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JNPT • Volume 40, April 2016
Copyright © 2016 Neurology Section, APTA. Unauthorized reproduction of this article is prohibited.
124 JNPT • Volume 40, April 2016
Vestibular Rehabilitation for
Peripheral Vestibular Hypofunction:
An Evidence-Based Clinical Practice
Guideline
FROM THE AMERICAN PHYSICAL THERAPY ASSOCIATION
NEUROLOGY SECTION
CLINICAL PRACTICE GUIDELINES
Courtney D. Hall, PT, PhD,
Susan J. Herdman, PT, PhD, FAPTA,
Susan L. Whitney, PT,
PhD, NCS, ATC, FAPTA,
Stephen P. Cass, MD, MPH,
Richard A. Clendaniel, PT, PhD,
Terry D. Fife, MD, FAAN, FANS,
Joseph M. Furman, MD, PhD,
Thomas S. D. Getchius, BA,
Joel A. Goebel, MD,
Neil T. Shepard, PhD, and
Sheelah N. Woodhouse, PT, BScPT
Auditory Vestibular Research
Enhancement Award Program
(C.D.H.), Mountain Home VAMC,
Mountain Home, and Department
of Physical Therapy, East Tennessee
State University, Johnson City,
Tennessee; Emory University
School of Medicine (S.J.H.), Atlanta,
Georgia; Department of Physical
Therapy (S.L.W.) and Department
of Otolaryngology (S.L.W., J.M.F.),
University of Pittsburgh, Pittsburgh,
Pennsylvania; Department of
Rehabilitation Sciences (S.L.W.),
King Saud University, Riyadh,
Saudi Arabia; Department of
Background: Uncompensated vestibular hypofunction results in postur-
al instability, visual blurring with head movement, and subjective com-
plaints of dizziness and/or imbalance. We sought to answer the question,
“Is vestibular exercise effective at enhancing recovery of function in
people with peripheral (unilateral or bilateral) vestibular hypofunction?”
Methods: A systematic review of the literature was performed in 5 data-
bases published after 1985 and 5 additional sources for relevant publica-
tions were searched. Article types included meta-analyses, systematic re-
views, randomized controlled trials, cohort studies, case control series, and
case series for human subjects, published in English. One hundred thirty-
five articles were identified as relevant to this clinical practice guideline.
Results/Discussion: Based on strong evidence and a preponderance
of benefit over harm, clinicians should offer vestibular rehabilitation
to persons with unilateral and bilateral vestibular hypofunction with
impairments and functional limitations related to the vestibular deficit.
Based on strong evidence and a preponderance of harm over benefit,
clinicians should not include voluntary saccadic or smooth-pursuit eye
movements in isolation (ie, without head movement) as specific exer-
cises for gaze stability. Based on moderate evidence, clinicians may
offer specific exercise techniques to target identified impairments or
functional limitations. Based on moderate evidence and in consider-
ation of patient preference, clinicians may provide supervised ves-
tibular rehabilitation. Based on expert opinion extrapolated from the
evidence, clinicians may prescribe a minimum of 3 times per day for
the performance of gaze stability exercises as 1 component of a home
exercise program. Based on expert opinion extrapolated from the evi-
dence (range of supervised visits: 2-38 weeks, mean = 10 weeks), clini-
cians may consider providing adequate supervised vestibular rehabilita-
tion sessions for the patient to understand the goals of the program and
how to manage and progress themselves independently. As a general
guide, persons without significant comorbidities that affect mobility
and with acute or subacute unilateral vestibular hypofunction may need
ABSTRACT
DOI: 10.1097/NPT.0000000000000120
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©2016 Neurology Section, APTA 125
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Copyright © 2016 Neurology Section, APTA. Unauthorized reproduction of this article is prohibited.
once a week supervised sessions for 2 to 3 weeks; persons with chronic
unilateral vestibular hypofunction may need once a week sessions for
4 to 6 weeks; and persons with bilateral vestibular hypofunction may
need once a week sessions for 8 to 12 weeks. In addition to supervised
sessions, patients are provided a daily home exercise program.
Disclaimer: These recommendations are intended as a guide for physi-
cal therapists and clinicians to optimize rehabilitation outcomes for
persons with peripheral vestibular hypofunction undergoing vestibular
rehabilitation.
Video Abstract available for more insights from the author (see Video,
Supplemental Digital Content 1, http://links.lww.com/JNPT/A124).
Key words: peripheral vestibular hypofunction; vestibular rehabilita-
tion; clinical practice guideline
Otolaryngology (S.P.C.), University
of Colorado School of Medicine,
Denver, Colorado; Department of
Community and Family Medicine
(R.A.C.), Doctor of Physical Therapy
Division, Duke University Medical
Center, Durham, North Carolina;
Balance Disorders and Vestibular
Neurology (T.D.F.), Barrow
Neurological Institute, and University
of Arizona College of Medicine,
Phoenix, Arizona; American
Academy of Neurology (T.S.D.G.),
Minneapolis, Minnesota; Dizziness
and Balance Center (J.A.G.),
Department of Otolaryngology–
Head and Neck Surgery, Washington
University School of Medicine, St
Louis, Missouri; Dizziness and
Balance Disorders Program (N.T.S.),
Mayo Clinical School of Medicine,
Rochester, Minnesota; LifeMark and
Centric Health (S.N.W.), Alberta,
Canada; and Vestibular Disorders
Association (S.N.W.), Portland,
Oregon.
REVIEWERS:
Kathryn E. Brown, PT, MS, NCS; Beth Crowner, PT,
DPT, NCS, MPPA; Kathleen Gill-Body, DPT, MS, NCS,
FAPTA; Joseph Godges, DPT, MA; Tim Hanke PT, PhD;
Tina Stoeckman, PT, DSc, MA; Michael Schubert, PT,
PhD; Rose Marie Rine, PT, PhD; Irene Ward PT, DPT,
NCS.
The APTA provided grant funding to support the
development and preparation of this document.
All members of the workgroup and advisory board
submitted written conflict-of-interest forms and CVs
which were evaluated by a member of the Neurology
Section Clinical Practice Director (Beth Crowner, PT,
DPT, NCS, MPPA) and found to be free of financial and
intellectual conflict of interest.
Supplemental digital content is available for this article.
Direct URL citation appears in the printed text and is
provided in the HTML and PDF versions of this article
on the journal’s Web site (www.jnpt.org).
Correspondence: Courtney D. Hall, PT, PhD, James H. Quillen
VAMC, Mountain Home, TN 37684 (hallcd1@etsu.edu).
The American Physical Therapy Association Neurology
Section welcomes comments on this guideline. Comments
may be sent to Neuro@apta.org.
This is an open-access article distributed under the terms
of the Creative Commons Attribution-Non Commercial-
No Derivatives License 4.0 (CCBY-NC-ND), where it is
permissible to download and share the work provided it is
properly cited. The work cannot be changed in any way or
used commercially.
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INTRODUCTION AND METHODS
Levels of Evidence and Grades of Recommendations ................................................127
Summary of Action Statements .................................................................................. 128
Introduction ................................................................................................................. 129
Methods ....................................................................................................................... 130
VESTIBULAR REHABILITATION RECOMMENDATIONS
Action Statements ....................................................................................................... 137
Guideline Implementation Recommendations ............................................................ 151
Summary of Research Recommendations .................................................................. 152
ACKNOWLEDGEMENTS AND REFERENCES
Acknowledgements ..................................................................................................... 153
References ................................................................................................................... 153
TABLES AND FIGURES
Table 1: Levels of Evidence ........................................................................................ 127
Table 2: Grades of Recommendations for Action Statements ....................................127
Table 3: Literature Search Query ................................................................................ 131
Table 4: Brief Core Set for Vertigo ............................................................................. 133
Table 5: Recommended Outcome Measures ............................................................... 135
Figure 1: Literature Search Flowchart ........................................................................ 132
TABLE OF CONTENTS
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LEVELS OF EVIDENCE AND GRADE OF RECOMMENDATIONS
This clinical practice guideline is intended to optimize reha-
bilitation outcomes for persons with vestibular hypofunction
undergoing vestibular rehabilitation. As such, the intention
of the recommendations is to provide guidance to clinicians
providing vestibular rehabilitation. The clinician should in-
terpret the guidelines in the context of their specific clinical
practice, patient situation, and preference, as well as the po-
tential for harm.
The methods of critical appraisal, assigning levels of
evidence to the literature and assigning levels of strength to
the recommendations, follow accepted international meth-
odologies of evidence-based practice. The guideline is orga-
nized to present the definitions of the levels of evidence and
grades for action statements (Tables 1 and 2), the summary
of 10 action statements, followed by the description of each
action statement with a standardized profile of information
that meets the Institute of Medicine’s criteria for transparent
clinical practice guidelines. Recommendations for research
are also made in the text.
Each individual research article was graded on the ba-
sis of criteria from the Centre for Evidence-Based Medicine
from 2009 to determine the level of evidence of intervention
studies (Table 1). Levels I and II differentiate stronger from
weaker studies by using key questions, adapted from Fetters
and Tilson1, that evaluate the research design, quality of study
execution, and reporting. The criteria for the grades of recom-
mendation assigned to each action statement are provided in
Table 2. The grade reflects the overall strength of the evidence
available to support the action statement. Throughout the
guideline, each action statement is preceded by a letter grade
indicating the strength of the recommendation, followed by
the statement and summary of the supporting evidence.
TABLE 1. Level of Evidencea
IEvidence obtained from high-quality (≥50% criti-
cal appraisal score) diagnostic studies, prospective
studies, or randomized controlled trials
II Evidence obtained from lesser quality (<50% criti-
cal appraisal score) diagnostic studies, prospective
studies, or randomized controlled trials
III Case-controlled studies or retrospective studies
IV Case study or case series
V Expert opinion
aBased on information from the Centre for Evidence Based Medicine
website: http://www.cebm.net/oxford-centre-evidence-based-medicine-
levels-evidence-march-2009/
TABLE 2. Grades of Recommendationsa
GRADE RECOMMENDATION STRENGTH OF RECOMMENDATION
AStrong evidence A preponderance of level I and/or level II studies supports the recommendation. This must
include at least 1 level I study
BModerate evidence A single high-quality randomized controlled trial or a preponderance of level II evidence sup-
ports the recommendation
CWeak evidence A single level II study or a preponderance of level III and IV studies supports the recommen-
dation
DExpert opinion Best practice based on the clinical experience of the guideline development team and guided
by the evidence, which may be conflicting. Where higher quality studies disagree with respect
to their conclusions, it may be possible to come to agreement on certain aspects of interven-
tion (eg, variations in treatment/diagnostic test, population, or setting that may account for
conflict)
aEach Action Statement is preceded by a bolded letter grade (A-D) indicating the strength of the recommendation.
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SUMMARY OF ACTION STATEMENTS
Therapeutic Intervention for Persons With
Peripheral Vestibular Hypofunction
A. Action Statement 1: EFFECTIVENESS OF VES-
TIBULAR REHABILITATION IN PERSONS WITH
ACUTE AND SUBACUTE UNILATERAL VESTIBU-
LAR HYPOFUNCTION. Clinicians should offer vestibu-
lar rehabilitation to patients with acute or subacute unilateral
vestibular hypofunction. (Evidence quality: I; recommenda-
tion strength: strong)
A. Action Statement 2: EFFECTIVENESS OF VES-
TIBULAR REHABILITATION IN PERSONS WITH
CHRONIC UNILATERAL VESTIBULAR HYPO-
FUNCTION. Clinicians should offer vestibular rehabili-
tation to patients with chronic unilateral vestibular hypo-
function. (Evidence quality: I; recommendation strength:
strong)
A. Action Statement 3: EFFECTIVENESS OF VES-
TIBULAR REHABILITATION IN PERSONS WITH
BILATERAL VESTIBULAR HYPOFUNCTION. Clini-
cians should offer vestibular rehabilitation to patients with
bilateral vestibular hypofunction. (Evidence quality: I; rec-
ommendation strength: strong)
A. Action Statement 4: EFFECTIVENESS OF SAC-
CADIC OR SMOOTH-PURSUIT EXERCISES IN
PERSONS WITH PERIPHERAL VESTIBULAR HY-
POFUNCTION (UNILATERAL OR BILATERAL). Cli-
nicians should not offer saccadic or smooth-pursuit exercises
in isolation (ie, without head movement) as specific exer-
cises for gaze stability to patients with unilateral or bilateral
vestibular hypofunction. (Evidence quality: I; recommenda-
tion strength: strong)
B. Action Statement 5: EFFECTIVENESS OF DIF-
FERENT TYPES OF EXERCISES IN PERSONS
WITH ACUTE OR CHRONIC UNILATERAL VES-
TIBULAR HYPOFUNCTION. Clinicians may provide
targeted exercise techniques to accomplish specific goals
appropriate to address identified impairments and func-
tional limitations. (Evidence quality: II; recommendation
strength: moderate)
B. Action Statement 6: EFFECTIVENESS OF SUPER-
VISED VESTIBULAR REHABILITATION. Clinicians
may offer supervised vestibular rehabilitation to patients with
unilateral or bilateral peripheral vestibular hypofunction.
(Evidence quality: I-III; recommendation strength: moderate)
D. Action Statement 7: OPTIMAL EXERCISE DOSE
OF TREATMENT IN PEOPLE WITH PERIPHERAL
VESTIBULAR HYPOFUNCTION (UNILATERAL
AND BILATERAL). 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 min-
utes per day for patients with acute/subacute vestibular hy-
pofunction and at least 20 minutes per day for patients with
chronic vestibular hypofunction. (Evidence quality: V; rec-
ommendation strength: expert opinion)
D. Action Statement 8: DECISION RULES FOR
STOPPING VESTIBULAR REHABILITATION IN
PERSONS WITH PERIPHERAL VESTIBULAR HY-
POFUNCTION (UNILATERAL AND BILATERAL).
Clinicians may use achievement of primary goals, resolu-
tion of symptoms, or plateau in progress as reasons for stop-
ping rehabilitation. (Evidence quality: V; recommendation
strength: expert opinion)
C. Action Statement 9: FACTORS THAT MODIFY RE-
HABILITATION OUTCOMES. Clinicians may evaluate
factors that could modify rehabilitation outcomes. (Evidence
quality: I-III; recommendation strength: weak to strong)
A. Action Statement 10: THE HARM/BENEFIT RATIO
FOR VESTIBULAR REHABILITATION IN TERMS
OF QUALITY OF LIFE/PSYCHOLOGICAL STRESS.
Clinicians should offer vestibular rehabilitation for persons
with peripheral vestibular hypofunction. (Evidence quality:
I-III; recommendation strength: strong)
These guidelines were issued in 2016 on the basis of the
scientific literature published between January 1985 and
February 2015. These guidelines will be considered for re-
view in 2020, or sooner if new evidence becomes available.
Any updates to the guidelines in the interim period will
be noted on the Neurology Section of the APTA website:
www.neuropt.org.
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INTRODUCTION
Purpose of Clinical Practice Guidelines
The Neurology Section of the American Physical Therapy
Association (APTA) supports the development of clinical
practice guidelines (CPGs) to assist physical therapists with
the treatment of persons with peripheral vestibular hypofunc-
tion to optimize rehabilitation outcomes. Generally, the pur-
pose of CPGs is to help clinicians know who, what, how, and
when to treat. Specifically, the purpose of this CPG for pe-
ripheral vestibular hypofunction is to describe the evidence
supporting vestibular rehabilitation including interventions
and discharge planning supported by current best evidence.
Furthermore, this CPG identifies areas of research that are
needed to improve the evidence base for clinical manage-
ment of peripheral vestibular hypofunction.
