPPV: Mechanical problem (crystals), treated with maneuvers (Epley), NOT VRT initially.
Unilateral Loss (UVH): Responds best to Adaptation.
Bilateral Loss (BVH): Responds best to Substitution.
Safety: High fall risk during exercises. Use a corner or chair for support.

7. FAQs

Q1. Will the exercises make me dizzy?

Yes. It is necessary to provoke mild dizziness to train the brain. "No pain, no gain" applies here—if you don't get slightly dizzy, the brain won't learn to fix it.

Q2. Is VRT effective for BPPV?

No. BPPV (displaced otoconia) requires a repositioning maneuver (like the Epley maneuver) to clear the crystals first. VRT is only used after the Epley if residual dizziness remains.

Q3. How long does recovery take?

For Unilateral Hypofunction (e.g., Neuritis), 6-8 weeks of daily exercise is typical. Bilateral loss takes longer and may be incomplete.

8. 10 Practice MCQs

Q1. VOR x1 exercise involves:

Answer: B) This trains the adaptation of the VOR gain.

Q2. Which mechanism is primarily used for bilateral vestibular loss?

Answer: C) Since there is no vestibular function left to adapt, the patient must substitute with vision and somatosensation.

Q3. Oscillopsia is defined as:

Answer: C) It indicates a defective VOR (the eyes bounce as the patient walks).

Q4. A patient with vertigo and "The 5 Ds" likely has:

Answer: C) The 5 Ds (Diplopia, Dysphagia, etc.) are brainstem signs.

Q5. Habituation exercises are best suited for:

Answer: B) Repeated exposure desensitizes the system to the provoking movement.

Q6. The primary goal of VRT in unilateral vestibular hypofunction is:

Answer: B) The brainstem and cerebellum compensate for the asymmetrical signal.

Q7. Which exercise protocol progresses from lying in bed to walking?

Answer: A) A classic general VRT protocol.

Q8. If a patient gets extremely dizzy/vomits during VRT:

Answer: B) Mild dizziness is good; incapacitating dizziness indicates overdose.

Q9. Which sense is NOT involved in maintaining balance?

Answer: D) Smell does not contribute to postural stability.

Q10. VOR x2 exercises are considered:

Answer: B) Moving both head and target requires greater processing and coordination.

References

• Herdman, S. J., & Clendaniel, R. A. (2014). Vestibular Rehabilitation (4th ed.). F.A. Davis.
• Han, B. I., et al. (2011). Vestibular Rehabilitation Therapy: Review of Indications, Mechanisms, and Key Exercises. J Clin Neurol.
• APTA Neurology Section. (2016). Clinical Practice Guideline: Peripheral Vestibular Hypofunction.