Current concepts and future approaches to vestibular rehabilitation

Abstract

Over the last decades methods of vestibular rehabilitation to enhance adaptation to vestibular loss, habituation to changing sensory conditions, and sensory reweighting in the compensation process have been developed. However, the use of these techniques still depends to a large part on the educational background of the therapist. Individualized assessment of deficits and specific therapeutic programs for different disorders are sparse. Currently, vestibular rehabilitation is often used in an unspecific way in dizzy patients irrespective of the clinical findings. When predicting the future of vestibular rehabilitation, it is tempting to foretell advances in technology for assessment and treatment only, but the current intense exchange between clinicians and basic scientists also predicts advances in truly understanding the complex interactions between the peripheral senses and central adaptation mechanisms. More research is needed to develop reliable techniques to measure sensory dependence and to learn how this knowledge can be best used--by playing off the patient's sensory strength or working on the weakness. To be able using the emerging concepts, the neuro-otological community must strive to educate physicians, physiotherapists and nurses to perform the correct examinations for assessment of individual deficits and to look for factors that might impede rehabilitation.

Keywords: Adaptation; Habituation; Sensory reweighting; Vestibular rehabilitation.

Fig. 1

Postural learning or rehabilitation follows the same processes as general memory formation, i.e., from short-term to long-term learning through the process of consolidation, in which the training experiences are reprocessed during inactivity [14]. The process is affected by the cognitive state of mind (e.g. anxiety [17]) and by central nervous plasticity [59, 60] and impeded by reduced alertness from sedatives [61] or sleep deprivation [62]. When designing rehabilitation exercises, it is important to take into account that one exercise might affect succeeding exercises [63], and that the exercises themselves must be sufficiently challenging to promote learning [16, 63]. Learning might be through sensory reweighting or formation of internal models, i.e., motor programs whose output consists of preformed neuromuscular strategies activated automatically or voluntarily in given situations (anticipated movements) [64]

Fig. 2

Summary of trends in vestibular rehabilitation. Individualized assessment of deficits is the prerequisite for individualized treatment. New technologies and modern assessment will support the development of disease specific programs. HIT head impulse test, PT physical therapist, VR vestibular rehabilitation