Rehabilitation of dynamic visual acuity in patients with unilateral vestibular hypofunction: earlier is better.

PURPOSE: Patients with acute peripheral unilateral hypofunction (UVH) complain of vertigo and dizziness and show posture imbalance and gaze instability. Vestibular rehabilitation therapy (VR) enhances the functional recovery and it has been shown that gaze stabilization exercises improved the dynamic visual acuity (DVA). Whether the effects of VR depend or not on the moment when it is applied remains however unknown, and investigation on how the recovery mechanisms could depend or not on the timing of VR has not yet been tested. METHODS: Our study investigated the recovery of DVA in 28 UVH patients whose unilateral deficit was attested by clinical history and video head impulse test (vHIT). Patients were tested under passive conditions before (pre-tests) and after (post-tests) being subjected to an active DVA rehabilitation protocol. The DVA protocol consisted in active gaze stabilization exercises with two training sessions per week, each lasting 30 min, during four weeks. Patients were sub-divided into three groups depending on the time delay between onset of acute UVH and beginning of VR. The early DVA group (N = 10) was composed of patients receiving the DVA protocol during the first 2 weeks after onset (mean = 8.9 days), the late group 1 (N = 9) between the 3rd and the 4th week (mean = 27.5 days after) and the late group 2 (N = 9) after the 1st month (mean: 82.5 days). We evaluated the DVA score, the angular aVOR gain, the directional preponderance and the percentage of compensatory saccades during the HIT, and the subjective perception of dizziness with the Dizziness Handicap Inventory (DHI). The pre- and post-VR tests were performed with passive head rotations done by the physiotherapist in the plane of the horizontal and vertical canals. RESULTS: The results showed that patients submitted to an early DVA rehab improved significantly their DVA score by increasing their passive aVOR gain and decreasing the percentage of compensatory saccades, while the late 1 and late 2 DVA groups 1 and 2 showed less DVA improvement and an inverse pattern, with no change in the aVOR gain and an increase in the percentage of compensatory saccades. All groups of patients exhibited significant reductions of the DHI score, with higher improvement in subjective perception of dizziness handicap in the patients receiving the DVA rehab protocol in the first month. CONCLUSION: Our data provide the first demonstration in UVH patients that earlier is better to improve DVA and passive aVOR gain. Gaze stabilization exercises would benefit from the plastic events occurring in brain structures during a sensitive period or opportunity time window to elaborate optimal functional reorganizations. This result is potentially very important for the VR programs to restore the aVOR gain instead of recruiting compensatory saccades assisting gaze stability.

[The compensation of the vestibulo-ocular reflex during rehabilitation of the patients presenting with vestibular neuritis]. / Kompensatsiia vestibulookuliarnogo refleksa pri reabilitatsii u patsientov s vestibuliarnym neironitom.

AIM: The objective of the present study was to elucidate the mechanisms behind the compensation of the vestibular ocular reflex and evaluate the effectiveness of vestibular rehabilitation in the patients presenting with vestibular neuritis (VN) with the application of the video head-impulse test (vHIT) and the dynamic visual acuity test (DVAT). METHODS: The study included 26 patients with vestibular neuritis whose condition was assessed by scoring based on the dizziness handicap inventory, the dynamic visual acuity test, and the video head-impulse test with the evaluation of saccades and the degree of eye-head movement coordination (gain) before and after the course of vestibular rehabilitation. RESULTS: The study has demonstrated that the course of vestibular rehabilitation of the patients presenting with vestibular neuritis resulted in a significant decrease in the scores of dizziness estimated based on the dizziness handicap inventory and an improvement of dynamic visual acuity in the case of the complete gain recovery as well as in the case of persisting impairment of the gain and the development of sufficient 'covert' saccade. Vestibular rehabilitation was unsuccessful in the patients with persistereduced gain and simultaneous development of 'covert' and 'overt' saccades.

