Vestibular Rehab after Stroke

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The following course content

Introduction   

A stroke can affect areas of the brain responsible for balance and coordination causing dizziness and vertigo. Clients who have had stroke are also at a high risk of falling due to the impairments in motor and higher cerebral functions.  

The vestibular system is the body’s internal balance mechanism. When it works well, clients can move around confidently and easily. But it can greatly impact their daily lives when it doesn’t work properly.  

Vestibular rehabilitation therapy offers a structured approach that aims to improve postural stability and has been found to be effective in improving balance and reducing dizziness with head movements. This type of therapy can assist clients overcome feelings of imbalance, vertigo and/ or general dizziness. Good balance depends on the brain, eyes and body working together. Adding vestibular rehabilitation exercises to the usual care during stroke rehabilitation can be of additional benefit for clients who have post-stroke dizziness and may improve gait and balance.  

Definitions 

Vestibular rehabilitation therapy (VRT) is a specialized form of therapy intended to alleviate the problems caused by vertigo, dizziness, gaze instability and imbalance and falls. Gaze instability and vertigo are both symptoms of vestibular disorders that stem from a disruption in the network between the inner ear and brain that process sensory cues and controls balance. With movement, the fluid in the ear moves also sending messages to the brain about special positioning. When this process is disrupted, balance problems can occur.  

Vestibular disorders can cause the following symptoms: 

• Gaze instability: often occurs as an issue following stokes and is the inability to focus on objects, especially while walking. It has also been called movement-induced dizziness.  
• Vertigo: typically characterized as a spinning or whirling sensation.  

Any condition that affects the blood supply to part of the brain preventing brain tissue from getting oxygen and nutrients can be categorized as an ischemic stroke: 

• Caused by a blocked artery in the brain where brain cells begin to die in minutes 
• Most common type of stroke 
• Occurs when fatty deposits, blood clots or other debris become lodged in the blood vessels in the brain 

Another type of stroke is a hemorrhagic stroke: 

• Caused by a blood vessel that leaks or bursts causing bleeding in the brain. The blood increases pressure on brain cells and damages them. 
• Brought on by high blood pressure that’s not under control or over treatment with anticoagulants. 
• Aneurysms at the weak spots in the blood vessel walls causing bulging   

Any form of stroke can cause temporary or permanent disabilities and complications depend on how long the brain lacks blood flow and which part of the brain is affected. (1) The friends and family members who care for a client with vestibular issues following a stroke need education and support to understand how this impacts their loved one’s lives and lessen the impacts.  

Vestibular therapy is not recommended for clients with unstable lesions, ongoing inner ear problems, or sudden episodes like those in Meniere’s disease so it is essential to have a thorough evaluation to accurately diagnose and determine if vestibular rehabilitation is appropriate.   

Etiology 

As different parts of the brain control different parts of the body, symptoms will depend on the part of the brain affected and the extent of the damage. Typical symptoms are paralysis, numbness, or inability to move parts of the face, arm or leg, particularly on one side of the body. Feeling dizzy is a common sign that something might be wrong with the vestibular system. There can be loss of vision, strength, coordination, feeling or speech, as well as problems understanding speech.  

Some clients may not be able to identify the stroke symptoms due to (2): 

1. Lack of awareness and not realizing they’re having a stroke and may ignore the signs.  
2. Anosognosia where the stroke itself can make the client unaware of the problem due to the brain’s inability to process the fact that their thoughts and moods don’t reflect reality 
3. The inability to call for help is common because the client may know there is a problem but they can’t call for emergency help on their own. 
4. Silent strokes, unlike typical strokes, occur without noticeable symptoms. 
5. The symptoms depend on the specific area of the brain affected.  

Strokes that affect the brain stem with an interruption in blood flow to the brain cause the vestibular symptoms of vertigo, dizziness and balance problems. The brain stem controls the body’s central nervous system and can affect both mental and physical activities and sensations. Both motor function and consciousness can be affected, creating the sensation of vertigo. Gaze stability and dizziness are common difficulties following a stroke.  

The client may also experience diplopia or double vision, dysarthria which causes a weakness in the muscles used for speech resulting in slurred speech, dysphagia resulting in difficulty swallowing, ataxia with lack of voluntary muscle control, visual field deficits, and unilateral limb weakness. Vestibular dysfunction is more prevalent following a stroke that has affected the cerebellum or brainstem but could also occur if the client experienced a fall or trauma to the head.  

