Describe vestibular rehabilitation.

Vestibular Rehabilitation

• Vestibular rehabilitation is a programme of exercises designed to promote central compensation for a vestibular deficit.
• It works by deliberately provoking the symptom so that the brain recalibrates — which is the opposite of what patients instinctively do.
• The three mechanisms it exploits — adaptation, in which the vestibulo-ocular reflex gain is recalibrated by repeated head movement while fixating a target; substitution, in which vision and proprioception take over from the missing vestibular input; and habituation, in which repeated exposure to a provoking movement reduces the response to it
• The central principle IS that compensation requires movement and error: the brain only recalibrates when it receives a mismatch signal. Rest, immobility and vestibular sedatives all prevent that signal and therefore prevent recovery
• The corollary is the single most useful instruction in this chapter: stop the sedatives and move. Prolonged prochlorperazine is the commonest reason a self-limiting vestibular illness becomes chronic
• Indications — vestibular neuritis and labyrinthitis; after labyrinthectomy or vestibular neurectomy; after acoustic neuroma surgery; bilateral vestibular loss, in which substitution is the only available mechanism; chronic uncompensated peripheral loss; persistent postural-perceptual dizziness; and multisensory imbalance in the elderly
• It is not the treatment for BPPV, which needs a repositioning manoeuvre; nor for fluctuating or actively progressing disease such as untreated Meniere disease, in which there is no stable deficit to compensate for
• Components — gaze stabilisation exercises (fixating a target while turning the head, progressively faster); cawthorne-cooksey exercises, the classical graded programme of eye, head and body movements progressing from lying to standing to walking; balance and gait training on progressively unstable surfaces and with eyes closed; habituation exercises repeating the specific movements that provoke symptoms; and general conditioning
• Principles OF prescription — start early; customise to the deficit; little and often, several short sessions daily rather than one long one; progress the difficulty; and warn the patient that the exercises will make them feel worse at first — because if they are not warned, they will stop
• Factors that impair compensation — vestibular sedatives; immobility and avoidance; anxiety and depression.
• Address the anxiety explicitly — fear of falling and avoidance behaviour are frequently the main obstacle, and cognitive behavioural approaches and antidepressants improve the physical outcome, not merely the mood
• Outcomes are good, with most patients improving substantially; and even bilateral vestibular loss improves through visual and proprioceptive substitution, though such patients remain disabled in the dark and on uneven ground and must be advised accordingly