Vestibular neuritis: Evaluation and effect of vestibular rehabilitation.

UNLABELLED: Vestibular neuritis (VN) is a caloric vestibular areflexia that occurs suddenly, and whose compensation can take several weeks, sometimes several months. Usually these patients are rehabilitated, but the most affected patients (cervical vestibular evoked myogenic potential (cVEMP) absent) have a worse prognosis of vestibulo-ocular compensation. Thanks to symptomatic, videographic and posturographic evaluation tools, we objectify and quantify which factors influence the recovery or more accurately the compensation of this type of disorder. EQUIPMENT AND METHOD: We have colligated 34 observations of VN whose beginning could be precisely dated. These 34 unilateral caloric areflexic patients had a symptomatic evaluation (SE) with scales (vertigo symptom scale, dizziness handicap inventory, short form 36), an evaluation of the vestibulo-ocular reflex (VOR) (spontaneous nystagmus, head shaking test, mastoid bone skull vibration test, and finally an evaluation of the vestibulo-spinal function (VSF) on a dynamic posturography platform (DPY). On the other hand were evaluated eight elements supposed to influence (influence factors FI) the care and/or the outcome of the treatment (age, cVEMP absent, duration of deficiency, sports and walk practice, rehabilitation of VOR, rehabilitation of VSF, waiting period before application of rehabilitation, vertigo medications treatment). RESULTS: By comparing averages and with a Fischer's exact test, we can show here that the medical treatment, the waiting period before the application of the rehabilitation, the number of rehabilitation sessions or the type of rehabilitation influence only partially the state of health of neuritis. The age of the patients and absent cVEMP don't have a major influence either. However, patients with the most important physical activity feel better from a symptomatic point of view, over a long period after the episode. The effect of rehabilitation might be temporary if daily activity is minimal. CONCLUSION: The evaluation of the vestibulo-ocular reflex has long remained the main element for the evaluation of the state of health of vestibular neuritis. But if you use in addition posturography and symptomatic scales to assess the state of health, the neuritis considered to be compensated with the VOR will not always be symptomatically compensated. Estimating the functional recovery of neuritis can't be limited to estimating or quantifying the VOR. Rehabilitating neuritis can't be limited to rehabilitating the VOR. Finally we show here that physical activity is probably more necessary than any type of rehabilitation.

Intraobserver reliability of posturography in patients with vestibular neuritis.

The aim of the study was to establish the intraobserver reliability of a posturographic method in patients (n = 34) with vestibular neuritis. Intraclass correlation coefficients (relative reliability) for all parameters and test positions (ALL(mean)) ranged from 0.71 (95% CI: 0.41-0.85) to 0.92 (95% CI: 0.84-0.96). Absolute reliability (coefficient of variation) ranged between 3.1% (95% CI: 2.60-8.67) and 42.3% (95% CI: 40.7-74.5). Reliability of single test positions is much lower. The posturographic system showed good relative and satisfactory absolute intraobserver reliability for ALL(mean).

What is the optimal number of treatment sessions of vestibular rehabilitation?

Vestibular rehabilitation is effective and safe in patients with instability. However, there is insufficient evidence for distinguishing between efficacies of different dosage of therapies. Therefore, the aim of the present study was to verify whether there were differences between two computerised dynamic posturography (CDP) therapies of different numbers of sessions, in order to establish the optimal strategy. We conducted a prospective, comparative study of two different dosage of CDP therapy (a 5-session group and another of 10-session group) in patients with instability due to chronic unilateral peripheral vestibular disorder. We used balanced block randomisation to include 13 patients in each group. Improvement was assessed using the Dizziness Handicap Inventory and the CDP with the sensorial organisation test (SOT) and limits of stability (LOS). We found a statistically significant improvement in both groups in composite score, visual and vestibular input (SOT); and in reaction time, distance and directional control (LOS). If we compare the groups regarding these improvements, we found that 10-session group showed a greater benefit in distance covered and directional control of LOS. Since significant improvement is obtained with only five sessions, we believe this to be the optimal number of treatment sessions for most patients with chronic unilateral peripheral vestibular disorder. Nevertheless, those patients with more reduced limits of stability, and consequently greater likelihood of falling as a result of their diminished base of support, are candidates for rehabilitation protocols with a greater number of sessions.