This CPG seeks to answer the question of whether ves-
tibular exercises are effective at enhancing recovery of func-
tion in people with peripheral vestibular hypofunction. The
primary purpose of this CPG is to systematically assess the
peer-reviewed literature and make recommendations on the
basis of the quality of the research for the treatment of pe-
ripheral vestibular hypofunction. A secondary purpose of
this CPG is to provide recommendations to reduce unwar-
ranted variation in care and to ensure that exercise interven-
tions provided by physical therapists and other clinicians
for vestibular hypofunction are consistent with current best
practice. Finally, it is hoped that this CPG will be helpful
in developing collaborative relationships among health care
providers and thus will serve to reduce unnecessary delays
(>1 year in some cases) in referring appropriate patients with
vestibular hypofunction for vestibular rehabilitation.2
Background and Need for a Clinical Practice
Guideline on Vestibular Rehabilitation in Persons
With Peripheral Vestibular Hypofunction
Uncompensated vestibular hypofunction results in postural
instability, visual blurring with head movement, and subjec-
tive complaints of dizziness and/or imbalance. On the basis
of data from the National Health and Nutrition Examina-
tion Survey for 2001 to 2004, it is estimated that 35.4% of
adults in the United States have vestibular dysfunction re-
quiring medical attention and the incidence increases with
age.3 Appropriate treatment is critical because dizziness is
a major risk factor for falls: the incidence of falls is greater
in individuals with vestibular hypofunction than in healthy
individuals of the same age living in the community.4 The
direct and indirect medical costs of fall-related injuries are
enormous.5,6
The precise incidence and prevalence of peripheral ves-
tibular hypofunction is difficult to ascertain. The reported in-
cidence of vestibular neuritis, a common etiology underlying
vestibular hypofunction, is approximately 15 per 100,000
people.7,8 Based on a meta-analysis of published studies,
Kroenke et al9 estimated that 9% of the approximately 7
million clinic visits (or 630,000 clinic visits) each year for
dizziness are due to vestibular neuritis or labyrinthitis. How-
ever, this figure does not include etiologies such as vestibu-
lar schwannoma or bilateral vestibular loss and, therefore,
underestimates the number of people with peripheral ves-
tibular hypofunction. In the 2008 Balance and Dizziness
Supplement to the US National Health Interview Survey, the
prevalence of bilateral vestibular hypofunction was reported
to be 28 per 100,000 US adults (or 64,046 Americans).10 Of
the respondents with bilateral vestibular hypofunction, 44%
had changed their driving habits, and approximately 55%
reported reduced participation in social activities and dif-
ficulties with activities of daily living. Although vestibular
dysfunction is less common in children with an estimated
prevalence of 0.45%,11 20% to 70% of all children with sen-
sorineural hearing loss also have vestibular loss that may be
undiagnosed.12,13
The National Health and Nutrition Examination Survey
trial revealed that vestibular dysfunction escalates with in-
creasing age such that nearly 85% of people aged 80 years
and more have vestibular dysfunction.3 According to Dillon
et al,14 the prevalence of balance (vestibular and sensory loss
in feet) impairment in persons older than 70 years is 75%.
In addition, people with vestibular disorders were reported
to have an 8-fold increase in their risk of falling, which is of
concern because of the morbidity and mortality associated
with falls.3,5
Persons with bilateral vestibular hypofunction had a 31-
fold increase in the odds of falling compared with all respon-
dents. In addition, 25% reported a recent fall-related injury.10
The Centers for Disease Control and Prevention reported the
cost of falls in 2000 exceeded $19 billion, and that cost is
projected to skyrocket to nearly $55 billion per year by the
year 2020.15 Cost-effective treatments that can reduce the
risk for falling, can therefore reduce overall health care costs
as well as the cost to personal independence and functional
decline of patients with vestibular dysfunction.
Therapeutic exercise interventions to address the signs,
symptoms, and functional limitations secondary to vestibu-
lar deficits have been shown to decrease dizziness, improve
postural stability thus reducing fall risk, and improve visual
acuity during head movement in individuals with vestibular
hypofunction.16-23 A newly-revised Cochrane Database Sys-
tematic Review published in 2015 concluded that there is
moderate to strong evidence in support of vestibular rehabil-
itation in the management of patients with unilateral vestib-
ular hypofunction, specifically for reducing symptoms and
improving function.24 A recent systematic review concluded
that there is moderate evidence to support the effectiveness
of vestibular exercises in individuals with bilateral vestibular
hypofunction for improving gaze and postural stability.25
At the time of submission, there are no clinical practice
guidelines for the treatment of peripheral vestibular hypo-
function. The 2015 Cochrane review24 of the treatment of
vestibular hypofunction included etiologies such as benign
paroxysmal positional vertigo, for which there are already
2 clinical practice guidelines from the American Academy
of Neurology26 and the American Academy of Otolaryngol-
ogy–Head and Neck Surgery Foundation.27 It was deter-
mined that a clinical practice guideline to address appro-
priate vestibular exercise options for use with patients with
unilateral and bilateral peripheral vestibular hypofunction
was appropriate.
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Statement of Intent
This guideline is intended for clinicians, family members,
educators, researchers, policy makers, and payers. It is not in-
tended to be construed or to serve as a legal standard of care.
As rehabilitation knowledge expands, clinical guidelines are
promoted as syntheses of current research and provisional
proposals of recommended actions under specific conditions.
Standards of care are determined on the basis of all clinical
data available for an individual patient/client and are subject
to change as knowledge and technology advance, patterns of
care evolve, and patient/family values are integrated. This
clinical practice guideline is a summary of practice recom-
mendations that are supported with current published litera-
ture that has been reviewed by expert practitioners and other
stakeholders. These parameters of practice should be consid-
ered guidelines only, not mandates. Adherence to them will
not ensure a successful outcome in every patient, nor should
they be construed as including all proper methods of care or
excluding other acceptable methods of care aimed at the same
results. The ultimate decision regarding a particular clinical
procedure or treatment plan must be made using the clinical
data presented by the patient/client/family, the diagnostic and
treatment options available, the patient’s values, expectations,
and preferences, and the clinician’s scope of practice and ex-
pertise. However, we suggest that significant departures from
accepted guidelines should be documented in patient records
at the time the relevant clinical decisions are made.
METHODS
The vestibular guideline workgroup (CDH, SJH, SLW) pro-
posed the topic to the APTA and Neurology Section. The
topic was accepted and the workgroup attended the APTA
Workshop on Developing Clinical Practice Guidelines in
July 2012. The workgroup submitted and received 3-year
grant funding from the APTA to support guideline develop-
ment in October 2012. The workgroup solicited members
to form an expert multidisciplinary (audiology, neurology,
otolaryngology, patient representative, and physical therapy)
Advisory Board of people who are actively involved in the
management of patients with vestibular dysfunction. The
first Advisory Board call took place in January 2013, and
5 subsequent conference calls occurred over the following
2 and a half years. The Advisory Board was intimately in-
volved in the development of the content and scope of the
guideline with key questions to be answered, determination
of articles for inclusion, and writing/critical edits of the clin-
ical practice guideline.
External Review Process by Stakeholders
Comments were solicited from the Practice Committee for
the Neurology Section of the APTA and the public via email
blasts to professional organizations (audiology, neurology,
otolaryngology, and physical therapy) as well as postings
on the Neurology Section and Vestibular Special Interest
Group websites at 2 critical junctures during the guideline
development. The first call for public comments on the
Project Development Plan (the outline of the guideline au-
thors, clinical questions to be answered, terms and databas-
es to be searched, and project timeline) occurred in October
2013. The second call for comments on the complete draft
of the clinical practice guideline occurred in April 2015.
The second call included solicitation for feedback via email
blasts to professional organizations as occurred with the
first call. In addition, the second call included solicitation
for feedback from consumers via postings on the Vestibular
Disorders Association’s (VEDA) website, Facebook page,
and email blast to all VEDA members. Applicable com-
ments have been incorporated into the final version of the
guideline.
Literature Search
A systematic review of the literature was performed by the
academic librarians from East Tennessee State University
(Nakia Woodward, MSIS, AHIP; Richard Wallace, MSLS,
EdD, AHIP), Emory University (Amy Allison, MLS, AHIP),
and the University of Pittsburgh (Linda Hartman, MLS,
AHIP) in collaboration with the workgroup (CDH, SJH,
SLW). The original search included the following 4 data-
bases: PubMed, EMBASE, Web of Science, and Cochrane
Library. The subsequent search included the following 4
databases: PubMed, CINAHL, EMBASE, and Cochrane
Library. The original PICO question was framed as, “Is ex-
ercise effective at enhancing recovery of function in people
with peripheral vestibular hypofunction?” The search query
in PubMed, CINAHL, EMBASE, and Web of Science com-
bined terms from the concept sets of patient population (pe-
ripheral vestibular hypofunction), intervention (exercise),
and outcomes (based on the International Classification of
Functioning, Disability and Health model) to retrieve all ar-
ticle records that include at least 1 term from each set be-
low (Table 3). The search query for the Cochrane Library
included vertigo or vestibular and exercise.
In addition, websites of agencies and organizations that
produce guidelines and/or systematic reviews on clinical
medicine were searched for relevant publications. These in-
cluded (1) Canada, Health Evidence; (2) UK, National Insti-
tute for Clinical Excellence; (3) United States, Agency for
Healthcare Research and Quality; (4) National Guidelines
Clearinghouse; and (5) ClinicalTrials.gov. The government
agencies and websites produced only duplicates that were
removed.
The study types included were meta-analyses, systemat-
ic reviews, randomized controlled trials, cohort studies, case
control studies, and case series/studies. Inclusion criteria for
articles included human subjects, published in English, and
published after 1985. Exclusion criteria included superior
canal dehiscence, blindness, primary diagnosis of benign
paroxysmal positional vertigo, migraine, central vestibular
disorder, or central nervous system pathology (Parkinson
disease, multiple sclerosis, stroke, cerebellar ataxia).
The initial systematic search was performed in March
2013 and 1540 potential articles were identified (Figure 1A).
Identification of relevant studies involved a 3-step process:
(1) a title/abstract review during which obviously irrelevant
articles were removed; (2) a full-text article review using
the inclusion/exclusion criteria; and (3) review article refer-
ence lists searched for relevant, missed articles. After dupli-
cates were removed (n = 778), 762 article titles and abstracts
were each reviewed by 2 of the 3 members of the workgroup
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(CDH, SJH, SLW) to exclude obviously irrelevant ones. In
the case of disagreement, the third member reviewed the ar-
ticle title and abstract to arbitrate. On the basis of the title
and abstract, 13 articles were excluded because of language
(not English) and 567 were excluded because of irrelevance
to the topic; thus, 182 full-text articles were reviewed. In
addition, review article reference lists were searched for
relevant, missed articles by a graduate assistant and 13 ad-
ditional articles were identified. Each full-text article was
examined by 2 reviewers from the workgroup and Advisory
Board using the inclusion/exclusion criteria. On the basis of
the full-text article, 121 articles were identified as relevant
to the CPG.
A follow-up literature search following the same strat-
egy was performed in February of 2015, and 573 articles
were identified. After duplicates were removed (n = 34), 539
article titles and abstracts were each reviewed by 2 members
of the workgroup to exclude obviously irrelevant articles. On
the basis of the title and abstract, 16 articles were excluded
because of language (not English) and 499 were excluded
because of irrelevance to the topic; thus, 24 full-text articles
were reviewed. On the basis of the full-text article, 14 ar-
ticles were identified as relevant to the CPG.
Critical Appraisal Process
Each intervention article was critically appraised using an
electronic appraisal form based on key questions adapted
from Fetters and Tilson.1 Critical appraisal scores based on
these key questions regarding methodological rigor of the
research design, study execution, and reporting have also
been used by other groups in the development of clinical
practice guidelines.28 Levels of evidence were determined
using criteria from the Centre for Evidence-Based Medicine
for intervention studies (Table 1), with the additional criteria
that levels I and II are differentiated based on the critical
appraisal score. Level I studies received a critical appraisal
score of at least 50% and level II studies received critical ap-
praisal scores less than 50%.
Volunteers were recruited from the Neurology Sec-
tion and Vestibular Special Interest Group using an online
“Call for Volunteers” to provide critical appraisals of the
articles identified as being relevant to this clinical practice
guideline. Two face-to-face training sessions (4 hours at
the APTA Combined Section Meeting in 2013 and 2 hours
at the Combined Section Meeting in 2014) were provided
by the workgroup to the volunteers before performance of
any critical appraisals. Selected intervention articles were
critically appraised by the workgroup to establish the test
standards. Volunteers performed 2 practice critical apprais-
als and were compared with scoring of the workgroup. Vol-
unteers were considered to be qualified to review with 80%
or more agreement with the workgroup. Critical appraisals
and study characteristics extractions from each article were
performed by 2 reviewers and the information entered into
an electronic data extraction form. Discrepancies in scoring
were discussed and resolved by the 2 reviewers. In situa-
tions that a score could not be agreed upon, the disagree-
ment was resolved by consensus among the workgroup.
Diagnostic Considerations
The focus of this clinical practice guideline is on the treat-
ment of peripheral vestibular hypofunction; thus, studies
where the patient group involved primarily central involve-
ment (eg, traumatic brain injury, concussion, multiple
TABLE 3. Search Query Combined Terms From the Following
Concept Sets (Patient Population, Intervention, Outcome)
to Retrieve All Articles That Included at Least One Term
From Each Set (ie, Patient Population and Intervention and
Outcome)
Concept Sets
Patient population set
Peripheral vestibular (hypofunction or loss)
Vestibular system
Vestibular labyrinth
Vestibular nervous system
Vestibular nerve
Vestibular nucleus
Vestibulocochlear nerve
Benign paroxysmal positional
Vertigo
Inner ear
Labyrinth disease
Vestibular disease
Labyrinth vestibule
Vestibulum auris
Ear vestibule
Vestibular apparatus
Oval window and ear
Saccule and utricle
Acoustic maculae
Vestibular aqueduct
Dizziness
Intervention set
Exercise
Visual-vestibular interaction
Adaptation exercises
Substitution exercises
Habituation exercises
Outcome set
Balance
Gait
Quality of life
Position
Falls
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FIGURE 1. (A) Flowchart of initial identification of relevant articles from 1985 through March 2013. (B) Flowchart of identifi-
cation of additional relevant articles through February 2015.
PubMed n=462
Web of Science n=149
EMBASE n=830
Cochrane Library n=99
Total Citations n=1540
Title/abstract review
n = 762
Duplicates removed
n = 778
Excluded based on:
Language, n = 13
Text/abstract, n = 567
Full text review
n = 182
Articles excluded
n = 74
Articles critically appraised
n = 121
Articles identified
through other
sources
n = 13
PubMed n = 199
CINAHL n = 36
EMBASE n = 313
Cochrane Library n = 25
Total Citations n = 573
Title/abstract review
n = 539
Duplicates removed
n = 34
Excluded based on:
Language, n = 16
Text/abstract, n = 499
Full text review (includes
additional articles identified)
n = 24
Articles excluded
n = 10
Articles critically appraised
n = 14
A B
sclerosis, and Parkinson disease) were excluded. Studies in
which the patient group involved primarily benign paroxys-
mal positional vertigo were excluded, whereas studies that
included individuals with benign paroxysmal positional ver-
tigo in addition to peripheral vestibular hypofunction were
included. Specific diagnoses such as Meniere disease (for
diagnostic criteria, see Lopez-Escamez et al29) or vestibu-
lar neuritis were included, but were not part of the search
strategy because the patient population of interest was per-
sons with peripheral vestibular hypofunction regardless of
the etiology. For purposes of this guideline, acute is defined
as the first 2 weeks after the onset of symptoms, subacute as
after the first 2 weeks and up to 3 months after the onset of
symptoms, and chronic as the presence of symptoms longer
than 3 months.
