The clinician may offer vestibular rehabilitation, either self-administered or with a clinician, for the initial treatment of BPPV. Option based on controlled observational studies and a balance of benefit and harm. Overview of Vestibular Therapy Vestibular rehabilitation is a form of physical therapy designed to promote habituation, adaptation, and compensation for deficits related to a wide variety of balance disorders. It may also be referred to as vestibular habituation, vestibular exercises, or vestibular therapy. There is no single specific protocol for vestibular rehabilitation, but rather a program of therapy is developed on the basis of the underlying diagnosis. Programs can include canalith repositioning exercises, adaptation exercises for gaze stabilization, habituation exercises, substitution training for visual or somatosensory input, postural control exercises, fall prevention training, relaxation training, conditioning exercises, functional skills retraining, and patient and family education (Herdman, et al., 2000) (Telian, et al., 1996) (Whitney, et al., 2000).

With respect to BPPV, vestibular rehabilitation programs most commonly focus on habituation exercises either in formal outpatient therapy programs or with home exercise programs. Vestibular rehabilitation programs may also include PRMs, but repositioning maneuvers will be covered separately in the guideline. Herein, we refer to vestibular rehabilitation as a series of exercises or training maneuvers performed by the patient for the treatment of BPPV with or without direct clinician supervision.

Vestibular rehabilitation habituation exercises were first described by Cawthorne and Cooksey in the 1940s (Cawthorne, et al., 1944). These exercises consist of a series of eye, head, and body movements in a hierarchy of increasing difficulty, which provokes vestibular symptoms. The exercises begin with simple head movements, performed in the sitting or supine position, and progress to complex activities, including walking on slopes and steps with eyes open and closed, and sports activities requiring eye-hand coordination. These exercises theoretically fatigue the vestibular response and force the CNS to compensate by habituation to the stimulus (Norre, et al., 1987a/b). In 1980, Brandt and Daroff (Brandt, et al., 1980) (Brandt, et al., 1994) described home repositioning exercises that involve a sequence of rapid lateral head/trunk tilts repeated serially to promote loosening and ultimately dispersion of debris toward the utricular cavity. In these exercises, the patient starts in a sitting position and moves quickly to the right-side lying position, with the head rotated 45 degrees and facing upward. This position is maintained for 30 seconds after the vertigo stops. The patient then moves rapidly to a left-side lying position, with the head rotated 45 degrees and facing upward. In early work with patients with BPPV, patients repeated these maneuvers moving from the sitting to side-lying position three times a day for 2 weeks while hospitalized and had excellent resolution of BPPV symptoms (Troost, et al., 1992).

Vestibular Rehabilitation as a Treatment of BPPV

Relatively few RCTs and case series have been published regarding the effectiveness of vestibular rehabilitation as the initial therapy for BPPV. In a prospective analysis of 25 consecutive patients with BPPV, Banfield et al (Banfield, et al., 2000) reported that patients demonstrate an excellent short-term response rate of 96 percent subjectively to vestibular rehabilitation treatment with an average of three clinic visits per patient, but the authors noted a significant recurrence rate of BPPV with long-term follow-up (mean follow-up 3.8 years). The authors cited one advantage of vestibular rehabilitation: the capability of patients to be self-reliant in their ability to return to habituation exercises should symptoms recur. In a controlled trial of 60 patients with BPPV comparing a PRM, vestibular rehabilitation exercises and no treatment, vestibular rehabilitation provided better resolution of vertigo compared with no treatment (Steenerson, et al., 1996). The PRM arm demonstrated resolution of symptoms with fewer treatments than those required for vestibular rehabilitation, although the relative improvements at 3-month follow-up were comparable.

Several studies have compared vestibular rehabilitation exercises to particle rehabilitation maneuvers in the treatment of posterior canal BPPV. In an RCT of 124 patients randomized to CRP, modified liberatory maneuver, sham maneuver, Brandt-Daroff exercises, and vestibular habituation exercises by Cohen, repositioning maneuvers were more effective than Brandt-Daroff exercises or habituation exercises (Cohen et.al., 2005). Both types of vestibular rehabilitation treatments, however, were individually more effective than a sham intervention (Cohen, et al., 2005)(Hillier, 2007). Soto Varela et al (Soto Varela, et al., 2001) comparatively analyzed a total of 106 BPPV patients randomly assigned to receive Brandt-Daroff habituation exercises, the Semont maneuver, or the Epley maneuver. At the 1-week follow-up, similar cure rates were obtained with the Semont and Epley maneuvers (74% and 71%, respectively), both cure rates being significantly higher than that obtained with Brandt- Daroff exercises (24%). At 3-month follow-up, the cure rate for the Brandt-Daroff exercises increased significantly to 62 percent, although the rate was still lower than that of PRMs. Other studies have demonstrated similar results for vestibular rehabilitation in BPPV (Furman, 1999) (Toledo, 2000). In a double blind RCT control study Chang WC et al. demonstrated that additional exercise training, which emphasizes vestibular stimulation, can improve balance ability and functional gait performance among patients with benign paroxysmal positional vertigo of the posterior semicircular canal who had already undergone the canalith repositioning manoeuvre (Chang, et al., 2008).

Vestibular rehabilitation is thought to improve long-term outcomes for BPPV. Although data are mixed, a few studies have indicated that use of vestibular rehabilitation may decrease recurrence rates for BPPV (Angeli, et al., 2003) (Helminski, et al., 2005). This protective  effect against recurrence of vestibular rehabilitation may be more pronounced in the elderly (Angeli, et al., 2003). Several prospective studies have demonstrated the safety and effectiveness of vestibular rehabilitation for unilateral peripheral vestibular disorders; the results are summarized in a recent Cochrane collaboration report (Hillier, et al., 2007). Among 21 included randomized trials, there were no reports of adverse effects due to vestibular rehabilitation therapy. Current published evidence is inadequate to indicate superiority for one form of vestibular rehabilitation vs another. There is also not enough evidence to favor formal outpatient vestibular therapy performed with a clinician over independent home therapy (Kammerlind, et al., 2005).

In summary, with respect to posterior canal BPPV, vestibular rehabilitation demonstrates superior treatment outcomes compared with placebo. In short-term evaluation, vestibular rehabilitation is less effective at producing complete symptom resolution than PRMs. With longer-term follow-up, however, its effectiveness approaches that of PRMs. Insufficient data exist concerning the response of lateral canal BPPV to vestibular therapy; this area needs further research.

Cost considerations may become important if repeated visits for clinician-supervised therapy are required as opposed to initial patient instruction followed by home-based therapy. Patients with certain comorbidities may not be appropriate candidates for vestibular rehabilitation or may need specialized, individually tailored vestibular rehabilitation protocols. Examples of such comorbidities include cervical stenosis, Down syndrome, severe rheumatoid arthritis, cervical radiculopathies, Paget’s disease, morbid obesity, ankylosing spondylitis, low back dysfunction, and spinal cord injuries. On the other hand, patients with preexisting otological or neurological disorders may derive more benefit from vestibular rehabilitation as a treatment for BPPV.