Efficacy of Vestibular Rehabilitation in Vestibular Neuritis: A Systematic Review and Meta-analysis.

OBJECTIVE: This study aimed to evaluate the efficacy of vestibular rehabilitation in vestibular neuritis. DESIGN: A randomized controlled trial was collected from MEDLINE, Embase, Cochrane Library, PEDro, LILACS, and Google Scholar before May 2023. RESULTS: This study included 12 randomized controlled trials involving 536 patients with vestibular neuritis. Vestibular rehabilitation was comparable with steroids in dizziness handicap inventory score at the first, sixth, and 12th months (pooled mean differences: -4.00, -0.21, and -0.31, respectively); caloric lateralization at the third, sixth, and 12th months (pooled mean difference: 1.10, 4.76, and -0.31, respectively); and abnormal numbers of vestibular-evoked myogenic potentials at the first, sixth, and 12th months. Patients receiving a combination of rehabilitation and steroid exhibited significant improvement in dizziness handicap inventory score at the first, third, and 12th months (mean difference: -14.86, pooled mean difference: -4.63, mean difference: -9.50, respectively); caloric lateralization at the first and third months (pooled mean difference: -10.28, pooled mean difference: -8.12, respectively); and numbers of vestibular-evoked myogenic potentials at the first and third months (risk ratios: 0.66 and 0.60, respectively) than did those receiving steroids alone. CONCLUSIONS: Vestibular rehabilitation is recommended for patients with vestibular neuritis. A combination of vestibular rehabilitation and steroids is more effective than steroids alone in the treatment of patients with vestibular neuritis.

Vestibular neuritis.

Vestibular neuritis is the most common cause of acute spontaneous vertigo. Vestibular neuritis is ascribed to acute unilateral loss of vestibular function, probably due to reactivation of herpes simplex virus in the vestibular ganglia. The diagnostic hallmarks of vestibular neuritis are spontaneous horizontal-torsional nystagmus beating away from the lesion side, abnormal head impulse test for the involved semicircular canals, ipsilesional caloric paresis, decreased responses of vestibular-evoked myogenic potentials during stimulation of the affected ear, and unsteadiness with a falling tendency toward the lesion side. Vestibular neuritis preferentially involves the superior vestibular labyrinth and its afferents. Accordingly, the function of the posterior semicircular canal and saccule, which constitute the inferior vestibular labyrinth, is mostly spared in vestibular neuritis. However, because the rare subtype of inferior vestibular neuritis lacks the typical features of vestibular neuritis, it may be misdiagnosed as a central vestibular disorder. Even in the patient with the typical pattern of spontaneous nystagmus observed in vestibular neuritis, brain imaging is indicated when the patient has unprecedented headache, negative head impulse test, severe unsteadiness, or no recovery within 1 to 2 days. Symptomatic medication is indicated only during the acute phase to relieve the vertigo and nausea/vomiting. Vestibular rehabilitation hastens the recovery. The efficacy of topical and systemic steroids requires further validation.

Implementation of a municipality-based rehabilitation program for patients with neuritis vestibularis: lessons learned and derived snowball effects.