Diagnostic Criteria for Vestibular Hypofunction
Diagnosis of peripheral vestibular hypofunction had to
have been confirmed with vestibular function laboratory
testing for an article to be included in this clinical prac-
tice guideline. Either caloric or rotational chair testing
was used for diagnostic purposes. Unilateral vestibular
hypofunction was determined by responses to bithermal
air or water caloric irrigations, with at least 25% reduced
vestibular responses on one side.30-32 Jongkees33 described
the formula, which is typically used to calculate right-left
asymmetry with caloric testing. Although caloric asymme-
try is abnormal in persons with unilateral loss, saccades
and smooth-pursuit eye movements are normal and there-
fore are not included in the diagnostic criteria.31 Rotational
chair data on gain, asymmetry, and phase have been used
to test the vestibulo-ocular system at higher frequencies up
to 1.0 Hz and are utilized to diagnose bilateral vestibular
hypofunction.22
Treatment Approach
The primary approach to the management of patients
with peripheral vestibular hypofunction is exercise-based.
Whereas management of the patient in the acute stage af-
ter vestibular neuritis or labyrinthitis may include medica-
tions, such as vestibular suppressants or antiemetics, the
evidence does not support medication use for management
of the chronic patient.21 A surgical or ablative approach
is limited to patients who have recurrent vertigo or fluc-
tuating vestibular function and symptoms that cannot be
controlled by other methods, such as lifestyle modifica-
tions or medication. The goal of the ablative approach is to
convert a fluctuating deficit into a stable deficit to facilitate
central vestibular compensation for unilateral vestibular
hypofunction.34
The original vestibular exercises were developed by
Cawthorne and Cooksey in the 1940s.35 Cawthorne-Cooksey
exercises are a general approach to vestibular rehabilitation
and include a standardized series of exercises that involve a
progression of eye movements only, head movements with
eyes open or closed, bending over, sit-stand, tossing a ball,
and walking.
Current vestibular rehabilitation is an exercise-based
approach that typically includes a combination of 4 differ-
ent exercise components to address the impairments and
functional limitations identified during evaluation: (1) ex-
ercises to promote gaze stability (gaze stability exercises),
(2) exercises to habituate symptoms (habituation exercises)
including optokinetic exercises, (3) exercises to improve bal-
ance and gait (balance and gait training), and (4) walking for
endurance.
Gaze stability exercises were developed on the basis
of the concepts of vestibulo-ocular reflex adaptation and
substitution (and are commonly referred to as adaptation
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TABLE 4. Components of the Brief Core Set for Vertigo, Which Is the Minimal Standard for Assessment and Description of
Functioning and Disability, Are Listed and Categorized According to the International Classification of Functioning, Disability
and Health (ICF) Modela
ICF CATEGORY DESCRIPTION
Body functions
Mental functions
b152 Emotional functions
b156 Perceptual functions
Sensory functions and pain
b210 Seeing functions
b215 Functions of structures adjoining the eye
b230 Hearing functions
b235 Vestibular functions
b240 Sensations associated with hearing and vestibular function
b260 Proprioceptive function
Neuromusculoskeletal and movement-related functions
b770 Gait pattern functions
(continues )
exercises and substitution exercises). In the vestibular lit-
erature, adaptation has referred to long-term changes in
the neuronal response to head movements with the goal of
reducing symptoms and normalizing gaze and postural sta-
bility. Gaze stability exercises based on the assumption that
they promote vestibular adaptation involve head movement
while maintaining focus on a target, which may be stationary
or moving. Gaze stability exercises based on the principles
of substitution were developed with the goal of promoting
alternative strategies (eg, smooth-pursuit eye movements or
central pre-programming of eye movements) to substitute
for missing vestibular function. For example, during active
eye-head exercise between targets, a large eye movement to a
target is made before the head moving to face the target, po-
tentially facilitating use of preprogrammed eye movements.
Both adaptation and substitution exercises are performed
with head movements in the horizontal and vertical planes.
In the vestibular literature, habituation has referred to
the reduction in a behavioral response to repeated expo-
sure to a provocative stimulus, with the goal of reducing
symptoms related to the vestibular system. Habituation
exercises are chosen on the basis of particular movements
or situations (eg, busy visual environments) that provoke
symptoms. In this approach the individual performs sev-
eral repetitions of the body or visual motions that cause
mild to moderate symptoms. Habituation involves repeated
exposure to the specific stimulus that provokes dizziness,
and this systematic repetition of provocative movements
leads to a reduction in symptoms over time. More recent
approaches involve the use of optokinetic stimuli or virtual
reality environments as habituation exercises. Optokinetic
stimuli involve the use of repetitive moving patterns and vir-
tual reality immerses patients in realistic, visually challeng-
ing environments; both are used to address visual motion
sensitivity (also known as visual vertigo, space and motion
discomfort, or visually-induced dizziness). Both approaches
use stimuli that can be graded in intensity through manipu-
lation of stimulus parameters such as velocity, direction of
stimulus motion, size/color of stimulus, and instructions to
the participant. The stimulus may be provided via high-tech
equipment, such as optokinetic discs, moving rooms or vir-
tual reality, or lower tech equipment, such as busy screen
savers on a computer or videos of busy visual environments.
Balance and gait training under challenging sensory and
dynamic conditions is typically included as part of vestibular
rehabilitation. These exercises are intended to facilitate use
of visual and/or somatosensory cues to substitute for miss-
ing vestibular function. Balance exercises include balancing
under conditions of altered visual (eg, vision distracted or
removed) and/or somatosensory input (eg, foam or moving
surfaces) and may involve changes in the base of support
(eg, Romberg, tandem, single-leg stance) to increase the
challenge. Weight shifting in stance is used to improve cen-
ter of gravity control and balance recovery. Gait exercises
involve dynamic conditions and may include walking with
head turns or performing a secondary task while walking.
Equipment is available that can augment balance and gait
training such as gaming technology, optokinetic drums, and
virtual reality systems.
General conditioning, such as walking for endurance or
aerobic exercise, is frequently an element of rehabilitation
because people with peripheral vestibular dysfunction often
limit physical activity to avoid symptom provocation. Gen-
eral conditioning exercise (eg, stationary bicycle) by itself
has not been found to be beneficial in patients with vestibu-
lar hypofunction.21,22
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TABLE 4. Components of the Brief Core Set for Vertigo, Which Is the Minimal Standard for Assessment and Description of
Functioning and Disability, Are Listed and Categorized According to the International Classification of Functioning, Disability
and Health (ICF) Modela (Continued )
ICF CATEGORY DESCRIPTION
Body Structure
Nervous system
s110 Structure of brain
s120 Spinal cord and related structures
The eye, ear, and related structures
s260 Structure of inner ear
Structures of the cardiovascular, immunological, and respiratory systems
s410 Structure of cardiovascular system
Activities and Participation
General tasks and demands
d230 Carrying out daily routine
Mobility
d410 Changing the basic body position
d415 Maintaining a body position
d450 Walking
d455 Moving around
d460 Moving around in different locations
d469 Walking and moving, other specified and unspecified
d475 Driving
Domestic life
d640 Doing housework
Environmental Factors
Products and technology
e110 Products or substances for personal consumption
e120 Products and technology for personal indoor and outdoor mobility and
transportation
Natural environment and human-made changes to environment
e240 Light
Support and relationships
e310 Immediate family
e355 Health professionals
Services, systems, and policies
e580 Health services, systems, and policies
Abbreviation: ICF, International Classification of Functioning, Disability and Health.
aCategories are denoted as follows: b for body functions, s for body structures, d for activities and participation, and e for environmental factors. The numbers refer to
the World Health Organization’s coding system for the specific domains.
Adapted from Grill et al36 with permission from IOS Press.
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Outcome Measures
A variety of outcome measures have been utilized to assess
the impact of vestibular dysfunction; however, there is no
consensus as to what aspects of function should be mea-
sured. An international group of investigators and health
care providers developed a core set of key aspects of func-
tioning that should be measured in the assessment of pa-
tients with vertigo, dizziness, and imbalance.36 The Brief
Core Set is a short list of categories and is the minimal
standard for assessment and description of functioning and
disability. As such, there may be aspects of functioning that
are relevant to a specific individual but are not included in
the Brief Core Set. The Brief Core Set for vertigo includes
both subjective complaints and physical function and has
been organized on the basis of the International Classifi-
cation of Functioning, Disability and Health (ICF) model
(Table 4). The specific domains of the ICF model include
(1) body function and structure (body level); (2) activity
(individual level); and (3) participation (societal level). In
addition, the ICF model considers personal and environ-
mental contributions.
Recommendations for specific rehabilitation outcome
measures to be used in the assessment of individuals with
vestibular dysfunction have been made by the Vestibular
Evidence Database to Guide Effectiveness task force. They
used a modified Delphi process to identify and select rec-
ommended measures. The vestibular outcome measure rec-
ommendations are available online at http://www.neuropt.
org/professional-resources/neurology-section-outcome-
measures-recommendations/vestibular-disorders. We pro-
vide a summary of recommended measures categorized
according to the ICF model (Table 5).
TABLE 5. Summary of Outcome Measures Recommended for Use by the Vestibular Evidence Database to Guide Effectiveness
Task Force to Assess Patients With Vestibular Hypofunctiona
ICF LEVEL MEASURE WHAT IT MEASURES
Body structure/
function
Dynamic Visual Acuity Visual acuity during fixed head movement velocity with decreasing
optotype size
Gaze Stabilization Test Visual acuity during increasing head movement velocity with fixed
optotype size
Sharpened Romberg Static stance with altered base of support (tandem)
Sensory Organization Test Computerized assessment of postural control by measuring sway under
conditions in which visual/somatosensory feedback is altered
Sensory Organization Test
With Head Shake
Postural stability during head rotations compared to head still
(Modified) Clinical Test
of Sensory Interaction on
Balance
Postural control under various sensory conditions, including eyes open
and closed and firm and foam surfaces
Visual Analog Scale Symptoms are quantified on a 10-cm line corresponding to intensity
Visual Vertigo Analog Scale Intensity of visual vertigo in 9 challenging situations of visual motions
using Visual Analog Scale
Motion Sensitivity Quotient Motion-provoked dizziness during a series of 16 quick changes to head
or body positions
Vertigo Symptoms Scale Symptoms of balance disorder and somatic anxiety and autonomic
arousal
Activity/participation Five Times Sit to Stand Functional lower extremity strength with published norms in older
adults
30-Second Chair Stand Functional lower extremity strength with published norms in older
adults
Functional Reach/Modified
Functional Reach
Stability of the maximum forward reaching distance while standing in a
fixed position. The modified version is performed sitting
Gait Velocity (10-m Walk
Test)
Walking at preferred speed
Balance Evaluation Systems
Test
Six different balance control systems
Mini Balance Evaluation
Systems Test
Shortened version of the Balance Evaluation Systems Test
Berg Balance Scale 14-item measure of static balance and fall risk during common activities
(continues )
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TABLE 5. Summary of Outcome Measures Recommended for Use by the Vestibular Evidence Database to Guide Effectiveness
Task Force to Assess Patients With Vestibular Hypofunctiona (Continued )
ICF LEVEL MEASURE WHAT IT MEASURES
Dynamic Gait Index Postural stability during various walking tasks including change speed,
turn head, walk over/around obstacles, and climb stairs
Functional Gait Assessment Postural stability during various walking tasks including tandem,
backwards, and eyes closed
Four-Square Step Test Ability to step over objects forward, sideways, and backwards
Unipedal Stance Test Static stance on 1 leg
Timed Up and Go Mobility and fall risk
Modified Timed Up and Go
With Dual-Task
Mobility under dual-task conditions and fall risk
Activities-Specific Balance
Confidence Scale
Confidence in balance without falling or being unsteady across a
continuum of activities
Disability Rating Scale Level of disability based on descriptions of symptoms and limited
activities
Dizziness Handicap
Inventory
Perceived handicap as a result of dizziness
UCLA Dizziness
Questionnaire
Severity, frequency, and fear of dizziness and its effect on quality of life
and activities of daily living
Vertigo Handicap
Questionnaire
Effects of vertigo on disability, handicap, and psychological distress
Vestibular Activities and
Participation
Effects of dizziness and/or balance problems on ability to perform
activity and participation tasks
Vestibular Disorders
Activities of Daily Living
Scale
Independence in everyday activities of daily living
Vestibular Rehabilitation
Benefit Questionnaire
Impact of symptoms on quality of life
Abbreviation: ICF, International Classification of Functioning, Disability and Health.
aThe measures are organized on the basis of the ICF model. Details regarding recommendations are available online at http://www.neuropt.org/professional-resources/
neurology-section-outcome-measures-recommendations/vestibular-disorders.
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ACTION STATEMENTS AND RESEARCH RECOMMENDATIONS
Here, we present each action statement followed by a stan-
dardized information profile and then the supporting evi-
dence for the statement. Recommendations for research are
also included.
A. Action Statement 1: EFFECTIVENESS OF VES-
TIBULAR REHABILITATION IN PERSONS WITH
ACUTE AND SUBACUTE UNILATERAL VESTIBU-
LAR HYPOFUNCTION. Clinicians should offer vestibu-
lar rehabilitation to patients with acute or subacute unilateral
vestibular hypofunction. (Evidence quality: I; recommenda-
tion strength: strong)
Action Statement Profile
Aggregate evidence quality: Level I. Based on 5 level
I randomized controlled trials and 4 level II random-
ized controlled trials.
Benefits: Improved outcomes in patients receiving
vestibular rehabilitation when compared with controls
given either no exercise or sham exercises.
Risk, harm, and cost:
• Increasedcostandtimespenttravelingassociatedwith
supervised vestibular rehabilitation.
• Increase in symptom intensity at the onset of treat-
ment.
Benefit-harm assessment:
• Preponderanceofbenet.
Value judgments:
• Early initiation of vestibular rehabilitation ensures
shorter episodes of care, higher levels of recovery of
balance function, reduced symptom complaints, im-
proved functional recovery to activities of daily living,
reduced fall risk, and improved quality of life.
Role of patient preferences:
• Costandavailabilityofpatienttimeandtransportation
may play a role.
Exclusions:
• Individualswhohavealreadycompensatedsufciently
to the vestibular loss and no longer experience symp-
toms or gait and balance impairments do not need for-
mal vestibular rehabilitation. For example, people who
resume their customary sporting or physical activities
may compensate quickly so that they do not need ves-
tibular rehabilitation and when evaluated by a physical
therapist have normal test results.
• Possible exclusions also include active Meniere dis-
ease or those with impairment of cognitive or general
mobility function that precludes adequate learning and
carryover or otherwise impedes meaningful applica-
tion of therapy.
Supporting Evidence and Clinical Interpretation
Acute unilateral vestibular hypofunction is the most com-
mon cause of acute spontaneous vertigo.37,38 Acute unilateral
vestibular hypofunction is most commonly due to vestibular
neuritis but may also be due to trauma, surgical transection,
ototoxic medication, Meniere disease, or other lesions of the
vestibulocochlear nerve or labyrinth. The acute asymmetry
results in imbalance in vestibular tone that manifests with
vertigo, nausea, and unsteadiness of gait as well as spon-
taneous nystagmus with the fast component beating away
from the dysfunctional ear. Although nystagmus and vertigo
usually subside within hours to 14 days, imbalance and the
sensation of dizziness, especially during head movement
may persist for many months, or longer, resulting in a more
chronic syndrome. Vestibular exercises have been used in
recent years as a means of aiding patients to make a more
speedy and thorough recovery.
Strong evidence indicates that vestibular rehabilitation
provides clear and substantial benefit to patients with acute
or subacute unilateral vestibular hypofunction, so, with the
exception of extenuating circumstances, vestibular reha-
bilitation should be offered to patients who are still expe-
riencing symptoms (eg, dizziness, dysequilibrium, motion
sensitivity, and oscillopsia) or imbalance due to unilateral
vestibular hypofunction. Two level I studies examined the
effects of vestibular rehabilitation solely within the acute/
subacute stage after resection of vestibular schwannoma. In
the first level I study, patients scheduled for resection were
randomly assigned to an exercise group (vestibular, n = 11,
or control, n = 8).18 Exercises were started 3 days after re-
section of the vestibular schwannomas and continued until
the patients were discharged from the hospital (average =
postoperative day 6). The vestibular group performed gaze
stabilization exercises for 1 minute each 5 times per day for
a maximum of 10 to 20 minutes per day. The control group
performed vertical and horizontal smooth-pursuit eye move-
ments against a featureless background on the same sched-
ule. Patients in both groups walked at least once each day.