The Vestibular System 

The vestibular system is made up of two structures that are tied in with the anatomical features of the inner ear and to the muscles in the eyes and neck that maintain good balance. They act as a sort of three-dimensional compass that can detect head movement and send signals through the nervous system to control eye muscle movements.  

Adjacent to the cochlea within the inner ear is a structure called the vestibular labyrinth made up of otolith organs and semicircular canals. The otolith organs are responsible for determining gravity through the tilt of the head and linear acceleration. The cochlea and otolith organs contain hair cells, similar to the hair cells within the auditory system, which bend and move with tilting of the head. (3)  The semi-circular canals are filled with fluid and the position of the fluid changes with movement. This information is then sent to the brain to add to your sense of balance.  

Clients with vestibular issues often experience a profound impact on their daily lives. The symptoms can be frightening and isolating, leading to anxiety, depression or PTSD that may go unaddressed. The stress that they may be having interferes with the brain’s re-calibration. Excessive worrying can magnify symptoms and prolong recovery. All of these issues could prevent the client from completing their exercises or performing self-care at home as instructed.  

People with insomnia often do not recover as quickly as other clients who can sleep deeply after a physical therapy session. Disrupted sleep can interfere with the vestibular recovery process. Sleep is the key time for the brain to reset and recalibrate after each treatment for VRT. (13) 

Diagnosing Vestibular Disorders 

There are many specialists involved in diagnosing a vestibular disorder following a stroke – usually, an audiologist for hearing or vestibular testing, a physical therapist for gait and balance related testing, and/or a radiologist for imaging testing. Vestibular dysfunction often presents as dizziness. Nearly one out of ten cases get overlooked or missed because geriatric clients do not always report their symptoms. Some clients think it’s normal to experience dizziness with aging, others don’t report “dizziness” they just say they feel unsteady. (10) 

It is important to assess for neck problems that may not have been addressed. These problems can become aggravated with VRT exercises. They can exacerbate headaches and neck pain. Lightheadedness can also be caused by neck problems being aggravated by the VRT exercises. If the exercise protocols are not followed correctly, they may not work. 

The exercise parameters include a lot of details such as the angle of the head, the speed of movement, the arc of motion, the direction of movement, the duration of the exercise and any pause or hold times. (13) 

Many of the vestibular tests use equipment to monitor the eyes for normal and abnormal movements when the vestibular system is actively stimulated. They can be fatiguing for the client and even result in temporary unsteadiness. The initial evaluation may feel like a mix between a doctor’s appointment and carnival fun house. The client may find themselves spinning in chairs, walking on foam surfaces, or tracking objects with their eyes. While these tests may seem quirky, they’re designed to challenge the vestibular system and uncover any underlying issues. (7) 

Diagnostic Tests 

Tests for vestibular disorders include electro/video-nystagmography, rotational testing, video head impulse testing, magnetic resonance imaging (MRI), and computerized axial tomography (CAT or CT) 

1. Electro/video-nystagmography (ENG or VNG):   
   1. ENG is a group of tests that involve using small electrodes placed over the skin around the eyes during testing.  
   2. VNG uses a set of video goggles to monitor the eyes. 
   3. Both tests measure eye movements as the head is placed in different positions to evaluate signs of vestibular dysfunction or neurological problems and are a key step in diagnosing vestibular disorders.  
   4. Usually performed in a room that is dark or with low lighting, the examiner asks random questions that are meant to distract the person being tested and keep them alert.  
   5. This is the most common set of tests administered to people with dizziness, vertigo and/ or imbalance as they follow different visual targets, which may be projected on either a light bar or TV screen.  
   6. The caloric test uses water or air to change the temperature within the ear canal to stimulate part of the inner ear’s vestibular organs. In a healthy ear, this does not result in a sensation of motion and jerking eye movements (nystagmus) for a short time.  
2. Rotational Testing: 
   1. Evaluates how well the eyes and inner ear work together at slow to moderate speeds. 
   2. While wearing video goggles or electrodes to detect eye movements, the head is rotated from side to side at slow to moderate speeds, and the eye movements are then analyzed.  
3. Video Head Impulse Testing 
   1. Evaluates how well the eyes and inner ears work together at speeds more consistent with natural everyday head movement.  
   2. A small set of glasses with a camera are used to monitor eye movements and very small, quick movements of the head to evaluate reflex functions as opposed to the slow or moderate speeds used in rotation testing.  
4. Magnetic Resonance Imaging (MRI) 
   1. Uses a magnetic field and radio waves to produce cross-sectional images of body tissues being scanned.  
   2. Can reveal the presence of tumors, stroke damage, and other soft-tissue abnormalities that might cause dizziness or vertigo.  
5. Computerized Axial Tomography (CAT or CT) 
   1. An x-ray technique that is best for studying bony structures and can look for abnormalities around the inner ear, such as fractures or areas with thinning bone.  

