A Path of Precision: The New Era of Balance and Dizziness Rehabilitation
For too long, vestibular rehabilitation has operated on a path of ambiguity, guided by symptoms and guesswork. Many therapists, with the best of intentions, relied on a simple theory: habituation. They would have a patient perform symptom-provoking exercises, hoping that repeated exposure would eventually lessen the dizziness. It's the 'just get used to it' approach, but this method often fails to provide lasting relief and leaves therapists without a clear direction. It is time to empower therapists with a new, precise approach that will instill confidence and capability in their practice.
The Symphony of Balance: An Analogy
Think of your balance system as a three-piece orchestra. Your vestibular system is the conductor, coordinating the other two sections and ensuring everything is in harmony. The visual system is the string section, providing clear, dominant melodies. The somatosensory system is the percussion section, providing a steady, reliable beat from the ground up.
In a healthy system, all three play together perfectly. But when the vestibular system—the conductor—is weak, the other two sections try to take over. The strings (vision) and percussion (somatosensory) start playing too loudly, trying to compensate for the missing leadership. This creates a chaotic, unpleasant noise, dizziness, and unsteadiness.
Our job as vestibular therapists is not just to turn down the volume of the visual and somatosensory systems, but to train the conductor (the vestibular system) to lead the orchestra again. This is the difference between simply muting the sound (habituation) and restoring the music to its proper, harmonious state (adaptation). In this new approach, the patient plays a crucial role, feeling involved and essential in their own recovery.
Abandoning the Path of Symptoms
The path of symptoms is a reactive one. A therapist observes a patient's dizziness or unsteadiness and then chooses an exercise based on the patient's tolerance. This approach, however, often unintentionally reinforces a patient's maladaptive sensory strategies. If a patient over-relies on their vision for balance and the therapist only provides exercises where visual cues are dominant, they are not correcting the underlying sensory mismatch—they are enabling it. The therapist has no way of knowing if they're genuinely helping or just teaching the patient to perform an exercise with a faulty strategy. This is a path of ambiguity, leaving both the patient and therapist unsure of the proper direction.
Forging a Path of Precision
The new era of vestibular rehabilitation is not about new exercises; it is about a new way of thinking. It begins with precision. We move beyond assumptions and use comprehensive diagnostic testing, including the FYZICAL-Computerized Dynamic Posturography (CDP)-Clinical Test of Sensory Interaction and Balance (CTSIB). This test measures a patient's ability to maintain balance under various sensory conditions, providing us with a precise map that pinpoints the exact source of the patient's sensory mismatch.
This precise analysis allows us to select exercises with a specific purpose: adaptation. Our goal is not just to make the patient dizzy, but to use controlled provocation as a tool for neural adaptation. We create a therapeutic environment that forces the brain to resolve the sensory conflict it experiences.
A VSVM (Visual>Somatosensory-Vestibular Mismatch) is a sensory strategy a patient uses to attempt to control balance. In this case, due to a profound vestibular weakness, the patient over-relies on visual and somatosensory (surface) cues. This leads to symptoms and signs of dizziness because the patient’s brain struggles with conflicting information. When they should rely on their inner ear for balance, they rely on their eyes and feet. This maladaptive strategy creates a chaotic sensory experience, as the patient’s brain tries to use the wrong systems to do the job of the inner ear.
For a patient with a Visual>Somatosensory-Vestibular Mismatch (VSVM), for instance, we do not just have them do random head movements. We utilize the Safety Overhead Support (SOS) System as a flight simulator for balance. This tool removes the fear of falling, allowing us to purposefully challenge the patient to the point of a potential fall or failure, which is where authentic learning occurs. This approach ensures the patient's safety, making them feel secure and cared for during their rehabilitation journey.
This shift from a path of symptoms to a path of precision is what truly defines this new era of care. It provides a clear, data-driven direction for every patient, ensuring that every exercise serves a purpose in their journey toward recovery.
Brian Werner, PT, MPT, is the National Director of Vestibular Education & Training at FYZICAL. He has been a physical therapist specializing in vestibular and balance disorders for over a quarter of a century.