The vestibular group was older (mean age 59 years vs 48
years in controls, (P < 0.04), but otherwise the groups were
similar. Both groups reported significantly more dizziness
after surgery than before (P < 0.05) and had more postural
sway on postoperative day 3 than preoperatively (P < 0.05).
By days 5 and 6, the vestibular group reported less subjec-
tive disequilibrium compared with the control group (P <
0.05). Some posturographic measures improved more in the
vestibular group compared with the control group on post-
operative day 6, and more patients in the vestibular group
were able to walk with head turns without staggering than in
the control group. This study has several limitations: (1) no
allocation concealment, (2) a relatively small number of sub-
jects, and (3) it was assumed that patients developed acute
unilateral vestibular hypofunction from surgery but this is
not known. Some of the patients may have had a progressive
loss of vestibular function over the years, with the growth of
the tumor, and had adapted, and as such did not experience
an acute loss postoperatively.
The second study examined the effectiveness of gaze
stabilization exercises started after vestibular schwan-
noma surgery to reduce patients’ perception of dizziness/
imbalance.16 In this level I study, subjects were randomized
into a vestibular exercise group who performed gaze stabil-
ity and balance exercises (n = 30) or a control group who did
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not perform any exercises (n = 27). Patients were assigned
to a group on the basis of a sequentially randomized design
(the first part of the study was the control group, and the
second part of the study was the vestibular exercise group).
Patients in the vestibular exercise group performed gaze sta-
bilization exercises starting on the third postoperative day.
Each exercise was performed for 1 minute, 4 or 5 times each
day. The exercises were initially performed while lying down
or seated and were then performed while standing. Patients
were reassessed for the first time at 2 to 3 weeks after sur-
gery. The main finding was that there was less dizziness in
the vestibular exercise group, based on the scores of the Diz-
ziness Handicap Inventory, compared with the control group
at 2 to 3 weeks, 6 to 7 weeks, and 10 to 12 weeks postop-
eratively. Secondary findings showed no difference between
groups in spontaneous nystagmus, subjective complaints of
vertigo, and vestibular asymmetry when measured over the
12-week course of the study.
Mruzek et al39 found that a course of vestibular exercises
after unilateral vestibular ablation in patients with vestibular
schwannoma or Meniere disease was beneficial in reducing
symptom intensity and disability compared with a control
group. In this level I study, they examined patients at post-
operative day 5 and then 2, 5, and 7 weeks after surgery.
Subjects were randomized into 3 groups: (1) vestibular exer-
cises + social reinforcement, (2) vestibular exercises alone,
and (3) a control group who performed range of motion
exercises + social reinforcement. All interventions lasted
8 weeks. Vestibular exercises were initiated on postopera-
tive day 5 and consisted of habituation exercises, based on
the results of the Motion Sensitivity Test and Cawthorne-
Cooksey exercises. The control group performed range of
motion exercises. Social reinforcement consisted of periodic
phone calls to urge adherence and encourage and praise the
patients. They found that all patients improved in the Mo-
tion Sensitivity Test, computerized dynamic posturography,
and Dizziness Handicap Inventory scores, but the patients
who performed the vestibular exercises had significantly less
motion sensitivity (groups 1 and 2) and had better (lower)
scores on the physical subscale of the Dizziness Handicap
Inventory (group 1) at 8 weeks after surgery than the control
group (group 3).
Another study also started vestibular exercises in pa-
tients after vestibular schwannoma surgery 3 to 5 days
postoperatively.40 In this level I study, patients were random-
ized (with allocation concealment) to 12 weeks of vestibu-
lar exercises (n = 16 younger, n = 15 older defined as older
than 50 years) or to a control group (n = 11 younger, n =
11 older). There were no differences in tumor sizes or mean
caloric asymmetry between the groups preoperatively. Ves-
tibular exercises included supervised gaze stabilization ex-
ercises, walking, narrow-based walking with head turning,
and treadmill training for a total of 4 sessions with a home
exercise program 3 times per day. The control group was told
to walk, read, and watch TV while in the hospital and then
told to gradually increase their activity level once at home.
There were no differences in balance measures between
groups during the acute/subacute phase except for tandem
gait, which was better in the vestibular exercise group.
However, when only older subjects were considered, static
balance, Timed Up and Go, and tandem gait were better in
those who received vestibular exercises than in controls (P <
0.05). At 9 to 12 weeks, older subjects who received vestibu-
lar exercises were better on static balance, Timed Up and Go,
tandem walk and the Dynamic Gait Index. This study found
essentially no benefit in vestibular exercises compared with
general instructions in those younger than 50 years. This
study’s limitations include a minimal period of supervised
vestibular exercises (4 supervised sessions over 12 weeks).
In the final level I study, comparisons were made be-
tween patients with acute unilateral vestibular hypofunction
treated with a course of Nintendo Wii Fit Balance Board
balance exercises (n = 37) and a control group (n = 34).41
They examined patients on the second day after admission
for vestibular neuritis and then randomly assigned the pa-
tients to the groups. The Wii exercise group performed
a customized program of 5 to 6 exercises for a total of 45
minutes. The program consisted of 10 training sessions,
partitioned in 2 daily sessions for 5 consecutive days. The
control group performed only 1 session consisting of 2 ex-
ercises (the “1-leg figure” and the vendor-specific training
test to calculate the “virtual fitness age”) for a total time of
5 minutes. Patients were reassessed on day 5 of treatment
and after 10 weeks. Outcome measure included performance
on 16 different exercises performed by the Wii group dur-
ing the 5 days of the study, Sensory Organization Test, the
Dizziness Handicap Inventory, Vertigo Symptom Scale, and
the Falls Efficacy Scale. There were no differences in age,
sex, or symptom duration between groups. Results showed
that patients in the control group required 2.4 days (standard
deviation = 0.4) longer hospitalization on average than pa-
tients after early rehabilitation with the Wii balance board.
In addition, an absence of nystagmus was observed 2.1 days
(standard deviation = 0.5) earlier in the exercise group than
in the control group. At both day 5 and 10 weeks after exer-
cise, the exercise group showed significantly better results in
the Sensory Organization Test, Dizziness Handicap Inven-
tory, Vertigo Symptom Scale, and Falls Efficacy Scale than
the control group (P < 0.05). The authors concluded that the
early use of a visual feedback system (Nintendo Wii Balance
Board) for balance training facilitated recovery of balance
and symptoms in patients with acute unilateral vestibular hy-
pofunction. Although this study received a level I rating us-
ing our criteria, there are several limitations that temper this
rating: (1) use of the same exercises performed by the exer-
cise group as an outcome measure; (2) although the authors
conclude that the Vertigo Symptom Scale improved only in
the exercise group, they provided no data to support this; (3)
a level of significance of alpha less than 0.05 was set, but
no adjustment was made for multiple comparisons, so the
potential for type I error is greater; (4) they do not account
for all the subjects recruited or enrolled in the study.
Several level II studies also support the use of vestibular
exercises in the treatment of patients with acute or subacute
unilateral vestibular hypofunction. Strupp et al42 conducted a
randomized controlled trial in which patients were random-
ized to a vestibular (n = 19) or a control group (n = 20).
The control group was given no particular exercises; how-
ever, both groups were encouraged to engage in regular daily
activities, such as walking to the bathroom and sitting up
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for meals. The vestibular group performed gaze stabilization
exercises as well as static and dynamic balance exercises,
which included head movement. The primary outcome was
postural stability with eyes closed on foam as measured by
sway path velocity. In general, both groups improved in pos-
tural stability across time; however, at the assessment 30 days
after symptom onset, the vestibular group was significantly
more stable compared with the control group (P < 0.001).
They found no differences between groups in the recovery
of signs and symptoms related to the tonic vestibular system
(eg, ocular torsion and subjective visual vertical). This study
shows that vestibular exercises administered early after onset
of unilateral vestibular hypofunction result in improvement in
sway and balance by day 30 after onset but that, as expected,
problems that affect the tonic vestibular system recover with
or without vestibular exercises.
A second level II study assessed 87 patients with at
least 1 vertigo spell and 2 abnormal tests (Romberg, Fukuda
Stepping Test, head shaking nystagmus, or spontaneous nys-
tagmus) within 5 days of study enrollment.43 They excluded
those with vestibular symptoms in the prior 6 months or
those with benign paroxysmal positional vertigo. Patients
were randomized and blinded to group: the vestibular group
(n = 45) was given supervised gaze stability exercises per-
formed with horizontal and vertical head movements for 1
minute 3 times per day for 21 days. The control group (n =
42) did gaze fixation without head movement while blinking
their eyes 3 times per day for 21 days. By 10 days, the ves-
tibular group showed significant improvement in Romberg,
Fukuda Stepping Test, spontaneous nystagmus, and post
head-shaking-induced nystagmus compared with the con-
trol group. Most patients in the vestibular group improved
in the timeframe of 3 to 10 days compared with controls,
but by 3 weeks the differences between the groups began
to diminish.
A level II study by Marioni et al44 enrolled 30 patients
starting 2 weeks after acute unilateral vestibular hypofunc-
tion: patients were randomized (no mention of allocation
concealment) to posturography-assisted vestibular exercises
+ a home exercise program (n = 15) or to a control group
(n = 15) that did no particular exercises. The vestibular group
performed supervised vestibular exercises during 30-minute
sessions once a week plus a home exercise program three
times per day for 5 weeks. The vestibular group improved in
static balance with eyes open on foam (P = 0.02) and eyes
closed on foam conditions (P = 0.00004), whereas the con-
trol group only improved with eyes closed on foam condi-
tions (P = 0.03). At 6 weeks, sway velocity with eyes open
on foam (P = 0.03) and eyes closed on foam conditions
(P = 0.000001) was better in treated than untreated subjects.
This study demonstrates improvement in computerized pos-
turography measures such as postural sway velocity when
vestibular exercises are administered starting 2 weeks after a
significant (defined as >50% asymmetry) unilateral vestibu-
lar hypofunction.
A level II study by Teggi et al45 examined the effect of
vestibular exercises on patients hospitalized with acute ves-
tibular neuritis. Patients were randomly assigned to either a
vestibular or control group. The vestibular group (n = 20)
underwent a total of 10 sessions of rehabilitation consisting
of balance exercises on a force platform using both visual
feedback and an optokinetic stimulus. They also performed
gaze stability exercises and a subset of Cawthorne-
Cooksey exercises. The control group was told only to “per-
form their daily activities.” Outcome measures included a
sway path analysis of stance with eyes open and eyes closed,
Dynamic Gait Index, Dizziness Handicap Inventory, and
a Visual Analog Scale for anxiety, at baseline, and after
25 days. There was a significant difference in the Dizziness
Handicap Inventory total scores (P < 0.002) and anxiety
scores (P < 0.001) between the 2 groups, with the vestibular
group showing more improvement than the control group;
there was no significant difference in the Dynamic Gait In-
dex scores between the groups.
Three level III retrospective studies introduced a new
concept of rehabilitation for patients scheduled for vestibu-
lar ablation, either for vestibular schwannoma or Meniere
disease.46-48 These studies advocate for treating the patients
with a combination of intratympanic gentamicin to induce
further loss of vestibular function and vestibular exercises to
induce vestibular compensation before surgery. They report
that patients undergoing this “pre-hab” had faster recovery
of symptoms and balance after surgery. Further research is
needed, however, to determine whether there is a significant
difference in the rate and level of recovery with pre-hab
compared with a control group who receives only postopera-
tive rehabilitation.
R. Research Recommendation 1: Researchers should ex-
amine the concept of a critical period for optimal vestibular
compensation through studies that examine early versus de-
layed intervention. Researchers should identify factors that
predict which patients will recover without the benefit of
vestibular rehabilitation and which patients will need ves-
tibular rehabilitation to optimize outcomes.
A. Action Statement 2: EFFECTIVENESS OF VES-
TIBULAR REHABILITATION IN PERSONS WITH
CHRONIC UNILATERAL VESTIBULAR HYPO-
FUNCTION. Clinicians should offer vestibular rehabili-
tation to patients with chronic unilateral vestibular hypo-
function. (Evidence quality: I; recommendation strength:
strong)
Action Statement Profile
Aggregate evidence quality: Level I. Based on 3
level I and 1 level II randomized controlled trials.
Benefits: Improved outcomes in patients receiving
vestibular rehabilitation when compared with controls
given either no exercise or sham exercises.
Risk, harm, and cost:
• Increasedcostandtimespenttravelingassociatedwith
supervised vestibular rehabilitation.
Benefit-harm assessment:
• Preponderanceofbenet.
Value judgments:
• Importanceofoptimizingandacceleratingrecoveryof
balance function and decreasing distress, improving
functional recovery to activities of daily living, and re-
ducing fall risk.
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Role of patient preferences:
• Costandavailabilityofpatienttimeandtransportation
may play a role.
Exclusions:
• Individualswhohavealreadycompensatedsufciently
to their vestibular loss and no longer experience symp-
toms or gait and balance impairments do not need for-
mal vestibular rehabilitation.
• Possibleadditional exclusionsinclude activeMeniere
disease or those with impairment of cognitive or gen-
eral mobility function that precludes adequate learning
and carryover or otherwise impedes meaningful appli-
cation of therapy.
Supporting Evidence and Clinical Interpretation
Strong evidence indicates that vestibular rehabilitation pro-
vides clear and substantial benefit to patients with chronic
unilateral vestibular hypofunction. Therefore, with the ex-
ception of extenuating circumstances, vestibular rehabilita-
tion should be offered to patients who are still experiencing
symptoms (eg, dizziness, dysequilibrium, motion sensitivity,
and oscillopsia) or imbalance because of unilateral vestibu-
lar hypofunction.
A level I randomized controlled trial studied 21 pa-
tients with chronic unilateral vestibular hypofunction (based
on caloric testing) of 2 weeks to 3 years of duration who
also had impairment of Dynamic Visual Acuity as well as a
measure of severity of oscillopsia (Visual Analog Scale).19
Patients were randomized to vestibular (n = 13) versus pla-
cebo exercises (n = 8). The vestibular exercises included
adaptation and substitution exercises to improve gaze sta-
bility, whereas the placebo exercises involved saccadic eye
movements against a Ganzfeld (a large featureless surface)
with head stationary. Vestibular and placebo exercises were
performed 4 to 5 times per day for 20 to 30 minutes plus
20 minutes of balance and gait exercises daily with individ-
ual programs adjusted as needed. Patients were seen once a
week in the clinic for 4 weeks and adherence was monitored.
The vestibular exercise group showed improvement in Dy-
namic Visual Acuity (P < 0.001) with 12 of the 13 returned
to normal, whereas no change in Dynamic Visual Acuity was
seen in the control group and no control subject returned to
normal. Thus, vestibular exercises facilitate recovery of gaze
stability as measured by Dynamic Visual Acuity. There was
no indication of failure to improve on the basis of age, and
improvement was seen even if exercises were administered
12 months after symptom onset. Improvement in Dynamic
Visual Acuity did not correlate with improvement in oscil-
lopsia measured by the Visual Analog Scale.
In a level I randomized controlled trial, Loader et al49
studied 24 patients with chronic unilateral vestibular hypo-
function who were randomly assigned to either a treatment
group (n = 12, exposure to optokinetic stimuli while stand-
ing) or a control group (n = 12, no treatment). The outcome
consisted of a measure of postural stability in stance (Sen-
sory Organization Test). The treatment group was required
to read randomly presented texts while standing. Patients
attended 10 treatment sessions over a 3-week period, with
each session lasting approximately 30 minutes. The control
group only had their balance tested before and after a 3-week
period. Neither group performed a home exercise program.
There were no differences between groups before the initia-
tion of treatment, but after the 3-week intervention period,
the treatment group had significantly better postural stabil-
ity. Two limitations of the study are that there is a difference
in how the 2 groups were treated (the control group having
limited contact with the therapists) and that the treatment
group practiced standing balance, which is closely related
to the outcome measure, whereas the control group did not.