BACKGROUND: Patients with dizziness are severely affected in their daily life. The dizziness may be caused by vestibular neuritis and this condition may be severe and result in hospitalization. Qualified municipal rehabilitation services are warranted for these patients after edischarge from the hospital. However, very few specialized municipal initiatives in Denmark are targeting this patient group. METHODS: This paper reports on the development of a clinically applicable municipality-based vestibular neuritis rehabilitation program and evaluates the acceptability of this initiative. RESULTS: The study recognized the need for a rehabilitation program after hospital discharge. However, the program was not evaluated as acceptable for multiple reasons. The exercise program was applicable and feasible but was experienced as a limitation for the practitioner, when addressing other balance issues was needed. It proved challenging to inform both the administrative staff and the clinicians about the new rehabilitation service to allow for sufficient implementation. CONCLUSION: Although the rehabilitation program was not considered an unequivocal success, there were several derived valuable snowball effects of the program. This paper advocates that focus should not only lie on the success of a single program, but also explore the derived benefits for patients and organizations, as well as the practice-oriented knowledge these programs generate.

Efficacy and safety of mecobalamin combined with vestibular rehabilitation training for acute vestibular neuritis: a systematic review and meta-analysis.

BACKGROUND: This study aimed to investigate the efficacy and safety of mecobalamin combined with vestibular rehabilitation training in acute vestibular neuritis and to improve the clinical therapeutic effect in vestibular nerve disease. METHODS: We performed a literature search of the PubMed, Medline, China National Knowledge Infrastructure (CNKI), and other databases from the date of establishment of the database until the present. The search terms included "mecobalamin", "vestibular rehabilitation training", "vestibular rehabilitation therapy", and "vestibular neuritis". References of the comparative study of vestibular rehabilitation training and vestibular rehabilitation training combined with mecobalamin were screened. Boolean logic retrieval was adopted, and Review Manager software was employed. RESULTS: Meta-analysis was conducted on a total of four studies with a low risk of bias. The activities specific balance confidence scale (ABC) scores of the two groups were heterogeneous (Chi2=8.56, I2=88%, P=0.003), and a fixed-effect model (FEM) analysis indicated that there were no significant differences in the ABC between the groups after treatment (Z=0.67, P=0.50). It may be that mecobalamin combined with vestibular rehabilitation training effectively alleviated the symptoms of vestibular neuritis in the experimental group, thereby reducing the canal paresis (CP) value. In addition, there was no heterogeneous dizziness handicap inventory (DHI) between the groups after treatment (Chi2=20.75, I2=86%, P=0.0001); finite element method (FEM) analysis showed that the DHI of the experimental group after 6 months of treatment was notably lower compared to that of the control group (Z=3.20, P=0.001). DISCUSSION: Mecobalamin combined with vestibular rehabilitation training can effectively improve vertigo and other symptoms of acute vestibular neuritis patients, with high effectiveness and safety.

Effects of stabilizing reversal technique and vestibular rehabilitation exercise on dizziness and balance ability in patients with vestibular neuritis: An observational study.

ABSTRACT: Vestibular neuritis is a common disease of peripheral dizziness. Studies have shown that vestibular rehabilitation exercise (VRE) and proprioceptive neuromuscular facilitation (PNF) are effective to treat the symptoms of vestibular neuritis. However, the effect of VRE and PNF on the balance ability and dizziness in this patient cohort remains unclear.The aim of our observational study was to determine the changes in dizziness and balance ability of patients with vestibular neuritis who participated in the VRE program with stabilizing reversal technique (SRT).The reporting of this study conforms to the STROBE statement. Ten men and women aged ≥ 20 years who were diagnosed with vestibular neuritis were included. Patients performed VRE with SRT for 4 weeks with assistance from a therapist. VRE without SRT can also be performed at home. Dizziness was evaluated using the dizziness handicap inventory (DHI) and visual analog scale (VAS). Balance ability was assessed using the Berg's balance scale (BBS) and timed up and go test (TUG). At pre- and post-exercise, paired t test was performed to compare the within-group differences.After the program, DHI (45.40 ±â€Š6.74 to 21.00 ±â€Š7.07), VAS (5.90 ±â€Š1.20 to 2.80 ±â€Š0.92), BBS (45.10 ±â€Š2.77 to 52.70 ±â€Š1.83), and TUG (15.29 ±â€Š1.13 to 12.06 ±â€Š1.61) scores improved significantly in the VRE program group (P = .05).The VRE program combined with SRT was effective in reducing dizziness and increasing balance ability in patients with vestibular neuritis.

