Vestibular Assessment and Rehabilitation
With more than half the US population affected by balance or
vestibular disorders at some point in their lives1, the need
for effective diagnostic and treatment approaches is clear. Unfortunately,
diagnosis and treatment of balance disorders that do not quickly resolve on
their own has historically been difficult due to the complex, multifactoral
nature of the problems.
is a complex process that depends on appropriate organization of information
from the gaze stabilization and postural stabilization systems, and coordinated
responses of the voluntary and automatic motor systems. Dizziness and imbalance
can be caused by disruptions in any one of these systems, or in the adaptive
brain mechanisms that coordinate the actions of these systems.
Vestibular system integrity is important in the balance control process, but it
is only one factor in the evaluation of balance function. Even when specific
vestibular pathology is identified, the diagnostic and treatment planning
process is incomplete, as the patient’s status may be further complicated by
problems in other sensory or motor systems, or problems in the brain’s adaptive
functions. "The first task of the practitioner, therefore, is to determine
whether the problem is sensory, integrative, or motor in nature" (Goebel).2
Once this has been established, then an effective treatment plan can be
prescribed, including medical, surgical, or rehabilitative strategies as
The Complete Balance Assessment
The patient with chronic dizziness, unsteadiness or imbalance is best served by
starting with a comprehensive clinical evaluation, which includes
History, focusing on both the nature of the dizziness and the associated
Physical examination, including oculomotor and vestibuloocular reflexes (VOR),
positioning tests, and evaluation of cerebellar, posture and gait functions
Objective tests are then used to confirm or refute a diagnostic hypothoses
formulated during the clinical evaluation, and to identify the functional
impairments resulting from the disease.
Site-of-lesion testing, such as ENG, Rotary Chair, MRI
Sensory, motor, and brain adaptive impairment testing, such as CDP
Effective treatment planning takes into consideration both pathology and
underlying impairments, and target those specific components of the balance
disorder. Controlled outcome studies have demonstrated that outcomes improves
significantly when rehabilitation is customized to target specific impairments.3,
4 Further, objective measures of balance impairment establish a
baseline to evaluate and document progress through rehabilitation.
For the complex balance patient, traditional diagnostic tests (ENG, rotary
chair, MRI, etc.), are helpful in confirming site-of-lesion diagnoses, but they
do not isolate the patient's functional problems. Objective measures of
underlying sensory/motor/adaptive impairments provide complementary functional
information that is essential for effective treatment planning and outcome
Advances in computerized
assessment technology have made it possible to isolate and quantify
specific impairments related to vestibular, somatosensory, and visual inputs to
balance; automatic motor responses and movement strategies; voluntary motor
responses; center of gravity alignment and weight bearing; and planning and
coordination of weight transfers for mobility function. Medical devices are
available that aid the clinician in classifying patients in terms of specific
pathology and specific impairments, as well as the resulting functional
limitations. This comprehensive information enables the effective integration
of traditional surgical and medical treatment options with targeted
rehabilitation methods. This evidence based approach allows the clinician to
minimize the impact of pathology and maximize the patient's functional
Tests of Vestibular and Balance Function
A review of the information provided by the routine vestibular and balance
studies illustrates how site-of-lesion and impairment tests may be utilized in
a collective manner to assist in patient management and which tests would be
the most useful and appropriate for a given patient.5, 6, 7, 8
Extent & Site of Lesion:
Electronystagmography (ENG) – electrodes or video
Motor components of Computerized
Dynamic Posturography (CDP)
Vestibular Evoked Myogenic Potentials
Impairments/Functional Performance/Objectify Complaints:
The preceding list highlights the designed utility of the available clinical
tests. It does not, however, reflect the way they are utilized. Typically, it
is the combination of test findings that are used to develop a final impression
from the evaluation.9 The site-of-lesion tests are typically used to
confirm the presumptive diagnosis, although there are situations where
unexpected results alter the initial presumption.9 The
site-of-lesion and impairment tests are then used to identify those underlying
problems having the greatest impact on the patient’s symptoms and functional
limitations, and those most likely to respond positively to treatment.
Vestibular and Balance Rehab
Vestibular and balance rehabilitation is effective for appropriately identified
patients and when customized to target specific impairment problems. The
comprehensive balance assessment, which includes pathology, underlying
impairments and functional limitations, can provide the necessary data for
accurate treatment customization. The rehabilitation intervention itself is
most appropriately provided by specially trained rehabilitation professionals
familiar with the appropriate sensory, motor and adaptive training exercises.