In another level I randomized controlled trial study, Gi-
ray et al50 examined 41 patients with chronic vestibular dys-
function treated with vestibular rehabilitation for 4 weeks (n
= 20) versus a no-treatment control group (n = 21). Interest-
ingly, the ratio of male to female was 11:2. They specifically
excluded patients with benign paroxysmal positional vertigo
and Meniere disease or any orthopedic or neurological co-
morbid condition that would confound recovery. All partici-
pants had chronic uncompensated unilateral vestibular hy-
pofunction based on caloric testing. No mention was made
of allocation concealment in the randomization process.
Patients were seen in the clinic twice per week for 4 weeks
for 30 to 45 minutes and monitored for adherence. Between
supervised sessions, patients did a twice-daily home exer-
cise program for a total of 30 to 40 minutes per day. The
home exercise program included a combination of adapta-
tion (without and with target moving in pitch and yaw planes
for 1 minute each for 3 times per day), substitution, habitu-
ation, and balance exercises. The vestibular rehabilitation
group made improvements from pre and posttreatment in all
measures, including disequilibrium on the basis of the Visu-
al Analog Scale (P < 0.003), Dizziness Handicap Inventory
(P < 0.001), Berg Balance Scale (P < 0.013), and Modified
Clinical Test for Sensory Interaction on Balance (P < 0.004),
whereas the control group did not change in any of the mea-
sures. Furthermore, there were significant differences (P <
0.05) in change scores of all measures for the vestibular re-
habilitation group compared with the control group.
Enticott et al16 reported, in their level II study, that on av-
erage, all subjects significantly improved pre- to posttherapy
for the Dizziness Handicap Inventory and Activities-Specific
Confidence Scale (P < 0.05). However, the experimental
group (vestibular exercises) improved to a greater extent
than the control group (strength and endurance exercises)
on the Dizziness Handicap Inventory and Activities-Specific
Balance Confidence (P < 0.05). On average, all subjects
significantly improved pre- to posttherapy for tandem walk,
step test, tandem stance, and single-leg stance test (P < 0.05).
The experimental group improved to a greater extent than
the control group on the tandem walk, step tests, and pos-
turography on foam and eyes closed conditions (P < 0.05).
Limitations of the study include no blinding and that some
patients had other vestibular disorders in addition to unilat-
eral vestibular hypofunction. Nine subjects had vestibular
migraine. Three subjects had benign paroxysmal positional
vertigo, which initially had not resolved, but had resolved by
the end of the study.
Finally, although not a traditional randomized con-
trolled trial, Shepard and Telian51 provide support specifi-
cally for the use of habituation exercises. In this level III
study of patients with chronic vestibular deficits, Shepard
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and Telian compared the efficacy of customized vestibular
exercise programs with a more generic exercise program
using a delayed treatment paradigm. Subjects first were as-
sessed to establish a baseline and identify specific deficits-
related motion-provoked symptoms or balance and gait
impairments and then re-assessed at 1 month before initiat-
ing any exercises. This delayed treatment model served as
a control for spontaneous recovery. Subjects who had not
shown spontaneous recovery were then stratified by age and
by pretreatment disability to receive a customized or generic
exercise program. The customized program included habitu-
ation exercises for motion-provoked or positional sensitivity
and balance and gait retraining. The generic exercise pro-
gram consisted of 1 active head movement, a Dix-Hallpike
movement with head in neutral position, 1 balance exercise
and graded walking. After 3 months of therapy, only the ves-
tibular rehabilitation group showed a significant reduction in
dizziness during routine daily activities. The vestibular reha-
bilitation group also showed a significant improvement on
both static and dynamic posturography, a reduction in mo-
tion sensitivity, and a decrease in asymmetry of vestibular
function. The generic exercise group improved only in their
performance of static balance tests.
Several other treatment modalities have been explored as
possible interventions for patients with unilateral vestibular
hypofunction. In a level III study, Verdecchia et al52 present
the results from a cohort of 69 patients with chronic unilater-
al vestibular hypofunction. All patients performed a vestibu-
lar rehabilitation program of gaze stability, balance, and gait
exercises to which the complementary use of video game
equipment (Wii) was added. Outcome measures included the
perception of handicap, fall risk, and gaze stability (clini-
cal Dynamic Visual Acuity). As a group, patients improved
significantly in all measures (P < 0.0001). Aquatic physio-
therapy may also be beneficial for people with chronic uni-
lateral vestibular hypofunction.53 In one study, patients per-
formed 10 sessions of aquatic physiotherapy consisting of
eye, head, and body movements that stimulate the vestibular
system and other systems involved in body balance, which
frequently generate dizziness in patients with unilateral ves-
tibular hypofunction. As a group, patients had lower Brazil-
ian Dizziness Handicap Inventory total scores, lower inten-
sity of dizziness, and better postural stability after aquatic
physiotherapy. They found no association between age, time
since symptom onset, and use of antivertigo medication with
rehabilitation outcomes.
A. Action Statement 3: EFFECTIVENESS OF VES-
TIBULAR REHABILITATION IN PERSONS WITH
BILATERAL VESTIBULAR HYPOFUNCTION. Clini-
cians should offer vestibular rehabilitation to patients with
bilateral vestibular hypofunction. (Evidence quality: I; rec-
ommendation strength: strong)
Action Statement Profile
Aggregate evidence quality: Level I. Based on 4 level
I randomized controlled trials.
Benefits: Improved function and decreased symptoms
in patients receiving vestibular rehabilitation when
compared with controls given sham exercises.
Risk, harm, and cost:
• Increasedsymptomintensityandimbalancewhenper-
forming the exercises.
• Increasedcostandtimespenttravelingassociatedwith
supervised vestibular rehabilitation.
Benefit-harm assessment:
• Preponderanceofbenet.
Value judgments:
• Benetofgazestabilityand balance exercises inpa-
tients with bilateral vestibular hypofunction has been
demonstrated in level I studies. However, the number
of subjects in these studies was small (with the excep-
tion of one study) and the outcome measures utilized
were variable.
Role of patient preferences:
• Costandavailabilityofpatienttimeandtransportation
may play a role.
Exclusions:
• Possible exclusions include impairment of cognitive
or general mobility function that precludes adequate
learning and carryover or otherwise impedes meaning-
ful application of therapy.
Supporting Evidence and Clinical Interpretation
Strong evidence indicates that vestibular rehabilitation pro-
vides clear and substantial benefit to patients with bilateral
vestibular hypofunction, so with the exception of extenuat-
ing circumstances vestibular rehabilitation should be offered
to patients who are still experiencing symptoms (eg, dizzi-
ness, dysequilibrium, and oscillopsia) or imbalance because
of bilateral vestibular hypofunction. Four level I, random-
ized controlled trials assessed the effectiveness of vestibular
exercises in individuals with bilateral vestibular hypofunc-
tion. Herdman et al20 examined the influence of gaze stabil-
ity exercises (a combination of adaptation and substitution
exercises) as compared with a vestibular-neutral placebo
treatment (saccadic eye movements without head movement
against a Ganzfeld) on Dynamic Visual Acuity in 13 patients
with bilateral vestibular hypofunction. All participants were
seen weekly in the clinic by a physical therapist and were
instructed to perform the home exercise program of eye ex-
ercises (either gaze stability or saccadic eye movements) 4
to 5 times per day for a total of 20 to 40 minutes. All par-
ticipants performed balance and gait exercises as part of a
home exercise program for 20 minutes per day. As a group,
the individuals performing the gaze stability exercises dem-
onstrated an improvement in their Dynamic Visual Acuity as
compared with the placebo group.
A level I study by Krebs et al22 examined 8 individuals
with bilateral vestibular hypofunction who performed either
an exercise program consisting of gaze stability exercises
and balance and gait activities or a placebo exercise program.
The vestibular exercises involved a staged progression of
gaze stability, balance, and gait exercises (eg, phase I—gaze
stability with fixed target and slow head movement; phase
II—gaze stability with fixed target and fast head movement;
phase III—gaze stability with moving target and fast head
movement). Participants were seen for weekly outpatient
physical therapy visits and were instructed to perform the
home exercise program 1 to 2 times per day for 8 weeks.
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The group performing the vestibular exercises demonstrated
increased gait speed and postural stability, as compared
with those who performed a placebo exercise program of
progressive isometric exercises. Both groups demonstrated
improvements in Dizziness Handicap Inventory scores; how-
ever, there were no differences between the experimental and
control groups in improvement in perceived disability.
There is one additional level I randomized controlled tri-
al that included a significant proportion of individuals with
bilateral vestibular hypofunction (53 of the 86) who com-
pleted 12 weeks of vestibular rehabilitation.54 On the basis of
improved gait biomechanics (preferred gait speed, decreased
double support time, and decreased vertical center of mass
excursion), Krebs and colleagues determined that patients
with vestibular hypofunction benefitted from vestibular re-
habilitation as compared with a placebo control group. As
described previously, vestibular rehabilitation included a
staged progression of gaze stability, balance, and gait re-
training exercises.22 Participants were seen for 6 weeks of
supervised visits and were instructed to perform a home ex-
ercise program at least once per day and 5 times per week for
an additional 6 weeks. Patients with unilateral and bilateral
vestibular hypofunction benefitted equally from vestibular
rehabilitation. Although the unilateral vestibular hypofunc-
tion group had more stable and faster gait characteristics at
baseline than the bilateral vestibular hypofunction group,
both groups’ gait characteristics improved significantly with
rehabilitation.54
Rine et al55 used a similar intervention approach as that
described by Krebs and colleagues22 but modified it for chil-
dren’s motor abilities, attention span, and motivational fac-
tors. The investigators reported a significant improvement in
motor development scores and a trend toward improvement
in sensory organization test scores in the treatment group
as compared with the placebo group. This study by Rine
and colleagues is the only experimental study in children in
which vestibular dysfunction was confirmed by laboratory
tests. The results suggest that children with bilateral periph-
eral vestibular dysfunction respond similarly to adults to
vestibular rehabilitation, although more research is needed.
The difference in vestibular rehabilitation provided to the
children was that it was delivered in the form of games to
engage the children. Together, these level I studies provide
strong support for the use of vestibular rehabilitation in pa-
tients with bilateral vestibular hypofunction to improve gaze
and postural stability.
There are 5 level III and IV studies that have examined
change with vestibular rehabilitation using a variety of out-
comes.56-60 Patten et al56 (level III) found that individuals with
bilateral vestibular hypofunction improved in coordinated
head-trunk control after vestibular rehabilitation although
no change in preferred gait speed was noted. Gillespie and
Minor57 (level III), using retrospective chart review, identi-
fied 35 patients with confirmed bilateral vestibular hypo-
function on the basis of clinical, caloric, and rotary chair
testing. The majority of patients (32 of the 35) underwent
vestibular rehabilitation that included gaze stability exercis-
es (adaptation and substitution) as well as gait and balance
exercises. Patients were instructed to perform gaze stabil-
ity exercises at least 3 times per day. Outcome measures in-
cluded Dynamic Visual Acuity, static balance in Romberg,
and gait speed as well as subjective measures of symptoms.
Half of the patients improved with vestibular rehabilitation.
Improvement was defined as normalization of at least 2 of
the 3 measures. The group that did not improve had more
comorbidities (2.5) than the group that did improve (1.7),
and having 4 or more comorbidities was associated with
poorer outcomes. Taken together, these studies demonstrate
improvements in measures of gaze stability, static postural
stability, gait, and symptoms. However, it is apparent from
these studies that not all individuals improved, individuals
did not improve on all measures, and there was a great deal
of variability in outcome measures.
R. Research Recommendation 2: With the advent of new
diagnostic tools, it is possible to assess the functioning of
each component of the vestibular apparatus. Researchers
should examine rehabilitation outcomes in persons with
damage to semicircular canal versus otolith components of
the vestibular apparatus. Furthermore, researchers should
examine the impact of the magnitude and range of hypofunc-
tion relative to functional recovery.
R. Research Recommendation 3: There is a paucity of
research on the effectiveness of vestibular rehabilitation in
children. Researchers should examine rehabilitation out-
comes in children with confirmed vestibular dysfunction
based on vestibular laboratory tests. In addition, researchers
should examine the concept of a critical period of balance
development in children in the context of providing vestibu-
lar rehabilitation. This is especially important in light of the
number of children who are receiving cochlear implants at a
very young age and the surgical procedure may affect ves-
tibular function.
A. Action Statement 4: EFFECTIVENESS OF SAC-
CADIC OR SMOOTH-PURSUIT EXERCISES IN
PERSONS WITH PERIPHERAL VESTIBULAR HY-
POFUNCTION (UNILATERAL OR BILATERAL).
Clinicians should not offer saccadic or smooth-pursuit eye
exercises in isolation (ie, without head movement) as spe-
cific exercises for gaze stability to patients with unilateral or
bilateral vestibular hypofunction. (Evidence quality: I; rec-
ommendation strength: strong)
Action Statement Profile
Aggregate evidence quality: Level I. Based on 3 level I
randomized controlled trials.
Benefits:
• Pooreroutcomesinpatientsperformingonlysaccadic
or smooth-pursuit eye movements without head move-
ment when compared with vestibular rehabilitation.
Risk, harm, and cost:
• Smooth-pursuitand saccadiceyemovementexercises
do not appear to harm patients with unilateral or bilat-
eral vestibular hypofunction.
• Delay in patients receivingan effective exercisepro-
gram.
• Increasedcostandtimespenttravelingassociatedwith
ineffective supervised exercises.
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Benefit-harm assessment:
• Preponderanceofharm.
Value judgments:
• Importance of prescribing an effective exercise pro-
gram rather than exercises that will not improve gaze
stability, symptom complaint, or balance while walk-
ing.
Role of patient preferences:
• Itisdoubtfulthatpatientswouldchoosetoperforman
ineffective exercise.
Exclusions:
• None.
Supporting Evidence and Clinical Interpretation
Three level I studies have used either saccadic or smooth-
pursuit eye movements in isolation (ie, without head move-
ment) as control (placebo) exercises.18-20 Note: The sac-
cadic and smooth-pursuit eye movements used in all 3 of
these studies are voluntary saccades and smooth-pursuit
eye movements without head movement, of the type used
when reading or following a moving object. The volun-
tary saccade and smooth-pursuit eye movements should
not be confused with compensatory eye movements (sac-
cadic or high-velocity, slow-phase eye movements) seen
after a head impulse (high acceleration of the head in yaw
through a small amplitude) in some patients with vestibular
hypofunction that potentially are facilitated by gaze stability
exercises. In one study, patients scheduled for resection of
vestibular schwannoma were randomly assigned to either an
exercise group (vestibular rehabilitation; n = 11) or a control
group (n = 8).18 Exercises were started 3 days after resec-
tion of the vestibular schwannomas and continued until the
patients were discharged from the hospital (average = post-
operative day 6). The control group performed vertical and
horizontal smooth-pursuit eye movements. Patients in both
groups walked at least once each day. The vestibular reha-
bilitation group was older (mean age 59 years vs 48 years in
controls, (P < 0.04), but both groups were similar in other
respects. Both groups reported significantly more dizziness
after surgery than before (P < 0.05) and more postural sway
on postoperative day 3 than preoperatively (P < 0.05). By
postoperative days 5 to 6, patients in the control group re-
ported significantly greater subjective disequilibrium than
the vestibular group who performed gaze stabilization ex-
ercises. In addition, none of the control groups were able to
walk and turn their head without a loss of balance, whereas
50% of the exercise groups were able to walk and turn their
head without losing their balance.
