Timothy C. Hain, MD • Page last modified: April 14, 2022
Begin with simpler exercises, progress to harder ones. So what does it mean harder ?
These exercises as incorporate many "dimensions" -- protocol, speed/frequency, base of support, visual input, vestibular input, surface , and other activities going on simultaneously. Of course, this defines a gigantic multidimensional treatment space.
The goal is to find the relevant areas in this space which are not working well and practice them. A vestibular physical therapist can be very helpful in selecting the appropriate variation.
These exercises are not "done" just at the (weekly) PT session - - you do them EVERY DAY. We usually recommend doing them for at least 60 minutes (which may be split over several sessions). The duration needs to be carefully adjusted so that it is enough to make a person "dizzy", but not enough to make them "sick".
Usually one can integrate these exercises with other ones so that one doesn't end up spending ones entire day doing exercise.
Training devices are often found in physical therapy settings. These include devices made by Neurocom (for example, the Smart Balance-Master), Bertec, Metitur, Micromedical Technology, and KAT. They provide a formalized method of "implementing the protocol above. Because you can't use them for long periods of time, they don't help very much. We had one patient tell us that they were referred to have training on a "KAT" for 30 minutes/week. This is obviously not going to help very much. Perhaps just getting out of the house is the most valuable part for that patient.
Little outcome information is available about posturography training. These procedures involves a moving platform coupled to a computer monitor. The patient is asked to keep their center of pressure within a box on the screen or to track a visual target by shifting their weight on the platform. Typically two sessions are given per week over several weeks. In our opinion, this procedure seems unlikely to promote neuroplasticity or adaptation (because it is too short), but it might assist individuals in forming internal models of their body and the outside world. Forming and recalibrating internal models is certainly a worthwhile endeavor, critical to recovery from lesions. It seems likely to occur in time whether or not a device like this is available, but the progress of revising an internal model might be accelerated through guided practice.
A major problem with these devices is their intrinsic expense and short exposure. We do not recommend them as the sole form of VRT.
Available evidence, however, has not been very encouraging. Two recent studies suggested that there is no benefit from the Smart Balance-master training paradigm over conventional PT for acute stroke balance rehabilitation (Walker et al, 2000; Geiger et al, 2001). In our opinion, these studies are flawed because in this situation, it would seem to us that the effects of the training might be obscured by natural time dependent neural processes involved in stroke recovery that would progress with or without a daily 30 minute exposure to a training device. Also, study of strokes seems to us a poor choice of model as it is very difficult to find a large number of people with stroke who have exactly the same size, and location of their neurological lesion. Computerized posturography training has also not been shown to reduce falls (Gillespie, Gillespie et al. 2001).
Nevertheless, as noted above, there are some theoretical reasons to suspect that such devices might be helpful in accelerating the pace of recovery even though the exposure time is short. Additional studies are needed to determine the utility of these devices in other contexts than acute stroke such as vestibular imbalance or loss. One interesting question would be to see whether these devices have utility in more static clinical situations (such as a person who has had imbalance for several years). Another would be to examine the utility of these devices in contexts where the lesion perturbing balance is well understood, standardized and acute.
Avocational activities can also be excellent for vestibular rehabilitation. In general, activities should involve using the eyes while the head and body are in motion. Of course, many avocational activities require this -- golf, bowling, tennis, racquetball, ping-pong, etc. The trick is to find one that is fun, safe, and somewhat stimulating. Just walking around the block looking from side to side may be a useful activity. Dancing is of course, an excellent vestibular rehabilitative activity. Martial arts activities are also beneficial, as long as physical injury is avoided.
|Tai Chi for Balance, An alternative balance activity.|
"Alternative" balance activities. Yoga, Tai Chi, and martial arts are the activities that have been considered in the literature. Tai Chi and Yoga both incorporate some relaxation which may be helpful for those who have anxiety accompanying their dizziness or imbalance. These activities are intrinsically lower in cost than individualized therapy, but their efficacy has not been compared in a head-on fashion to individualized therapy.