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GERICLINICS

GeriQBank · Paper III · Q14

Vestibular rehabilitation

Moderate YieldAsked ×17-mark note
Topic
Falls, Gait & Syncope
Chapter
Falls, Gait, Syncope & Dizziness
Years asked
Not recorded in the source
Frequency
Set 1× in Paper III (2009–2025)

As set in the university paper

  • Vestibular rehabilitation.

    Paper III · Falls, Gait, Balance & Dizziness · asked ×1 · 7-mark note · see in paper list

Answer framework

  1. Principle — cerebral compensation; what recovery requires; structures involved; slower compensation in old age; decompensation
  2. Cawthorne–Cooksey exercises — origin; deliberate provocation; adapting to the older patient; the progression
  3. Evidence and effects — efficacy; ADLs and falls; peripheral and central disorders; age not a negative factor; customised programmes; start early
  4. Relationship with repositioning manoeuvres — Epley is distinct; combined treatment in BPPV
  5. Drugs and surgery — vestibular sedatives; avoid prochlorperazine; psychotropics; cautious surgery
  6. Recent updates — APTA 2022 guideline; supervised therapy; gaze-stabilisation dosing; no isolated eye exercises; early start; balance and gait modalities; modifying factors; PPPD; Indian delivery

An exam answer plan drawn from the detailed answer below. Use it to attempt the question first.

Detailed answer

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Attempt it firstOutline your answer as a 7-mark note before revealing it — definition, causes, evaluation, management and the geriatric angle.Reveal answer

Short revision answer

  • After an acute unilateral vestibular loss, vertigo usually settles in 6–12 weeks through cerebral compensation — reducing tone asymmetry and recalibrating VOR and vestibulospinal gain, using the brainstem, cerebellum, cortex, vision, somatosensory input and the remaining labyrinth. Vestibular rehabilitation drives and speeds this.
  • In older people CNS plasticity is reduced, so recovery is slower and rarely complete; cerebellar damage, poor proprioception, visual loss, mild cerebral dysfunction and psychological disorders impair compensation. Illness or bereavement can trigger decompensation, felt as floating or rocking rather than spinning.
  • Cawthorne–Cooksey exercises (mid-1940s): graduated head and eye movements that deliberately provoke dizziness to drive compensation — not an endurance test, so adapt them to the older patient. Progression: eyes alone → head movements (eyes open, then closed) → sitting → standing (sit-to-stand, throwing a ball) → moving about (walking with eyes closed, slopes, steps, ball games).
  • Evidence: rehabilitation improves ADLs and reduces fall risk, in both peripheral and central balance disorders; age is not a negative prognostic factor; customised exercises work as well as the standard regime — start early and emphatically.
  • BPPV: the Epley canalith repositioning manoeuvre is distinct and the most effective treatment; adding vestibular rehabilitation improves results, given frequent recurrence.
  • Drugs: vestibular sedatives (cinnarizine) only for acute vertigo — they suppress the asymmetry signal that drives compensation; avoid prochlorperazine (irreversible extrapyramidal syndrome); psychotropics only for psychiatric indications. Surgery in older people only after full neuro-otological work-up and exhaustive medical treatment, weighing the risk of lasting imbalance after a destructive procedure.
  • Updates (APTA 2022 guideline): offer supervised vestibular rehabilitation (strong recommendation) to adults with unilateral or bilateral hypofunction. Gaze stabilisation: ≥12 minutes a day in 3 sessions (acute unilateral), ≥20 minutes in 3–5 sessions (chronic unilateral), 20–40 minutes (bilateral). Don't prescribe eye exercises without head movement — retinal slip is the error signal that drives adaptation.
  • Start within 2 weeks of acute onset; add balance and gait training (virtual reality, optokinetic stimulation, perturbations, sensory feedback, dual-task walking, turning, task practice); suppressants, psychotropics and MCI worsen outcome. PPPD: rehabilitation plus SSRI/SNRI plus CBT. India: therapist-taught home programmes in the local language, family supervision, telerehabilitation and NPHCE clinics.

Condensed by GeriClinics from the detailed answer below, with no new facts added.

15–20 High-Yield Points (Textbook)

A. Principle — Cerebral Compensation

1.