Herdman et al,19 in a level I study in patients with chronic
unilateral vestibular hypofunction, used saccadic eye move-
ments as the exercise for the control group. Patients were
randomized to vestibular rehabilitation (n = 13) versus
placebo exercises (n = 8). The vestibular group was taken
through supervised adaptation and substitution exercises to
improve gaze stability, whereas the control group performed
saccadic eye movements against a Ganzfeld (a large feature-
less background) with their head stationary. Exercises were
done 4 to 5 times daily for 20 to 30 minutes plus 20 minutes
of gait and balance exercises for 4 weeks, with adherence
monitored and progressed as indicated. On average, there
was no change in Dynamic Visual Acuity in the control
group and no control subject achieved normal Dynamic Vi-
sual Acuity for their age. In contrast, the vestibular treatment
group showed improvement in Dynamic Visual Acuity (P <
0.001), and 12 of the 13 individuals improved their Dynamic
Visual Acuity to normal. The same experimental design was
used to examine the effect of exercises in patients with bi-
lateral vestibular hypofunction.20 As a group, the individu-
als performing the control saccadic eye movement exercises
showed no improvement in Dynamic Visual Acuity whereas
those performing gaze stability exercises improved signifi-
cantly. Thus, saccadic eye movement exercises did not fa-
cilitate recovery of gaze stability as measured by Dynamic
Visual Acuity.
B. Action Statement 5: EFFECTIVENESS OF DIFFER-
ENT TYPES OF EXERCISES IN PERSONS WITH
ACUTE OR CHRONIC UNILATERAL VESTIBULAR
HYPOFUNCTION. Clinicians may provide targeted exer-
cise techniques to accomplish specific goals appropriate to
address identified impairments and functional limitations.
(Evidence quality: II; recommendation strength: moderate)
Action Statement Profile
Aggregate evidence quality: Level II. Based on 1 lev-
el I and 2 level II randomized controlled trials exam-
ining whether one type of vestibular exercise is more
beneficial than another. In addition, 2 level II studies
compared a traditional vestibular exercise with a novel
exercise.
Benefits:
• Unknown.
Risk, harm, and cost:
• Increasedcostandtimespenttravelingassociatedwith
supervised vestibular rehabilitation.
Benefit-harm assessment:
• Unknown;there is apotentialfor patients toperform
an exercise that will not address their primary prob-
lems.
Value judgments:
• Importance of identifying the most appropriate exer-
cise approach to optimize and accelerate recovery of
balance function and decreasing distress, improving
functional recovery to activities of daily living, and re-
ducing fall risk.
Role of patient preferences:
• Costandavailabilityofpatienttimeandtransportation
may play a role.
Exclusions:
• PossibleexclusionsincludeactiveMenieredisease or
those with impairment of cognitive or general mobil-
ity function that precludes adequate learning and car-
ryover or otherwise impedes meaningful application of
therapy.
Supporting Evidence and Clinical Interpretation
On the basis of the few randomized trials, clinicians may of-
fer targeted exercise techniques to accomplish specific goals
for improvement in exercise programs (eg, exercises related
to gaze stability and visual motion sensitivity for improved
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stability of the visual world and decreased sensitivity to
visual motion; head movements in a habituation format to
decrease sensitivity to head movement provoked symptoms;
and activities related to body sway control for improved gen-
eral stance and gait).
Few studies have examined whether any one vestibu-
lar exercise is more beneficial than another. A few stud-
ies have compared a standard vestibular exercise (eg,
Cawthorne-Cooksey exercises) with a novel exercise (eg,
moving platform practice). Of the 14 randomized clinical
trials initially thought to compare the standard vestibular
exercise approaches (gaze stabilization, adaptation, habitu-
ation, substitution, Cawthorne-Cooksey), only 3 actually
compared different exercise approaches with vestibular
rehabilitation for peripheral vestibular hypofunction. Two
other randomized controlled trials examined the concept
that particular exercises should be used to accomplish spe-
cific goals.
In a level I randomized trial, Pavlou et al61 compared pa-
tients performing a customized exercise program (n = 20;
balance, gait, Cawthorne-Cooksey, gaze stability) with pa-
tients performing exercises in an optokinetic environment
(n = 20). Outcome measures included the Sensory Organi-
zation Test, the Berg Balance Scale, and several symptom
complaint measures including the Vertigo Symptom Scale,
Situational Characteristics Questionnaire, and Hospital
Anxiety and Depression Scale. Both groups improved sig-
nificantly in the Sensory Organization Test and symptom
scores; however, the optokinetic stimulus group improved
more in the symptom measures. Although the optokinetic
stimulus group seems to have improved more in the Sensory
Organization Test score, the customized exercise group had
higher (better) scores to begin with and therefore there may
have been a ceiling effect for that group.
In a level II study, Clendaniel62 studied 7 patients with
chronic uncompensated unilateral vestibular hypofunction
on the basis of caloric testing or clinical examination. Pa-
tients were randomized (no mention of allocation conceal-
ment) to habituation exercises (n = 4) designed to reduce
patient sensitivity to head movement or gaze stabilization
exercises (n = 3) designed to improve visual acuity during
head movement. Both patient groups also performed bal-
ance and gait exercises and were provided a home exercise
program. Both groups were to perform the exercises 3 times
daily over a 6-week period. Exercise adherence averaged
69.7% (range 34%-90%). In this preliminary study, both
exercise interventions resulted in improved self-reported
ability to perform daily activities, decreased sensitivity to
movement, and better visual acuity during head movements.
However, because of the small number of subjects in the
study and the fact that some patients had normal values on
the outcome measures at baseline, further research is strongly
recommended.
In another level II study, Szturm et al63 examined pos-
tural stability (Sensory Organization Test) and vestibular
asymmetry (rotary chair and optokinetic testing) in patients
with chronic uncompensated unilateral vestibular hypofunc-
tion. Patients were randomly assigned to perform either ves-
tibular rehabilitation (gaze stability and balance exercises
performed in the clinic and as a home program) or control
exercises (Cawthorne-Cooksey exercises performed only as
an unsupervised home program). The vestibular rehabilita-
tion group showed improvement in both postural stabil-
ity and vestibular symmetry, whereas those performing the
Cawthorne-Cooksey exercises did not. The study, however,
has several limitations. First, not all patients seem to have
unilateral vestibular hypofunction on the basis of the inves-
tigators’ criteria (approximately 25% in each group). Sec-
ond, the investigators examined vestibulo-ocular reflex gain
asymmetry by rotational testing, which is insensitive to uni-
lateral vestibular hypofunction. Finally, because one group
was supervised and the other group was not, the differences
in outcome may be attributed to a supervision effect rather
than to the type of exercise.
Two studies provide support for using particular exercis-
es for specific problems. One, a level I study by McGibbon
et al64 randomly assigned 53 patients with vestibular hypo-
function and documented gait and balance impairments to
either a group-based vestibular exercise intervention or a
group-based Tai Chi exercise intervention. Fifteen subjects
dropped out of the study and another 12 were unable to
perform the step-up/step-down test; thus, the final sample
size was 26, and 8 subjects had unilateral and 5 subjects had
bilateral vestibular hypofunction in each treatment group.
Subjects met once a week for 10 weeks in small groups for
70 minutes of exercise. The study demonstrated that balance
exercises (Tai Chi) selectively improved whole body stabil-
ity during a step-up and step-down test, whereas vestibular
exercises (adaptation and eye-head exercises) selectively im-
proved gaze stability. The role of severity of vestibular hypo-
function (unilateral vs bilateral) is unclear.
In a level II study, Jauregui-Renaud et al65 compared the
effectiveness of Cawthorne-Cooksey exercises, Cawthorne-
Cooksey exercises plus training in breathing rhythm, and
Cawthorne-Cooksey exercises plus proprioceptive exercises.
The outcome measures included disability (Dizziness Hand-
icap Inventory) and static balance in patients with chronic
vestibular hypofunction. Although all 3 groups showed im-
provement in Dizziness Handicap Inventory scores and in
static balance, the group performing Cawthorne-Cooksey
exercises plus breathing training was more likely to have
a meaningful clinical improvement in Dizziness Handicap
Inventory scores and the patients performing Cawthorne-
Cooksey plus proprioceptive exercises had decreased sway
during static balance tests. Although not conclusive, the
results from these 2 studies support the concept of exer-
cise specificity in the treatment of patients with vestibular
hypofunction.
Pavlou et al66 examined the effect of different virtual
reality experiences on outcome in patients with unilateral
peripheral vestibular hypofunction. Patients were randomly
allocated to a virtual reality regime incorporating exposure
to a static (group S) or dynamic (group D) virtual reality en-
vironment. Participants practiced vestibular exercises, twice
weekly for 4 weeks, inside a virtual crowded square environ-
ment. Both groups also received a vestibular exercise home
program to practice on days not attending clinic. A third
group (D1) completed both the static and dynamic virtual
reality training. Outcome measures included the Dynamic
Gait Index and questionnaires concerning symptom triggers
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and psychological state. Those groups who performed exer-
cises within the dynamic virtual reality environment (D and
D1) had significantly better Visual Vertigo Scores than those
who performed exercises inside the static virtual reality en-
vironment (S). In contrast, depression scores increased only
in group S. The Dynamic Gait Index did not differ across
groups; however, many subjects were already within the
normal range before the initiation of the intervention. The
investigators concluded that use of dynamic virtual reality
environments should be considered as a useful adjunct to
vestibular exercises for patients with chronic vestibular dis-
orders and visual vertigo symptoms.
R. Research Recommendation 4: There is sufficient evi-
dence that vestibular exercises compared with no or placebo
exercises is effective; thus, future research efforts should be
directed to comparative effectiveness research. Research-
ers should directly compare different types of vestibular
exercise in large clinical trials to determine optimal exercise
approaches.
B. Action Statement 6: EFFECTIVENESS OF SUPER-
VISED VESTIBULAR REHABILITATION. Clinicians
may offer supervised vestibular physical therapy in patients
with unilateral or bilateral peripheral vestibular hypofunc-
tion. (Evidence quality: I-III; recommendation strength:
moderate)
Action Statement Profile
Aggregate evidence quality: Level II. Based on nu-
merous level I, II, and III studies.
Benefits: Possibly better adherence with a supervised
exercise program.
Risk, harm, and cost:
• Thereisanincreasedcostandtimespenttravelingas-
sociated with supervised vestibular rehabilitation.
• Withoutfeedbackfromthesupervisingphysicalthera-
pist, the patient may under- or overcomply with the ex-
ercise prescription resulting in either lack of progress/
improvement or increased symptoms potentially lead-
ing to stopping therapy.
Benefit-harm assessment:
• Preponderanceofbenetforsupervision.
• Evidencesuggeststhatpatientsdropoutathigherrates
when unsupervised.
Value judgments:
• Supervised vestibular rehabilitation appears to pro-
mote adherence and continued performance of vestibu-
lar exercises, which may lead to improved outcomes.
• Persons with impairment of cognition or moderate-
severe mobility dysfunction may need supervision to
benefit from vestibular rehabilitation.
• Peoplewhoarefearfuloffallingmaynotdowellinan
unsupervised exercise program.
Role of patient preferences:
• Costandavailabilityofpatienttimeandtransportation
may play a role.
Exclusions:
• Patientswholiveatadistancemaynotbeabletopar-
ticipate in supervised vestibular rehabilitation.
Supporting Evidence and Clinical Interpretation
Several studies (Levels I63 and II21,45,67-69) demonstrate that
patients may respond better to customized, supervised reha-
bilitation than to generic exercises or solely a home program.
The reason for these differences may be that supervised ves-
tibular rehabilitation promotes adherence and continued
performance of vestibular exercises, which may lead to im-
proved outcomes.
Two studies examined the effect of supervision during
the acute stages of vestibular dysfunction with different
outcomes. Kammerlind et al70 in a level I study compared
a supervised versus a home training group of vestibular ex-
ercises that included gaze stability, balance, and gait exer-
cises. All patients received oral and written instructions for
the vestibular exercises in the hospital and were instructed to
exercise 15 minutes per day. The supervised group received
3 additional supervised physical therapy sessions in the hos-
pital. Once discharged home, the supervised group received
10 additional supervised visits. At 1 week, 10 weeks, and
6 months postdischarge, both groups improved in measures
of balance and symptoms of vertigo, but were not different
from each other. A level I study in postsurgical acute patients
compared patients who started exercises in the hospital with
a control group who did no exercise.40 In patients younger
than 50 years, outcomes were equally good whether or not
exercises were performed. The average age of Kammerlind
et al’s participants was 52 years, so the study outcomes may
reflect the age of patients versus the role of supervision.70
Teggi et al,45 in a level II study, compared a supervised
exercise program with usual activity for patients hospital-
ized for an acute episode of vertigo. Participants were ran-
domly assigned to attend 10 therapy sessions (n = 20) within
10 days of baseline assessment or were instructed to perform
daily activities (n = 20). Twenty-five days later, the group
that underwent a supervised exercise program had better
outcomes on all measures (Dynamic Gait Index, computer-
ized Clinical Test of Sensory Interaction on Balance, Diz-
ziness Handicap Inventory, and a Visual Analog Scale for
anxiety), with the greatest change noted in the Dynamic Gait
Index. The results of this study are confounded by differ-
ences in exercises (vestibular exercises vs daily activities)
and may explain the difference in outcomes compared with
Kammerlind et al.45,70
Kao et al,67 in a level II study, compared supervised and
home-based (unsupervised) vestibular rehabilitation. Both
groups performed seated and standing eye movements and
adaptation exercises, as well as walking with head turns.
The supervised group received an initial evaluation and
individualized treatment plan followed by three 30-minute
sessions per week with a physical therapist. The home group
participants received an individualized treatment plan on
the basis of an initial evaluation and were not seen again
by the physical therapist until outcomes were assessed at
2 months. The subjects self-selected their treatment group,
with 28 choosing supervised rehabilitation and 13 choosing
home-based or unsupervised rehabilitation. Both groups
improved, but there were greater improvements in the su-
pervised group compared with the home group for the Dy-
namic Gait Index (86% vs 14%) and Dizziness Handicap
Inventory (74% vs 26%). There are several limitations of
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this study that limit generalizability including small sample
size, no randomization, and assessors that were not blinded
to group.
Optokinetic training for visual vertigo was utilized in a
level I study.71 Sixty patients were randomized into 3 groups:
a supervised training group that utilized a full field environ-
mental rotator, a supervised training group provided with a
DVD, and an unsupervised training group using a DVD. All
subjects also received a customized program of gaze and
postural stability exercises to perform at home. The outcome
measures were Visual Vertigo Symptoms, Sensory Organi-
zation Test, and Functional Gait Assessment. The Sensory
Organization Test and Functional Gait Assessment improved
significantly for the supervised groups (full field and DVD
groups), and anxiety scores improved for the supervised
DVD group. The study has a major limitation related to the
high dropout rate of 55% in the unsupervised group com-
pared with 10% in the supervised groups. Pavlou et al71
concluded that supervision promotes greater adherence and
improvements in postural stability and psychological state.
Yardley et al72, in a level I study, reported “fair” self-reported
adherence to an exercise booklet for persons with vestibular
disorders. In a subsequent study, she reported that addition-
al advice or encouragement might improve adherence in a
home-based program.
Monitoring of the exercise program may have value,
as demonstrated by Shepard et al73 in a level III study. The
investigators reported that nausea, emesis, and vertigo pro-
voked by exercises could be managed by stopping the exer-
cise session and resuming the exercises at the next session.
In most cases, they found this approach to successfully al-
low continued participation. In those cases where this was
not successful, they suggested that antiemetic or vestibular
suppressant medication may be required. Recommendations
for use of antiemetic drugs should be carefully considered
because of concerns about slowing central compensation.
For example, Strupp et al42 limited antiemetic use to a maxi-
mum of 3 days because of concerns for slowed vestibular
compensation.
Failure to return to the clinic,66,71,74 failure to comply with
the exercise program,67,74 and illness have been noted as rea-
sons for why people do not complete a program of vestibular
exercises. In Pavlou’s work, those with an unsupervised ex-
ercise program had higher dropout rates.66,71 It is not known
why the dropout rate was higher in the unsupervised group.
R. Research Recommendation 5. Researchers should in-
clude measures of adherence to understand the impact of
supervision. Researchers need to incorporate intent-to-treat
research designs to understand dropout rates related to su-
pervision.