Sensorimotor Rehabilitation Promotes Vestibular Compensation in a Rodent Model of Acute Peripheral Vestibulopathy by Promoting Microgliogenesis in the Deafferented Vestibular Nuclei.

Acute peripheral vestibulopathy leads to a cascade of symptoms involving balance and gait disorders that are particularly disabling for vestibular patients. Vestibular rehabilitation protocols have proven to be effective in improving vestibular compensation in clinical practice. Yet, the underlying neurobiological correlates remain unknown. The aim of this study was to highlight the behavioural and cellular consequences of a vestibular rehabilitation protocol adapted to a rat model of unilateral vestibular neurectomy. We developed a progressive sensory-motor rehabilitation task, and the behavioural consequences were quantified using a weight-distribution device. This analysis method provides a precise and ecological analysis of posturolocomotor vestibular deficits. At the cellular level, we focused on the analysis of plasticity mechanisms expressed in the vestibular nuclei. The results obtained show that vestibular rehabilitation induces a faster recovery of posturolocomotor deficits during vestibular compensation associated with a decrease in neurogenesis and an increase in microgliogenesis in the deafferented medial vestibular nucleus. This study reveals for the first time a part of the underlying adaptative neuroplasticity mechanisms of vestibular rehabilitation. These original data incite further investigation of the impact of rehabilitation on animal models of vestibulopathy. This new line of research should improve the management of vestibular patients.

Efficacy of Vestibular Rehabilitation Following Acute Vestibular Neuritis: A Randomized Controlled Trial.

OBJECTIVE: To investigate whether a vestibular rehabilitation program started early after diagnosis of vestibular neuritis combined with standard care reduces dizziness and improves functions of daily life more effectively than standard care alone in patients with acute vestibular neuritis. STUDY DESIGN: Non-blinded, randomized controlled trial with 2 parallel groups. SETTING: Specialist centers in 2 university hospitals. PATIENTS: Patients, 18-70 years, with acute vestibular neuritis confirmed by videonystagmography. INTERVENTION: Standard care was 10 days of prednisolone, general information, and counseling given to all patients. In addition to standard care, the intervention group received supervised exercise therapy (vestibular rehabilitation). Vestibular rehabilitation was given in a group format, individually tailored, and supported by home exercises. MAIN OUTCOME MEASURE: Perceived dizziness during head motion. Secondary outcomes were walking speed, standing balance, Hospital Anxiety and Depression Scale (HADS), Vertigo Symptom Scale, Visual Analog Scales (VASs), Dizziness Handicap Inventory (DHI), The University of California Los Angeles Dizziness Questionnaire. RESULTS: Sixty-five patients were included, 27 participated in the vestibular rehabilitation group. There was a statistically significant difference in favor of the vestibular rehabilitation group in overall perceived dizziness at 3 (p = 0.007) and 12 months (p = 0.001). No statistically significant differences were found in standing balance and walking speed. Results from self-report measures showed a statistically significant difference at 12 months in HADS (p = 0.039), DHI (p = 0.049) and VAS-C (p = 0.012). CONCLUSION: A vestibular rehabilitation program started early after confirmed vestibular neuritis diagnosis in addition to standard care reduces the perception of dizziness and improves functions of daily life more effectively than standard care alone.

The functional head impulse test: preliminary data.

The functional head impulse test is a new test of vestibular function based on the ability to recognize the orientation of a Landolt C optotype that briefly appears on a computer screen during passive head impulses imposed by the examiner over a range of head accelerations. Here, we compare its results with those of the video head impulse test on a population of vestibular neuritis patients recorded acutely and after 3 months from symptoms onset. The preliminary results presented here show that while both tests are able to identify the affected labyrinth and to show a recovery of vestibular functionality at 3 months, the two tests are not redundant, but complementary.