Assessment Questions 

Assessment questions that are useful in determining the effects of the client’s dizziness and unsteadiness (12): 

1. Do you refrain from going out or traveling due to dizziness and unsteadiness? 
2. Do you dislike walking in the dark places around your home? 
3. Do you dislike going downstairs? 
4. Is the degree of dizziness or unsteadiness strengthened when you suddenly move your head? 
5. Do you dislike walking through narrow spaces? 
6. Do you feel that you have a handicap in your body and are inferior to others due to the dizziness and unsteadiness? 
7. Do you think it’s too much trouble to read books or newspapers due to the dizziness or unsteadiness? 
8. Does the dizziness increase when getting up from a chair? 
9. Do you refrain from meeting or going out with family or friends due to dizziness and unsteadiness? 

Vestibular Rehabilitation with Physical Therapy and Occupational Therapy 

VRT is an exercise-based program that aims to promote recovery from vestibular disorders by encouraging adaptation and substitution mechanisms using customized exercise programs tailored to specific vestibular impairments and individual client responses. It can have a transformative effect, providing emotional and physical relief that clients feel when their symptoms are managed. Dizziness and balance go hand-in-hand because the central nervous system pulls all the information together from the vestibular labyrinth in the inner ear, the eyes and the skin, joints and muscles and tells the body how to maintain balance. A stroke can interfere with this connection so the central nervous system can’t process the information correctly. VRT helps restore these connections, reducing the symptoms of dizziness and imbalance. (8) 

Before starting VRT a client’s symptoms need to be evaluated which may include a visit to an audiologist for a vestibular test battery. These tests evaluate how well the vestibular part of the inner ear is working. The physical therapist will then evaluate the client’s balance, gait, arm and leg strength and flexibility. 

Clients typically engage in a vestibular rehabilitation program for about 6-12 weeks until they experience no dizziness for two consecutive weeks and then follow up visits usually occur afterwards every 1-2 weeks to monitor progress and adjust the exercise program as needed. (8) 

Physical Therapist’s Role in Vestibular Therapy 

Physical therapists (PTs) play a crucial role in managing dysfunction by using various techniques to help retrain the brain to cope with the changes in the vestibular system. During the treatment process, a home exercise program may also be customized to meet the client’s physical condition. Most of the exercises are designed to retrain the brain to recognize and process signals from the inner ear, eliminating dizziness. Some treatments involve repositioning of the small crystals inside the inner ear to stop vertigo. The exercises will also work on restoring any balance issues that are present also. (4, 5) 

Along with exercise, client and caregiver education is an integral part of VRT and many find it useful to understand the science behind their vestibular problems as well as how it relates to the difficulties they may face functioning in everyday life. Education also takes away the mystery of what they are experiencing. (4) 

Even though the exercises are not difficult to learn they’re not necessarily easy to do and may at first make symptoms worse. They can be tedious and committing to doing them is key to helping the client achieve success. It’s important to have the client set up a regular schedule so that it is incorporated into their day. (4) 

Symptomatic relapses can occasionally occur because the brain de-compensates due to different emotional and / or physical stressors like personal or job-related pressures, periods of inactivity, a bad cold or flu, extreme fatigue or chronic lack of sleep, changes in medication, or sometimes surgery. Returning to the exercises that helped them in the beginning will help them recover again more quickly. (4) 

Occupational Therapist’s Role in Vestibular Therapy  

Occupational therapists (OTs) provide VRT not only from an exercise point of view but in help to manage and improve their symptoms for better participation in their purposeful daily activities. The vestibular effects can wreak havoc on a client’s daily life, making simple tasks like getting out of bed, walking to the mailbox, or even reading a book feel like monumental challenges. They look at the whole person and recognize and treat the social/ behavioral, cognitive, visual, and physical aspects that contribute to dizziness and imbalance and how their challenge affects participation in daily activities. (6) 