D. Action Statement 7: OPTIMAL EXERCISE DOSE
OF TREATMENT IN PEOPLE WITH PERIPHERAL
VESTIBULAR HYPOFUNCTION (UNILATERAL
AND BILATERAL). 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 min-
utes per day for patients with acute/subacute vestibular hy-
pofunction and at least 20 minutes per day for patients with
chronic vestibular hypofunction. (Evidence quality: V; rec-
ommendation strength: expert opinion)
Action Statement Profile
Aggregate evidence quality: Level V. Based on lack
of direct evidence on exercise dose. Best practice based
on the clinical experience of the guideline development
team and guided by the evidence.
Benefit:
• Improvedoutcomeswithappropriateexercisedose.
Risk, harm, and cost:
• Riskofprovokingtemporarydizzinessduringandaf-
ter performance of exercises.
• Riskofincreasednauseaandpossibleemesiswhenex-
ercises are performed during the most acute stage.
• Some physicians maywant to delay exercisesduring
the early postoperative stage in some patients because
of risk of bleeding or cerebrospinal fluid leak.
• Increasedcostandtimespenttravelingassociatedwith
supervised vestibular rehabilitation.
Benefit-harm assessment:
• Preponderanceofbenetoverharm.
Value judgments:
• Benetofgazestabilityexercisesinpatientswithuni-
lateral vestibular hypofunction has been demonstrated
in numerous level l and level II studies; however, the
frequency and intensity of the exercises is based on ex-
trapolation from research studies rather than based on
direct evidence.
Role of patient preferences:
• Minimal.
Exclusions:
• Patientsatriskforbleedingorcerebrospinaluidleak.
Supporting Evidence and Clinical Interpretation
There are few studies to date that have examined in what
ways (if any) exercise dose (frequency and intensity) af-
fects outcomes in patients with unilateral or bilateral ves-
tibular hypofunction. Two studies examined the influence
of exercise intensity on outcomes.75,76 Cohen et al compared
2 groups of patients who performed the same exercise but at
different levels of intensity. One group performed exercises
with rapid head movements (ie, approximately 1-2 Hz) and
the other group performed exercises with slow head move-
ments (approximately 0.04 Hz), 5 times per day for a total of
4 weeks. They reported both groups improved equally in ver-
tigo intensity, vertigo frequency, and on a functional repeti-
tive head movement task, suggesting that the dose intensity
(frequency of head movement) was not a factor in recovery.
There are some limitations to the study that confound the in-
terpretation of the data however. First, it is not clear that the
groups were equivalent at baseline on the timed repetitive
head movement task and second, the data suggest that the
time to perform the repetitive head movement task did not
improve until 4 months after initiation of exercises.
Although far from ideal, some information on exercise
dose can be found by comparing the findings from multiple
studies.
• Acute and subacute postoperative patients: Two level
I and 1 level II studies have examined the effect of
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gaze stabilization exercises on the recovery of patients
during the early postoperative period after vestibular
schwannoma resection.16,18,40 Patients performed gaze
stabilization exercises 3 to 5 times daily for a total
of 12 to 20 minutes a day and reported improvement
in subjective complaints of imbalance,18,40 Dizziness
Handicap Inventory,16 and stability while walking with
voluntary head movements.18 These results suggest that
as little as 12 minutes of gaze stabilization exercises
a day over 3 exercise periods may be sufficient to in-
duce recovery in patients during the acute and subacute
stages after vestibular schwannoma resection.
• Chronic unilateral vestibular hypofunction: Four stud-
ies (2 level I and 2 level II), each examining the effect
of vestibular rehabilitation on outcomes in patients
with chronic unilateral vestibular hypofunction, in-
cluded sufficient details on the type, frequency, and
duration of exercise to provide some guideline as
to exercise dose in these patients. In these studies,
patients performed the gaze stability exercises 3 to
5 times per day for a total of 20 to 40 minutes each
day.19,20,67,77 Patients performing these exercises im-
proved compared with a control group. The data sug-
gest that a minimum performance of the exercises
3 times per day for a total of 20 minutes daily may be
sufficient to induce recovery.
R. Research Recommendation 6. Researchers should ex-
amine the impact of frequency, intensity, time, and type of
exercises on rehabilitation outcomes. Researchers should
determine the difficulty of exercises and how to progress pa-
tients in a systematic manner.
D. Action Statement 8: DECISION RULES FOR STOP-
PING VESTIBULAR REHABILITATION IN PER-
SONS WITH PERIPHERAL VESTIBULAR HYPO-
FUNCTION (UNILATERAL AND BILATERAL).
Clinicians may use achievement of primary goals, resolution
of symptoms, or plateau in progress as reasons for stopping
therapy. (Evidence quality: V; recommendation strength: ex-
pert opinion)
Action Statement Profile
Aggregate evidence quality: Level V. Based on ex-
trapolation from methodology and results in 69 stud-
ies, it may be advisable to consider the following in the
decision to stop treatment:
1. Goals are met, a plateau has been reached, or the pa-
tient is no longer symptomatic.
2. Nonadherence/patient choice.
3. Deterioration of clinical status or a prolonged increase
in symptoms.
4. Fluctuating/unstable vestibular conditions (eg, Me-
niere) and comorbid musculoskeletal, neurologic, cardi-
ac, visual, cognitive, psychological, or disability-related
conditions affecting ability to participate.
5. Overall length of treatment.
Benefits:
• More efcient management of treatment duration,
avoiding cessation of treatment before optimal recov-
ery is achieved, or continuing treatment for unreason-
ably protracted periods.
Risk, harm, and cost:
• Prematurelystoppingtreatmentbeforemaximumgains
are achieved.
• Protractedtreatmentiscostlytothepayer,thepatient,
and the clinician who are not seeing documented im-
provement, and to other patients who are waiting to re-
ceive treatment.
Benefit-harm assessment:
• Preponderanceofbenetoverharm.
Value judgments:
• Noconcrete stoppingruleshavebeenexploredinthe
research; however, numerous level I through IV studies
provide comments and findings that can assist in the
decision-making process.
Role of patient preferences:
• Itisthepatient’sdecisionwhetherornottoparticipate
in vestibular rehabilitation and when to stop vestibular
rehabilitation.
Patient exclusions:
• Patients with impaired cognition or moderate to se-
vere mobility dysfunction may need a greater number
of treatment sessions, so using the treatment duration
based on research (which typically excludes these pa-
tients) may not be appropriate.
• Patients with moderate to severe motion sensitivity
may also benefit from a greater number of treatment
sessions.
• InalevelIIstudy,patientstakingvestibular-suppressant
medication required additional treatment sessions (11
weeks vs 9 weeks before plateau).68
Supporting Evidence and Clinical Interpretation
There are no studies that have specifically examined deci-
sion rules for stopping vestibular rehabilitation in those with
unilateral or bilateral peripheral vestibular hypofunction. An
investigator’s a priori decision relative to the research design
determines the length of the intervention; thus, the duration
of treatment is protocol-driven and not based on patient out-
comes. Furthermore, the length of the study intervention may
affect a patient’s willingness to participate in the study. Thus,
we cannot extrapolate from research studies to create clinical
stopping rules on the basis of current research design.
Implicit reasons for stopping therapy in a clinic setting
ideally include the patient no longer being symptomatic,
goals being met, or a plateau being reached.2,78 For example,
Hall et al’s level III study reported discharge from treatment
when 75% of goals were met.17 Multiple studies cited non-
adherence as a reason to discontinue treatment. Only a few
studies provided specific criteria, such as missing at least 3
treatment sessions or 30% of therapy sessions.42,69,79 Some
reasons that patients report nonadherence with vestibular re-
habilitation include the following: unrelated health issues,
finding the exercises too provoking, family or work conflicts,
litigation, travel or time inconvenience, loss of interest or
motivation, and feeling better.
Deterioration of clinical status was cited as a reason for
9 of the 37 patients showing an increased Dizziness Hand-
icap Inventory score in a level II study by Perez et al80 and
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seems an obvious reason to pause or stop treatment; how-
ever, if worsening of subjective complaints is a factor in the
consideration to stop treatment, the following studies may
provide some guidance. A level IV study found that nau-
sea, body shift, dizziness, and stress were increased dur-
ing first 2 weeks of intervention, but subsided by week 2.81
Szturm’s level I randomized controlled trial study found
that the adverse effects of moderate to strong dizziness,
nausea, and disorientation during exercises subsided
within 2 to 5 weeks.63 Thus, worsening symptoms during
the 1 or 2 weeks of the vestibular rehabilitation program
should not necessarily be considered a reason for stopping
therapy. However, more persistent worsening symptoms
should be carefully considered a reason to discontinue
therapy.
Numerous factors were identified by researchers to ex-
clude patients from studies or to drop subjects from study
participation. These factors may also provide guidance for
stopping or deferring therapy if a patient is not showing prog-
ress. Factors include (1) progressive, fluctuating, or unstable
vestibular conditions (ie, vestibular schwannoma, episodes
of spontaneous vertigo, unrepaired perilymphatic fistula,
and active Meniere disease); (2) musculoskeletal conditions
affecting the ability to stand or perform exercises; (3) central
nervous system or other neurologic diseases or conditions
(eg, head injury) affecting balance, motor control, muscle
strength, or somatosensation; (4) significant cardiac prob-
lems; (5) severe visual disorders or blindness; (6) cognitive
impairment affecting comprehension; (7) severe migraine;
and (8) psychological conditions. In Shepard et al’s level II
study in 1993, those with head injury showed a substantially
less reduction in symptoms than the rest of the subjects and
comprised a significantly higher percentage of those show-
ing no change or worsening.68
Pretreatment disability could also be considered when
deciding whether or not to discontinue therapy in a patient,
as patients with high disability scores may be more resistant
to change and may be less likely to improve on the basis of 2
level II studies68,82 and 2 level III studies.60,73
On the basis of expert opinion extrapolated from the
evidence, clinicians may consider providing adequate su-
pervised vestibular rehabilitation sessions for the patient
to understand the goals of the program and how to manage
and progress themselves independently. Sixty-one of the
prospective studies reported that treatment duration for ves-
tibular rehabilitation ranged from 5 days to 16 weeks (av-
erage = 6.7 weeks). However, the researchers did not pro-
vide justification for the length of treatment time chosen for
their studies. In 20 retrospective studies that reflect clinical
practice (based on chart review), treatment duration for ves-
tibular rehabilitation ranged from 2 to 38 weeks (average =
10.0 weeks); however, some patients with bilateral vestibular
hypofunction may need a longer course of treatment than
individuals with unilateral vestibular hypofunction. As a
general guide, persons without significant comorbidities that
affect mobility and with acute or subacute unilateral vestibu-
lar hypofunction may only need 1 time per week supervised
sessions for 2 to 3 sessions; persons with chronic unilateral
vestibular hypofunction may need 1 time per week super-
vised sessions for 4 to 6 weeks; and persons with bilateral
vestibular hypofunction may need a longer course of treat-
ment (1 time per week supervised sessions for 8-12 weeks)
than persons with unilateral vestibular hypofunction.
Finally, on the basis of expert opinion, the advisory
panel recommends that before stopping therapy for patients
who remain symptomatic or have not met their goals, con-
sultation with another vestibular physical therapist colleague
would be advisable.
R. Research Recommendation 7: Researchers should de-
termine optimal duration of vestibular rehabilitation for
favorable outcomes and the factors that impact functional
recovery.
C. Action Statement 9: FACTORS THAT MODIFY RE-
HABILITATION OUTCOMES. Clinicians may evaluate
factors that could modify rehabilitation outcomes. (Evidence
quality: I-III; recommendation strength: weak to strong)
Action Statement Profile
Aggregate evidence quality: Age: Level I. Based on
4 level I randomized controlled trials and 2 level II
quasiexperimental studies. Sex: Level III. Based on 1
level II and 2 level III studies. Time from onset: Level
III. Based on 1 level I randomized controlled trial and
3 level III studies, 1 with contradictory results to the
others. Comorbidities: Level III. Based on 1 level I ran-
domized controlled trial, 2 level II and 1 level III stud-
ies. Use of vestibular-suppressant medications: Level
III. Based on 1 level II and 1 level III studies.
Benefits:
• Olderpatientsobtainsimilarbenetsfrom vestibular
rehabilitation.
Risk, harm, and cost:
• Peripheralneuropathymayincreaseriskoffallingand
negatively impact rehabilitation outcomes.
Benefit-harm assessment:
• Vestibular rehabilitation has been shown to improve
outcomes regardless of the time from onset; however,
the potential harm (decreased quality of life, falls) to
initiating rehabilitation later warrants initiating reha-
bilitation as soon as possible.
Value judgments:
• Little evidence is available to make decisions about
how to consider factors that may affect outcomes.
Role of patient preferences:
• Costandavailabilityofpatienttimeandtransportation
may play a role, especially with older patients who may
have transportation issues.
Exclusions:
• None.
Supporting Evidence and Clinical Interpretation
Several non-disease-related modifying factors—including
age, sex, time from onset of symptoms to start of rehabilita-
tion, comorbidities, and use of vestibular-suppressant medi-
cations—have been evaluated for their impact on vestibular
rehabilitation outcomes.
Age: Increased age does not affect potential for im-
provement with vestibular rehabilitation. Clinicians should
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offer vestibular rehabilitation to older adults with the expec-
tation of good outcomes. (Evidence quality: I; recommenda-
tion strength: strong)
Sex: Sex may not impact rehabilitation outcomes and
clinicians may offer vestibular rehabilitation to males and
females with expectation of similar outcomes. (Evidence
quality: III; recommendation strength: weak)
Time from onset (acute): Earlier intervention improves
rehabilitation outcomes; thus, vestibular rehabilitation may
be started as soon as possible after acute onset of vertigo.
(Evidence quality: II; recommendation strength: moderate)
Time from onset (chronic): Vestibular exercises have
been shown to improve outcomes regardless of the time from
onset; however, the potential for harm related to decreased
quality of life or falls suggests that clinicians may initiate
rehabilitation as soon as possible. (Evidence quality: I-III;
recommendation strength: moderate)
Comorbidities: Anxiety, migraine, and peripheral neu-
ropathy may negatively impact rehabilitation outcomes.
(Evidence quality: III; recommendation strength: weak)
Vestibular-suppressant medications: Long-term use of
valium or meclizine may negatively impact patient recovery.
(Evidence quality: II-III; recommendation strength: moderate)
Supporting Evidence and Clinical Interpretation
Several non-disease-related modifying factors have been
evaluated in various studies. These factors include age, sex,
time from onset of symptoms until starting vestibular reha-
bilitation, comorbidities, and use of vestibular-suppressant
medications. The level of evidence for these studies ranged
from level I to level III.
Eleven studies evaluated the effect of age and none dem-
onstrated a significant effect of age on the efficacy of vestibu-
lar rehabilitation. Six studies evaluated the influence of age
on vestibular rehabilitation in patients with unilateral vestib-
ular hypofunction; of these, 3 studies had an evidence level
of I,19,40,83 1 study had an evidence level of II,69 and 2 stud-
ies had an evidence level of III.2,17 Four studies evaluated the
influence of age on vestibular rehabilitation in patients with
various diagnoses including both peripheral and central ves-
tibular deficits; of these, 1 study had an evidence level of II,67
and 3 studies had an evidence level of III.82,84,85 One level I
study evaluated the influence of age on vestibular rehabilita-
tion in patients with bilateral peripheral vestibular deficits.20
Three studies evaluated the effect of sex, and none dem-
onstrated a significant effect of sex on the efficacy of ves-
tibular rehabilitation. Two of these—1 level II69 and 1 level
III2—evaluated the influence of sex on vestibular rehabilita-
tion in patients with unilateral vestibular hypofunction. One
level II study evaluated the influence of sex on vestibular
rehabilitation in patients with various diagnoses including
both peripheral and central vestibular deficits.67
Two level I studies examined the effects of vestibular ex-
ercises solely in the acute stage after resection of vestibular
schwannoma.16,18 Both studies provide evidence that early
intervention is beneficial. Herdman et al18 started vestibular
exercises 3 days postsurgery and continued until discharge
from the hospital. Participants randomized to receive gaze
stability exercises were less symptomatic and had better
postural stability at discharge than the placebo group.