Assessment of Vestibulo-ocular Reflex Gain and Catch-up Saccades During Vestibular Rehabilitation.

OBJECTIVE: To assess, in patients referred to vestibular rehabilitation (VR) for persistence of disability after acute unilateral vestibulopathy (AUV), whether the video head impulse test (vHIT) can be a useful technique to define the efficacy of the treatment. STUDY DESIGN: Prospective clinical study. SETTING: Tertiary academic referral hospitals. PATIENTS: Thirty patients with residual symptoms after AUV were included. INTERVENTION: Patients underwent a 10-week VR program. MAIN OUTCOME MEASURES: Evaluation of dizziness handicap inventory score, high-velocity vestibulo-ocular reflex gain, asymmetry index, and catch-up saccade parameters before and after VR. RESULTS: All patients reported a clear clinical improvement after VR, also demonstrated by better dizziness handicap inventory scores (p < 0.001). A consistent increased gain and decreased asymmetry index were also observed (p < 0.001 for both). Patients did not show any change in covert catch-up saccades, while a statistically significant reduction of the number and amplitude of the overt catch-up saccades was interestingly detected (p = 0.009 and p = 0.030, respectively). CONCLUSION: VR is a valid approach for patients with residual disability after AUV. A reduction in number and amplitude of overt catch-up saccades seems useful to evaluate the efficacy of VR and to be related to clinical improvement.

Clinical use of subjective visual horizontal and vertical in patients of unilateral vestibular neuritis.

OBJECTIVES: Subjective visual horizontal (SVH) and subjective visual vertical (SVV) used to assess otolith dysfunction and ipsilesional deviation of SVV and SVH in unilateral vestibular dysfunction is well known. The goal of this study was to investigate the clinical use of SVH/SVV and a dizziness scale in the clinical setting of acute unilateral vestibular neuritis. METHODS: Thirty-five patients with unilateral vestibular neuritis were investigated. Every patient was diagnosed by physical examination and electronystagmography. Subjective visual horizontal and SVV were assessed during the acute or subacute period; the Dizziness Handicap Inventory (DHI) and Vestibular Disorder Activities of Daily Living Scale (VADL) were used for a self-dizziness scale at the same time. All patients underwent rehabilitation therapy. Subjective visual horizontal/SVV and DHI/VADL were assessed again approximately 4 weeks later. Postrehabilitation SVH/SVV and DHI/VADL data were compared with initial data. RESULTS: Dizziness Handicap Inventory and VADL were improved after 4 weeks of rehabilitation, and the deviation toward ipsilesional side SVH and SVV was also improved. CONCLUSION: These results demonstrate that SVH and SVV correlated with clinical dizziness symptoms in patients with acute unilateral vestibular neuritis. Therefore, SVH and SVV would be useful tools for the evaluation of clinical manifestations of unilateral vestibular neuritis.

Effects of Saccular Function on Recovery of Subjective Dizziness After Vestibular Rehabilitation.