They can implement vestibular, vision, cognitive, and home modification advice since falls are a significant concern following a stroke and with vestibular dysfunction. They can adapt their environment or instruct on approaches to handling challenging situations such as work-related or driving challenges as well as managing their home environment and personal interactions affected by their dizziness and imbalance. The OT can implement appropriate durable medical equipment and ambulatory assistive devices along with the balance training. (6)  

Types of Vestibular Rehabilitation Exercises 

The VRT exercises aren’t like a typical gym workout but are carefully crafted routines designed to retrain the brain and body to work in harmony. Little equipment is needed for a clinician in the home to complete vestibular rehabilitation assessments and exercises. Access to a detailed history from the client or caregiver is needed to guide treatment.  

One key approach is the use of adaptation and habituation techniques. These work by gradually exposing clients to movements or situations that trigger their symptoms. Over time, the brain learns to interpret these signals correctly, reducing the intensity of symptoms.  

A client may start with simple head movements and progress to more complex activities like visual special activities in occupational therapy. These exercises not only address the vestibular issue but also enhance overall cognitive skills and daily functioning.  

Balance training is another crucial component of vestibular therapy. Therapists use a variety of tools and techniques to challenge and improve balance, from simple exercises on firm ground to more advanced activities using balance boards or virtual reality systems. 

The most important aspect of vestibular therapy is its focus on integrating these exercises into daily life in their everyday environments. It might involve practicing grocery shopping in a busy store, navigating crowded sidewalks or even getting back to work. (7) The client’s agreement and participation in the modification of the home environment will be an important aspect of the client’s success. The primary caregiver or other individuals in the home or living environment need to learn the importance of the changes that may need to be made.  

Vestibular rehabilitation exercises (8): 

1. Habituation exercises 
   1. Focuses on reducing dizziness by exposing the client to specific movements that cause symptoms helping the brain to adapt and reduce symptoms 
   2. The goal is to desensitize the vestibular system to these movements, gradually decreasing the intensity of the dizziness experienced 
   3. The therapist designs a program that includes various head and body movements and encourages the client to practice these regularly. Over time the brain learns to ignore the abnormal vestibular responses, improving symptoms 
2. Gaze stabilization exercises 
   1. Aims to improve visual stability during head movements, essential for reducing dizziness 
   2. Involve fixating on an object while moving the head back and forth or up and down.  
   3. Helps to retrain the vestibular-ocular reflex which improves the brain’s ability to maintain visual stability during head motion 
   4. Common exercises include horizontal and vertical head movements by instructing clients to fixate on a stationary object while moving their heads in different directions.  
   5. Progression of gaze stabilization exercises requires increasing degrees of light and visually stimulating backgrounds with appropriate equipment. (9) 
3. Balance training exercises 
   1. Vital to vestibular rehabilitation to help clients regain confidence and stability in daily activities.  
   2. Enhances steadiness for daily activities and improves walking ability on uneven ground and maintaining overall balance.  
   3. Involves exercises that challenge the client’s postural control, such as standing on a narrow base or a cushion with their eyes closed. 
   4. Helps to improve postural stability and enhance the client’s ability to maintain balance in various situations 
   5. Three primary postural strategies are used for balance recovery while standing (the ankle strategy, hip strategy, and step strategy) 
   6. Includes tasks that mimic real-life scenarios, such as walking on uneven surfaces or navigating crowded spaces to help clients handle everyday challenges. (8) 

Vestibular rehabilitation also includes walking for endurance and exercises to improve gait and overall balance. These exercises are intended to facilitate improvement in sensory and visual systems. A variety of methods can be used including foam or uneven surfaces during gait and functional tasks, decreasing base of support, weight shifting to facilitate balance recovery and balance activities under changing visual stimuli (such as a busy background or eyes closed). General conditioning is also included as well because many clients avoid provoking any type of motion and become deconditioned. (9) 

Benefits of Vestibular Rehabilitation 

One of the advantages of vestibular rehabilitation is the ability to perform exercises at home with minimal equipment. This allows the client to integrate the exercises into their daily routines, making it easier to maintain consistency. Vestibular rehabilitation exercises have few complications, but nausea and symptom increase are the most prevalent. Exercises can be modified through duration and intensity, and sometimes antiemetic medication may be necessary in conjunction with exercises in the case of prolonged vertigo following vestibular exercises. (9) 

Clients often experience significant improvement in their balance and coordination. Tasks that once seemed impossible, like walking in a straight line or turning quickly to look at something, become manageable again. It can significantly increase independence in activities of daily living. From personal care tasks like showering and dressing to more complex activities like cooking or driving, clients often regain the ability to safely and confidently perform them again.  

