Vestibular rehabilitation.

Vestibular rehabilitation is a physical therapy programme for persons with symptomatic lesions of the vestibular system. When applied early in the course of recovery, it can hasten compensation. It can also reduce symptoms resulting from permanent deficits caused by vestibular injury. It has been shown to be effective when applied to patients with unilateral or bilateral losses, and reduces both dizziness and imbalance. Compensation occurs through tonic re-balancing at the level of the vestibular nuclei; by substitution of vision, proprioception and peripheral sensation for the missing vestibular input; and by the use of behavioural strategies to deal with residual deficits. The latter two mechanisms can be facilitated with rehabilitation exercises. Treatment methods must be varied, based on the patient's underlying disorder. The best prognosis for full recovery is for individuals with acute, unilateral vestibular injury. Patients with bilateral lesions will show improvement, but will have permanent deficits. Persons with progressive vestibular disorders, those having central involvement and persons with visual or somatosensory impairments may require more prolonged courses of treatment or demonstrate incomplete recovery. Patients with a previous history of vestibular loss with recent decompensation require a thorough re-evaluation to rule out these more complex problems. Rehabilitation includes vestibular exercises, management of vestibular suppressant medications, general conditioning and patient instruction. Exercises should be directed at static and active posture and balance, eye-head co-ordination and symptomatic dizziness. Balance exercises include practice with standing, walking and turning. Eye-head co-ordination exercises require head movement during visual fixation or visual target changes. Treatment of symptomatic dizziness is based upon habituation to the provoking stimulus, usually head or eye movement. Home exercises are combined with formal physical therapy sessions and patient education to complete the process of rehabilitation.