Vestibular Habituation Protocol

Clinical Presentation

Vestibular habituation therapy aims to reduce dizziness and imbalance by repeatedly exposing patients to specific movements that provoke their symptoms. Patients who benefit from this protocol typically present with the following:

• Provoked Dizziness: Symptoms are triggered by specific head movements or visual stimuli.
• Motion Sensitivity: Increased dizziness with rapid head turns, changes in body position, or visual scanning.
• Imbalance: Feeling unsteady or wobbly, especially in dynamic environments.
• Possible Nausea/Vomiting: In severe cases, nausea and vomiting may accompany dizziness.
• Visual Disturbances: Blurred vision, difficulty focusing, or oscillopsia (a sensation of objects moving when they are still).
• Diagnoses: Common diagnoses include unilateral or bilateral vestibular hypofunction, persistent postural-perceptual dizziness (3PD), or motion sickness.

Rehabilitation Phases

Phase 1: Identification & Education

1. Thorough Assessment: Detailed history, dizziness handicap inventory (DHI), ocular motor examination (smooth pursuits, saccades, VOR), positional testing (Dix-Hallpike, Roll Test), dynamic visual acuity (DVA) and balance testing.
2. Patient Education: Explain the vestibular system's role, the rationale behind habituation, and the importance of adhering to the protocol. Address fears and anxieties associated with dizziness. Explain the expected initial increase in symptoms during exercises.
3. Safety Precautions: Emphasize the importance of performing exercises in a safe environment (near a wall or with assistance) and stopping if symptoms become overwhelming.

Phase 2: Habituation Exercises (Symptom Provocation)

The key principle is to induce mild to moderate dizziness with each exercise, allowing the brain to habituate to the sensation. Exercises are performed 2-3 times daily, with 2-3 repetitions each, gradually increasing repetitions as tolerated.

Phase 3: Progression & Functional Integration

Once the patient can tolerate the habituation exercises with minimal symptoms, progress to more challenging activities that simulate real-world situations. This phase focuses on improving balance, coordination, and visual stabilization during movement.

Specific Exercise Examples

1. Brandt-Daroff Exercises: Start seated, rapidly lie down on one side with head turned up 45 degrees. Hold until dizziness subsides. Return to seated and repeat on the other side.
2. Head Turns (Horizontal): Seated or standing, slowly turn the head from side to side, focusing on a distant target. Gradually increase speed and range of motion.
3. Head Nods (Vertical): Seated or standing, slowly nod the head up and down, focusing on a distant target. Gradually increase speed and range of motion.
4. Gaze Stabilization (VOR x1): Hold a small target at arm's length. Move your head horizontally or vertically while keeping your eyes focused on the target. Gradually increase speed.
5. Gaze Stabilization (VOR x2): Hold a small target at arm's length. Move both your head and the target in opposite directions while keeping your eyes focused on the target. Gradually increase speed.
6. Shoulder Shrugs with Head Turns: Perform head turns while simultaneously shrugging your shoulders.
7. Walking with Head Turns: Walk across a room while turning your head from side to side, focusing on different objects. Gradually increase speed.
8. Walking on Uneven Surfaces: Practice walking on foam pads, grass, or other uneven surfaces while maintaining balance.
9. Ball Toss with Head Turns: Toss a ball to a partner while simultaneously turning your head.
10. Visual Scanning: Practice visually scanning a busy environment (e.g., supermarket aisle) without becoming dizzy.
11. Chair Spins (Controlled): Sit in a swivel chair and slowly spin yourself in a circle, focusing on a fixed point.
12. Object Transfer with Head Movements While seated, transfer objects of varying weights from one location to another, deliberately turning your head during each transfer.

Evidence-Based Return to Function Criteria

1. Reduced Dizziness Severity: Subjective reports of decreased dizziness intensity and frequency, as measured by the DHI or similar scales. A clinically significant change is often considered a reduction of 18 points on the DHI.
2. Improved Balance: Improved performance on balance tests, such as the Berg Balance Scale, Timed Up and Go (TUG) test, and sharpened Romberg test. Demonstrating improved stability during dynamic activities.
3. Enhanced Visual Stabilization: Improved dynamic visual acuity (DVA). The ability to read at least 2 lines lower on a Snellen chart during head movements compared to static conditions.
4. Functional Task Completion: Ability to perform daily activities (e.g., walking, grocery shopping, driving) without significant dizziness or imbalance.
5. Independence: Patient demonstrates understanding of their condition and can independently manage their symptoms with home exercises.
6. Physiological Measures (If available) Resolution or improvement in objective findings such as nystagmus with repeat testing (e.g., positional testing).