After an acute unilateral vestibular upset the patient experiences vertigo, but symptoms are usually short-lived and resolve in 6–12 weeks by processes collectively known as cerebral compensation. Vestibular rehabilitation exists to drive and accelerate this compensation.

2.

Restoration of balance involves reducing or abolishing the asymmetry in postural and ocular motor tone and recalibrating the gain of dynamic vestibular reflexes to ensure symmetrical vestibulospinal and vestibulo-ocular reflex action during head and body movement.

3.

Compensation depends on brainstem, cerebellar and cortical structures together with sensory inputs including vision, somatosensory afferents and the remaining labyrinthine input.

4.

In the older patient the plasticity of the CNS is compromised, so recovery is often slower and is rarely complete. Contributing factors to failed compensation or intermittent decompensation include cerebellar damage, impaired proprioception, visual impairment, mild cerebral dysfunction and psychological disorders.

5.

Decompensation can be triggered by an intercurrent illness or a psychological upset such as bereavement, and then presents as vague floating, rocking or depersonalisation rather than true rotational vertigo.

B. Cawthorne–Cooksey Exercises

6.

Physical exercise regimes were introduced as early as the mid-1940s (the Cawthorne–Cooksey exercises) as a means of expediting recovery from peripheral vestibular disorders.

7.

They are a graduated series of exercises aimed at encouraging head and eye movements, which systematically provoke dizziness and facilitate vestibular compensation. The therapeutic principle is deliberate, controlled provocation of symptoms, not avoidance.

8.

The exercises are not an endurance test. In the older patient it is important to modify the regime within the limits of the patient’s physical abilities.

9.

Progression follows a standard order supplementary : eye movements alone (up-down, side-to-side, focusing on a finger), then head movements with eyes open and then closed, then movements while sitting (shoulder shrugging, bending forward to pick objects), then standing (sit-to-stand with eyes open and closed, throwing a ball), then moving about (walking across the room with eyes open and closed, walking up and down a slope and steps, ball games, and activities requiring bending and stretching).

C. Evidence and Effects

10.

The passage of time has supported the efficacy of these exercises.

11.

Successful vestibular rehabilitation improves activities of daily living and reduces fall risk — the key statement linking this topic to the falls syllabus.

12.

Significant improvement has been shown in patients with peripheral vestibular dysfunction and also in patients with central balance disorders.

13.

There is no evidence that age is a negative prognostic factor. Older patients should therefore be offered vestibular rehabilitation on exactly the same basis as younger patients.

14.

“Customised” exercises tailored to the individual patient are equally effective as the standard regime.

15.

Introduce vestibular rehabilitation and gait strategy exercises in the elderly early and emphatically — this is one of the chapter’s key points.

D. Relationship with Repositioning Manoeuvres

16.

Specific positional manoeuvres for benign positional vertigo, such as the Epley manoeuvre, form an important element of vestibular management and are distinct from vestibular rehabilitation.

17.

A combination of canalith repositioning manoeuvre and vestibular rehabilitation improves benign positional vertigo in the elderly. Although the repositioning manoeuvre is the most effective treatment, vestibular rehabilitation can be added to improve results, particularly given the high recurrence of positional vertigo.

E. Drugs and Vestibular Rehabilitation

18.

Vestibular sedatives such as cinnarizine are of value in managing acute vertigo but have a very limited role in managing chronic vestibular syndromes, because they suppress the very asymmetry signal that drives compensation.

19.

Anti-emetics such as prochlorperazine should be avoided because of the rare but irreversible syndrome of extrapyramidal dysfunction — a particularly important warning in older patients.

20.

Psychotropic drugs should be administered only for specific psychiatric indications, as such medication may interfere with compensatory mechanisms for peripheral vestibular disorders.

21.

Surgery: in the elderly the indications for otological surgery must be carefully weighed against the general medical state and the likely extent of postoperative recovery. Destructive surgical procedures should not be considered until detailed neuro-otological investigations have been performed and medical management has been tried exhaustively, and the risk of persisting imbalance after vestibular destruction must be borne in mind.

Latest Updates (2023–Present)

The updated Clinical Practice Guideline on Vestibular Rehabilitation for Peripheral Vestibular Hypofunction (Academy of Neurologic Physical Therapy, APTA, 2022; a revision of the 2016 guideline) is now the reference standard and gives, for the first time, explicit exercise dosing.