Educating clients about the role of activity in recovery can provide the first step toward encouraging self-management of symptoms. They should be encouraged to resume activity and understand that movement provoked symptoms are an inevitable part of the recovery process and are not warning signals of possible serious damage, illness, or set-backs. (11) 

VRT should be stopped when (14): 

• The main goals are met or symptoms resolve 
• When symptoms no longer improve or worsen for a prolonged time 
• If problems (co-morbidities), other than those due to inner ear, prevent participation 
• Prescribed home exercises are not regularly performed (non-adherence) 
• Client chooses to discontinue 

The visual-vestibular integration is another area where clients see dramatic improvements which is crucial for activities like reading while moving or tracking objects in a busy environment. It also can reduce the risk of falls, potentially preventing serious injuries and maintaining quality of life. (7)  Dizziness and associated postural imbalance increase the risk of falls and are the leading cause of injury-related emergency room visits, hospital admissions, and accidental deaths in the elderly population.  

Side Effects from Vestibular Rehabilitation Therapy 

VRT can be journey that test both the body and mind so the path to recovery for those with inner ear disorders is not without challenges. Even the simplest activities can turn into daunting obstacles. Trying to teach the brain and body to work in harmony can be extremely challenging. The dizziness, vertigo, nausea, motion sickness, fatigue, and exhaustion are all symptoms the client going through VRT needs to overcome to be successful.  

Proper pacing and gradual progression are key. The balance system won’t be fixed overnight so the therapist should tailor the exercises to the client’s tolerance level gradually ramping things up as they improve. Educating the client on hydration and nutrition is important as hydration can help combat fatigue and headaches and a balanced diet provides the energy for the body to heal and adapt.  

Rest and recovery can help ease some of the side effects and it is crucial for the client to listen to their body to give it time to adapt to the therapy. The brain and body need time to adapt to the new normal that the client is experiencing. Most clients can start to see improvements in a few weeks to a few months. Maintenance exercises are important to prevent future problems. Lack of improvement over time though would be a reason to check with the healthcare provider.  

If dizziness is so bad that the client can’t function in daily life, or if the nausea is completely taking over their daily activity, they need to check with their provider. Managing the side effects is about balancing all parts of the therapy with regular checkups. (15) 

The Future of Vestibular Rehabilitation 

The field of vestibular rehabilitation continues to evolve and expand with new techniques and technologies to enhance treatment outcomes. The goal is to improve clients’ quality of life. The future of VRT includes virtual reality, wearable technologies, and mobile/smart phone apps (11). 

Virtual Reality 

Virtual reality allows the ability to practice navigating a crowded street or riding a roller coaster from the safety of a therapy clinic. These immersive experiences can provide controlled, repeatable environments for clients to challenge their vestibular systems and build confidence. (11) 

Wearable Technology 

Wearable technology includes devices that track movement, balance, and even eye movements throughout the day can provide valuable data to therapists allowing for more personalized and precise treatment plans. (7) Emergency alert bracelets or pendants give the client the ability to call for help if a fall occurs or they feel they are incapacitated in any way. (11) 

Mobile/Smart Phone Apps 

Mobile/smart phone apps may include a daily episode app that allows the client to track dizziness, vertigo, headache, and off-balance severity and graphs the episodes over time. These apps can also pull in weather and barometric pressure data. These apps can even provide home-based virtual reality exercise programs and give feed-back guided postural training in virtual reality. The concept of geo-tagging could be applied (i.e. a “real” reality walk on a specific route that has postural and sensory challenges). (11) 

Conclusion

Every stroke is different with injury to the brain but when the vestibular system is involved, balance and equilibrium are affected because of the approximation of this system to the inner ear and the way it communicates with the brain to relay information about balance and the body’s orientation in space.  

Vestibular therapy is a vital but overlooked area of physical and occupational therapy. It requires a detailed understanding of the vestibular system obtained through specialized training that allows the therapist to make assessments, accurately implement the exercises to reset the vestibular system, and evaluate the progress.  

Compassion for those suffering with vestibular dysfunction and an understanding that this is a life changing event can make the difference between a life of discomfort and one of recovery and hope.  

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