Specifically, the specialist providing the rehabilitation component of the
program should possess advanced training in the area of vestibular dysfunction
and balance. Currently, core physical therapy education does not include
entry-level knowledge of this complex patient population. For vestibular
rehabilitation and balance retraining therapy, the hallmarks to look for in a
rehabilitation professional is a thorough understanding of the interactions
among pathological and impairment mechanisms and the use of objective
assessment data for treatment planning that targets the individual patient’s
To maximize the benefit of a rehabilitation program, the prescribed exercises
must focus on resolving the underlying impairments and functional limitations.
The exercises must also be appropriately challenging and keep the patient
motivated. A generic approach to balance treatment will not be as effective as
an approach that singles out the underlying impairments, and may not improve
function at all.
To support effective treatment planning and improve functional outcomes, the
clinician may use computerized training protocols, which can be customized to target the
specific impairments of the individual patient. Deficits in multi-sensory
integration exist in many individuals with vestibular loss. Retraining should,
therefore, include protocols to address the sensory processing deficits,
including sensory substitution and sensory-challenge exercises. Further,
prescribed tasks in a variety of environments (unstable surface, moving visual
field) will require the patient to update and prioritize sensory inputs and
motor response. The difficulty level of the targeted exercises can be adjusted
to match patient ability, and then increased to keep the patient challenged and
maximize learning as the patient recovers.
Real time visual biofeedback further enhances motor learning by helping the
patient understand the prescribed training task, and by providing both the
patient and the clinician with instant feedback on how they are performing a
prescribed task. As treatment progresses, this feedback can be gradually
withdrawn and then eliminated as the patient’s functional capabilities improve
and newly learned skills are integrated into more complex motor activities.
By accurately identifying pathology, as well as underlying
sensory/motor/central adaptive impairments and functional limitations, patient
care and functional outcome can be significantly improved. To aid in accurate
diagnosis and objective functional assessment, the physician should follow a
systematic and standardized procedure for each patient, beginning with a
thorough history and physical exam. Based on the findings of this initial
evaluation a presumptive or conclusive diagnosis may be made in some instances.
When the diagnosis is presumptive, site of lesion testing such as ENG, rotary
chair may be warranted. Whether or not a conclusive diagnosis can be
established, treatments can only be effectively targeted after the patient's
underlying impairments and functional limitations have been quantified.
Practical Management of the Dizzy Patient
Joel A. Goebel, MD, FACS, Editor
Lippincott, Williams & Wilkins 2001
Management of the Patient with Chronic Complaints of Dizziness: An Overview of Laboratory Studies
Neil T. Shepard, PhD
NeuroCom®, a division of Natus® Publication 2003
Clinical Utility of the Motor Control Test (MCT) and Postural Evoked Responses
Neil T. Shepard, PhD
NeuroCom Publication 2000
"Cost Effectiveness of the Diagnostic Evaluation of Vertigo"
Michael G. Stewart, MD, MPH; et al.
The Laryngoscope 109:600-605 1999
The Vestibular Labyrinth in Health and Disease
Joel A. Goebel MD, FACS, and Stephen M. Highstein Editors
Vol 942; Annals of the NY Academy of Sciences, 2001
National Institute on Deafness and Other Communication Disorders, March 1997
Goebel, JA (ed.) (2001) Practical Management of the Dizzy Patient. Lippincott,
Williams & Wilkins.
Black F, Angel C, Pesznecker S, Gianna C. "Outcome analysis of individualized
vestibular rehabilitation protocols." Am J Otology 2000 21:543-551.
Rose D, Clark S (2000). "Can the control of bodily orientation be significantly
improved in a group of older adults with a history of falls?" JAGS 48:275-282.
Baloh RW, Halmagyi GM (eds.) (1996). Disorders of the vestibular system.
New York: Oxford University Press.
Leigh RJ, Zee DS (1999). The Neurology of Eye Movements. 3rd ed. Philadelphia:
F.A. Davis Company.
Halmagyi GM & Colebatch JG (1995). "Vestibular evoked myogenic potentials in
the sternoclidomastoid muscle are not of lateral canal origin." Acta
Otolaryngol (Stockh) supp 520, pp 1-3.
Shepard NT & Howarth AE (1999). Vestibulocollic auditory evoked potentials:
Normative ranges. Midwinter Research Meeting of the ARO.
Shepard NT (2003). Laboratory Studies in the Management of the Dizzy and
Balance Disordered Patient. NeuroCom Short Communication Publication.
NeuroCom, Clackamas, OR.