Enticott et al16 compared a cohort of patients who were ran-
domized to vestibular exercises (gaze stability exercises)
versus a control group starting on postoperative day 3. The
vestibular group had lower perceived disability (based on the
Dizziness Handicap Inventory) over the course of 12 weeks.
Six studies of patients with chronic vestibular hypofunc-
tion evaluated the effect of time from onset of symptoms
until starting vestibular rehabilitation. Four studies evalu-
ated patients with unilateral vestibular hypofunction with
conflicting results. One level III study indicated that earlier
intervention produced better results.86 The other 3 studies,
one of which had level I evidence19 and 2 with level III evi-
dence,2,17 showed no effect of duration of symptoms before
initiation of vestibular rehabilitation therapy. A level II study
of patients with various diagnosis including both peripheral
and central vestibular deficits also found no effect of time
from onset of symptoms until starting vestibular rehabilita-
tion.82 One level I study determined that time from onset of
symptoms did not affect the outcomes of the vestibular reha-
bilitation in individuals with bilateral vestibular hypofunc-
tion.20 In each of these studies, participants improved with
vestibular rehabilitation; thus, these studies demonstrate that
vestibular rehabilitation improves outcomes regardless of
the time from onset.
Five studies evaluated the effect of comorbidities on re-
sponse to vestibular rehabilitation. Two studies evaluated the
influence of anxiety. In a study of patients with unilateral
peripheral vestibular deficits, anxiety was found to result in
decreased balance confidence on the basis of level III evi-
dence.2 In a study of patients with various diagnoses, higher
anxiety was associated with poorer scores on the Dynamic
Gait Index on the basis of level II evidence.45 In persons with
psychological conditions (anxiety/depression), addressing
psychological needs as an adjunct to physical therapy may
increase the success of the intervention on the basis of evi-
dence from level I, II, and III studies.45,72,87,88
A single study reported a negative effect of peripheral
neuropathy on vestibular rehabilitation in patients with pe-
ripheral vestibular disorders on the basis of level II evidence.
Aranda et al89 examined a mixed population of individuals
with unilateral or bilateral vestibular hypofunction and dia-
betes with or without peripheral neuropathy. They found that
individuals with peripheral neuropathy had no improvement
on measures of standing balance with eyes open and closed
on a firm surface, and eyes open on a compliant surface;
individuals without peripheral neuropathy demonstrated sig-
nificant improvements in these test conditions. These find-
ings suggest that peripheral neuropathy may have a negative
impact on recovery of function.
Two studies (1 level I90 and 1 level III91) investigated the
impact of migraine on rehabilitation outcomes and found that
individuals with vestibular dysfunction and migraine had
poorer outcomes in terms of quality of life as measured by
the Dizziness Handicap Inventory. Another level I study re-
ported that patients with migraine improved in symptoms of
visual vertigo more than patients without migraine.71 These
study findings are in contrast to Vitkovic et al90 and Wrisley
et al91 and may reflect the use of an optokinetic stimulus.
Two studies have examined the impact of medications on
outcomes. A level II study found that patients with vestibular
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hypofunction who were treated with valium or meclizine dai-
ly had no improvement in postural sway over a 6-week treat-
ment period.21 These patients did report a decrease in diz-
ziness and in symptomatic complaints over time with these
medications. Another study, on the basis of level III evidence,
reported that patients with various disorders who were using
centrally active medications, such as vestibular suppressants,
antidepressants, tranquilizers, and anticonvulsants, required
a longer duration of therapy to achieve the same benefit as
compared with patients who were not using medications.73
R. Research Recommendation 8. Researchers should per-
form longitudinal studies. Researchers should examine time
from onset and see whether it affects short- and long-term
outcomes.
A. Action Statement 10: THE HARM/BENEFIT RATIO
FOR VESTIBULAR REHABILITATION IN TERMS
OF QUALITY OF LIFE/PSYCHOLOGICAL STRESS.
Clinicians should offer vestibular rehabilitation to persons
with peripheral vestibular hypofunction. (Evidence quality:
I-III; recommendation strength: strong)
Action Statement Profile
Aggregate evidence quality: Level I-III. Based on
randomized trials and descriptive studies. No targeted
randomized trials are available to directly answer the
question to the harm/benefit ratio of vestibular rehabili-
tation for persons with vestibular hypofunction; howev-
er, quality of life measures have been used as primary
outcome measures in a number of studies.
Benefits:
• There are improvedquality of life and psychological
outcomes in persons undergoing vestibular rehabilita-
tion when compared with controls who receive sham or
no exercise interventions.
Risk, harm, and cost:
• Neckpain,motionsickness,andnauseahavebeenre-
ported as side effects of rehabilitation and these can
affect quality of life.
• Dizziness as a side effect of the exercises could in-
crease psychological distress in some patients.
Benefit-harm assessment:
• Preponderanceofbenet,althoughnotallpatientsim-
prove with vestibular rehabilitation.
Value judgments:
• There is sufcient evidence of improved quality of
life and reduced psychological distress with vestibular
rehabilitation.
Role of patient preferences:
• Cost and availability of patient time, location of the
vestibular rehabilitation clinic, and transportation may
play a role.
Exclusions:
• None.
Supporting Evidence and Clinical Interpretation
Loss of vestibular function can result in postural instability,
visual blurring with head movement, and subjective com-
plaints of dizziness and/or imbalance. Although vestibular
rehabilitation was not provided, Sun et al92 recently reported
via a quality of life survey that persons with bilateral ves-
tibular loss had impaired quality of life plus loss of work
days as a result of their dizziness.
Quality of life has been reported to improve postvestibu-
lar rehabilitation for persons with unilateral vestibular dys-
function (level I: Johansson et al,93 Rossi-Izquierdo et al,94
Winkler and Esses95; level II: Clendaniel,62 Badaracco et al,96
Enticott et al,16 Gottshall et al,97 Mantello et al,98 Meli et al,99
Morozetti et al,100 Murray et al,87 Perez et al,80 Schubert et
al,77 Tee et al,101 Teggi et al,45 Topuz et al69; level III: Cowand
et al,102 Patatas et al84; level IV: Bittar et al103) and bilateral
loss (level I: Krebs et al22; level III: Brown et al,58 Gillespie
and Minor57) on the basis of improvements in the Dizziness
Handicap Inventory. Although the Dizziness Handicap In-
ventory was designed to measure the handicapping effects
of dizziness, it has also been used as a measure of quality of
life to record improvements over time. Others have utilized
the Activities-Specific Balance Confidence scale to note
beneficial changes over time in patients’ balance (level I: En-
ticott et al16; level II: Gottshall et al,97 Badaracco et al,96 Meli
et al99; level III: Brown et al58). The improvements in the Diz-
ziness Handicap Inventory and the Activities-Specific Bal-
ance Confidence scale suggest that persons are less dizzy
and have improved perception of balance after a course of
vestibular rehabilitation.
Harm/benefit ratios were not specifically noted in any of
the literature reviewed related to quality of life and psycho-
logical distress. Occasional mentions were made about side
effects of the vestibular rehabilitation program and that not
all patients improve. Herdman et al2 recently reported in a
level III study that anxiety and depression were associated
with lower balance confidence scores, a quality of life mea-
sure in persons with unilateral hypofunction. This suggests
that coexisting anxiety and depression might potentially di-
minish potential beneficial effects of an exercise program.
Cohen and Kimball,75 in a level II study, reported nausea
as a side effect of the exercise program, which could affect
quality of life. Although nausea is a common side effect of
exercise, it has not been routinely reported in the literature
as being “harmful” or resulting in dropouts from a vestibular
exercise program.
Telian et al,82 in a level II study, reported that a majority
of patients (82% of the patients, n = 65) indicated that they
had improved, whereas 12% reported feeling worse. Almost
half of their subjects had central vestibular disorders. Of the
12% who were worse after vestibular rehabilitation therapy, it
is not reported whether these people had central or peripheral
vestibular diagnoses. Bittar et al,104 in a level IV study, also
reported that 14% of their subjects were not any better after
rehabilitation, which is similar to the Telian et al. report.82
Therefore, there is the possibility that people will undergo
the exercise program and not change their quality of life.
Meli et al99 (level III) studied 42 people prospectively
and followed up at 6 months to determine whether they had
improved after a course of vestibular rehabilitation. The
Medical Outcomes Study 36 item-short form improved in
their subjects, except bodily pain and vitality. Younger sub-
jects reported worse Medical Outcomes Study 36 item-short
form scores, suggesting that dizziness may have more effect
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on their lives with work and possibly a busier schedule than
the older adults studied.
Return to work is an important measure of the benefit
of any exercise program; however, virtually no researchers
have incorporated a measure of return to work. Chen et al,81
in a level IV trial, reported that in 3 of 3 of their subjects
they were able to return to work and drive. All had chronic
symptoms before starting the Wiimote gaze stabilization ex-
ercise program. Improvements in driving have been noted in
others with chronic unilateral hypofunction after an exercise
program.105 In 2 level II studies and 3 level III studies, pa-
tients’ perceived disability has been reported to positively
change after rehabilitation. This disability scale includes
ability to work as a portion of the instrument, yet no studies
specifically report how frequently people are able to return
to work effectively after vestibular rehabilitation (level II:
Giray et al,50 Shepard et al,68 Telian et al82; level III: Shepard
et al,73 Telian et al60).
In 2 randomized trials (level I), Pavlou et al66,71 reported
that the autonomic/somatic anxiety scores decreased (im-
proved anxiety) with vestibular rehabilitation. Pavlou et al
also reported positive changes on the Hospital Anxiety and
Depression–A and B Scale plus the Spielberger State Trait
Anxiety Inventory, suggesting that after rehabilitation their
subjects were less anxious. Teggi et al45 reported that a Vi-
sual Analog Scale for anxiety improved when compared
with control subjects at 25 days posthospitalization for acute
vertigo (level II). The exercise group participated in 10
sessions that included dynamic posturography training and
gaze stabilization exercises. There is emerging evidence that
psychological distress and anxiety are decreased with exer-
cise in persons with vestibular hypofunction.
R. Research Recommendation 9. Researchers should ex-
amine the concept of return to work. Areas for study in-
clude job requirements that may be difficult for patients
with vestibular hypofunction, job modification, or assistive
technology to allow return to work, criteria for return to
work or disability assignment, indicators for return to safe
driving.
GUIDELINE IMPLEMENTATION
RECOMMENDATIONS
The following strategies are provided as suggestions for
clinicians to implement the action statements of this CPG,
but are not an exhaustive list. Many variables affect the
successful translation of evidence into practice, and clini-
cians need to assess their own practice environment and
clinical skills to determine the best approach to implement
the action statements as individuals.
Strategies for implementation:
• Keepa copyofthevestibularrehabilitationCPG ina
convenient clinic location.
• Seektrainingintheuseoftherecommendedinterven-
tion approaches.
• Buildrelationshipswithreferralsourcesto encourage
early referral of persons with peripheral vestibular hy-
pofunction.
• Measure outcomes of care using recommended out-
come measures across the ICF domains.
• SharetheJNPT Perspectives for Patients that accom-
panies this article with patients and others who are in-
terested in learning about the management of dizziness
related to vestibular disorders.
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R. Research Recommendation 1: Researchers should ex-
amine the concept of a critical period for optimal vestibular
compensation through studies that examine early versus de-
layed intervention. Researchers should identify factors that
predict which patients will recover without the benefit of
vestibular rehabilitation and which patients will need ves-
tibular rehabilitation to optimize outcomes.
R. Research Recommendation 2: With the advent of new
diagnostic tools, it is possible to assess the functioning of
each component of the vestibular apparatus. Researchers
should examine rehabilitation outcomes in persons with
damage to semicircular canal versus otolith components of
the vestibular apparatus. Furthermore, researchers should
examine the impact of the magnitude and range of hypofunc-
tion relative to functional recovery.
R. Research Recommendation 3: There is a paucity of
research on the effectiveness of vestibular rehabilitation in
children. Researchers should examine rehabilitation out-
comes in children with confirmed vestibular dysfunction
on the basis of vestibular laboratory tests. In addition, re-
searchers should examine the concept of a critical period of
balance development in children in the context of provid-
ing vestibular rehabilitation. This is especially important in
light of the number of children who are receiving cochlear
implants at a very young age and the surgical procedure may
affect vestibular function.
R. Research Recommendation 4: There is sufficient evi-
dence that vestibular exercises compared with no or placebo
exercises are effective; thus, future research efforts should be
directed to comparative effectiveness research. Researchers
should directly compare different types of vestibular exer-
cise in large clinical trials to determine optimal exercise ap-
proaches.
R. Research Recommendation 5: Researchers should in-
clude measures of adherence to understand the impact of
supervision. Researchers need to incorporate intent-to-treat
research designs to understand dropout rates related to su-
pervision.
R. Research Recommendation 6: Researchers should ex-
amine the impact of frequency, intensity, time, and type of
exercises on rehabilitation outcomes. Researchers should
determine the difficulty of exercises and how to progress pa-
tients in a systematic manner.
R. Research Recommendation 7: Researchers should de-
termine optimal duration of vestibular rehabilitation for
favorable outcomes and the factors that impact functional
recovery.
R. Research Recommendation 8: Researchers should per-
form longitudinal studies. Researchers should examine time
from onset and see whether it affects short- and long-term
outcomes.
R. Research Recommendation 9: Researchers should ex-
amine the concept of return to work. Areas for study in-
clude job requirements that may be difficult for patients
with vestibular hypofunction, job modification, or assistive
technology to allow return to work, criteria for return to
work or disability assignment, indicators for return to safe
driving.
SUMMARY OF RESEARCH RECOMMENDATIONS
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Copyright © 2016 Neurology Section, APTA. Unauthorized reproduction of this article is prohibited.
ACKNOWLEDGMENTS
We are grateful to Jacob O’Dell, MS, SPT, for countless
hours of research and assistance with data management
throughout this project.
The academic librarians from East Tennessee State Uni-
versity (Richard Wallace, MSLS, EdD, AHIP; Nakia Wood-
ward, MSIS, AHIP), Emory University (Amy Allison, MLS,
AHIP), and the University of Pittsburgh (Linda Hartman,
MLS, AHIP) performed the systematic literature searches.
We gratefully acknowledge Thomas Getchius, Director,
Clinical Practice at the American Academy of Neurology
for his generosity in sharing his expertise and the American
Academy of Neurology Clinical Practice Guideline Process
Manual.
We also thank John Engberg, PhD, who, as our patient
representative, provided valuable feedback to the process
and content of the guideline.
We are grateful to members of the Neurology Section
and Vestibular Special Interest Group who volunteered their
time and efforts to perform critical appraisals of the litera-
ture. The physical therapist critical appraisal team included
Carmen Abbott, Eric Anson, Kathryn Brown, Lisa Brown,
Janet Callahan, Diron Cassidy, Jennifer Braswell Christy,
Pam Cornwell, Renee Crumley, Elizabeth Dannenbaum,
Pamela Dunlap, Lisa Farrell, Julie Grove, John Heick, Ja-
net Helminski, Lisa Heusel-Gillig, Janene Holmberg, Jen-
nifer Kelly, Brooke Klatt, Jodi Krause, Karen Lambert, Rob
Landel, Lara Martin, Joann Moriarty-Baron, Laura Morris,
Charles Plishka, Nora Riley, Britta Smith, Debbie Struiksma,
Derek Steele, Brady Whetten, and Wendy Wood.
We acknowledge the support of Matthew Elrod, PT, DPT,
MEd, NCS, and Anita Bemis-Dougherty, PT, DPT, MAS,
of the APTA. The Neurology Section provided support and
guidance throughout the process, specifically through the
efforts of Beth Crowner, PT, DPT, NCS, MPPA, Director of
Practice, Neurology Section.
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