OBJECTIVE: We attempted to investigate whether the integrity of saccular function influences the severity of subjective dizziness after vestibular rehabilitation in vestibular neuritis. STUDY DESIGN: Retrospective analysis. SETTING: Tertiary referral center. PATIENTS: Forty-six patients with acute unilateral vestibular neuritis were included. INTERVENTIONS: Diagnostic, therapeutic, and rehabilitative. MAIN OUTCOME MEASURES: All the patients completed vestibular rehabilitation therapy until their computerized dynamic posturography and rotary chair test results were significantly improved. The rehabilitation patients were classified into the normal to mild subjective dizziness and moderate to severe subjective dizziness groups according to the dizziness handicap inventory score (cutoff of 40). Differences between the two groups were analyzed. RESULTS: After rehabilitation, 32.6% of the patients still complained of moderate to severe dizziness. Age, sex distribution, the presence of comorbidities, caloric weakness, pre- and postrehabilitation gain values in rotary chair test, postrehabilitation composite scores in posturography, and the duration of rehabilitation were not significantly different between the two groups. However, initial dizziness handicap inventory (DHI) score and composite score in dynamic posturography were worse and the proportion of patients with absent cervical vestibular-evoked myogenic potential in the moderate to severe group was much higher (93.3% vs. 35.5%, p < 0.001). After multiple regression analysis of those factors, initial DHI score and absent cervical vestibular-evoked myogenic potential response were identified as being associated with higher postrehabilitation DHI score. CONCLUSION: Saccular dysfunction in acute vestibular neuritis can contribute to persistent subjective dizziness, even after the objective parameters of vestibular function tests have been improved by vestibular rehabilitation.

Modification of compensatory saccades after aVOR gain recovery.

The recruitment of extra-vestibular mechanisms to assist a deficient angular vestibulo-ocular reflex (aVOR) during ipsilesional head rotations is well established and includes saccades of reduced latency that occur in the direction of the lesioned aVOR, termed compensatory saccades (CS). Less well known is the functional relevance of these unique saccades. Here we report a 42 y.o. male diagnosed with right unilateral vestibular hypofunction due to vestibular neuronitis who underwent a vestibular rehabilitation program including gaze stabilization exercises. After three weeks, he had a significant improvement in his ability to see clearly during head rotation. Our data show a reduction in the recruitment and magnitude of CS as well as improved peripheral aVOR gain (eye velocity/head velocity) and retinal eye velocity. Our data suggest an inverse, dynamic relationship between the recruitment of CS and the gain of the aVOR.

Treatment and rehabilitation in vestibular neuritis.

During the acute phase, symptomatic treatment is practically the only option, and a wide variety of drugs are available. For years, much has been focused on the possibility of using corticosteroids in the treatment of vestibular neuritis. Clearly, if we suspect an inflammatory cause, a treatment that reduces that inflammatory process would, if not reduce the severity of the attack, at least help recovery. If the different studies on this matter failed to concord in many aspects, they do however agree that the use of corticosteroids in the acute phase entails long term beneficial effects for the recovery of vestibular function and allows for a better vestibular compensation. The second part of the treatment is the rehabilitation. In my experience most of the patients undergo a spontaneous vestibular compensation in a short time. Nevertheless, some exercises of visual fixation while the patient is still bed-ridden, can accelerate the recovery process. Those patients, in whom certain instability persists, who are too anxious after their experience or those who will demand this type of treatment, are candidates to undergo a rehabilitative vestibular program. In this paper I will comment on the instrumental and non-instrumental techniques that I use in my daily practice.

Home-Based Computer Gaming in Vestibular Rehabilitation of Gaze and Balance Impairment.

Disease or damage of the vestibular sense organs cause a range of distressing symptoms and functional problems that could include loss of balance, gaze instability, disorientation, and dizziness. A novel computer-based rehabilitation system with therapeutic gaming application has been developed. This method allows different gaze and head movement exercises to be coupled to a wide range of inexpensive, commercial computer games. It can be used in standing, and thus graded balance demands using a sponge pad can be incorporated into the program. A case series pre- and postintervention study was conducted of nine adults diagnosed with peripheral vestibular dysfunction who received a 12-week home rehabilitation program. The feasibility and usability of the home computer-based therapeutic program were established. Study findings revealed that using head rotation to interact with computer games, when coupled to demanding balance conditions, resulted in significant improvements in standing balance, dynamic visual acuity, gaze control, and walking performance. Perception of dizziness as measured by the Dizziness Handicap Inventory also decreased significantly. These preliminary findings provide support that a low-cost home game-based exercise program is well suited to train standing balance and gaze control (with active and passive head motion).