Strong recommendation: clinicians should offer vestibular rehabilitation to adults with unilateral and bilateral vestibular hypofunction who have impairments, activity limitations or participation restrictions, and should offer supervised vestibular rehabilitation rather than an unsupervised home programme alone. Gaze stabilisation dosing: at least 12 minutes daily, in 3 sessions, for acute or sub-acute unilateral vestibular hypofunction; at least 20 minutes daily, in 3 to 5 sessions, for chronic unilateral hypofunction; and a higher total daily dose (typically 20–40 minutes) for bilateral vestibular hypofunction, which also needs a longer progression.

Strong recommendation against: do not use voluntary saccadic or smooth-pursuit eye movements in isolation (that is, without head movement) to promote gaze stability — the guideline judged harm to outweigh benefit. Retinal slip produced by head movement is the necessary error signal for VOR adaptation. This is an important update, because “eye exercises” are still widely prescribed.

Early initiation of vestibular physical therapy, ideally within 2 weeks of acute onset of unilateral vestibular hypofunction, may optimise outcomes.

Balance and gait training should accompany gaze stabilisation, using a variety of modalities: low-technology exercise, virtual reality, optokinetic stimulation, platform perturbations, vibrotactile and augmented sensory feedback, dual-task walking, obstacle negotiation, uneven surfaces and turning, and task-specific ADL practice (sit-to-stand, stairs, bed mobility, tight-space turning).

The guideline gives expanded recommendations on factors that modify outcome, specifically medications (vestibular suppressants and psychotropics impair compensation) and mild cognitive impairment — which supports and updates the textbook’s warning about drugs and about failed compensation in the older brain. Persistent postural-perceptual dizziness (PPPD) is now a defined Bárány Society entity treated with vestibular rehabilitation plus SSRI/SNRI plus cognitive behavioural therapy, not with vestibular sedatives — the modern equivalent of the “anxious elderly patient with chronic disequilibrium” described in the textbook. Indian delivery: formal vestibular physiotherapy services are scarce outside tertiary centres. Practical approaches are therapist-taught, home-based customised Cawthorne–Cooksey and gaze stabilisation programmes with a written or illustrated schedule in the local language, family-supervised practice, telerehabilitation, and integration with NPHCE geriatric clinics and district physiotherapy services. This is supported by the textbook’s own finding that customised exercises are equally effective and that age is not a negative prognostic factor.

Current Practice Update

Issue Textbook position Current position

Exercise dose Graduated exercises, modified to the patient’s Explicit dosing: gaze stabilisation ≥12 min/day in ability; not an endurance test 3 sessions (acute/subacute UVH); ≥20 min/day in 3–5 sessions (chronic UVH); 20–40 min/day (BVH)

Eye exercises Head and eye movement exercises encouraged Strong recommendation against isolated saccadic or smooth-pursuit eye exercises without head movement Supervision Customised exercises equally effective Supervised programmes recommended (strong evidence); customisation retained Timing Introduce early and emphatically Quantified — within 2 weeks of acute onset may optimise outcomes Modalities Cawthorne–Cooksey exercises Plus virtual reality, optokinetic stimulation, vibrotactile and augmented sensory feedback, dual-task and gait training Drugs Vestibular sedatives limited to acute vertigo; avoid Unchanged and reinforced — medication effect is prochlorperazine; psychotropics interfere with now a formal outcome-modifying factor in the compensation guideline Exam One-Liners Vestibular rehabilitation works by driving cerebral compensation — abolishing tone asymmetry and recalibrating VOR gain. Cawthorne–Cooksey exercises (mid-1940s): graduated head and eye movements that deliberately provoke dizziness. Progression: eyes → head → sitting → standing → moving about.

Improves ADLs and reduces fall risk; effective in peripheral AND central balance disorders. Age is NOT a negative prognostic factor; customised exercises are equally effective. Dose (APTA 2022): ≥12 min/day acute UVH; ≥20 min/day chronic UVH; 20–40 min/day BVH. Do NOT prescribe isolated eye movements without head movement.

Avoid vestibular sedatives in chronic vertigo; avoid prochlorperazine (extrapyramidal risk). Epley + vestibular rehabilitation together give the best outcome in elderly BPPV.

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