Physical rehabilitation therapy for vestibular weakness

By Marcello Cherchi, MD PhD

For patients

Some illnesses can reduce balance-related signals traveling from the ear to the brain, which may make you feel unsteady. A specific kind of physical therapy may help this.

For clinicians

Practical summary

Physical rehabilitation therapy for vestibular weakness may include a variety of exercises. These exercises probably benefit patients by facilitating central vestibular compensation. Such exercises are generally regarded as the standard of care for vestibular weakness, but a number of questions remain, such as whether treatment of unilateral vestibular hypofunction differs from that of bilateral vestibular hypofunction.

Introduction

Sir Terence Edward Cawthorne (1902 – 1970) was an English otorhinolaryngologist who trained at King’s College, London. Dr. Frank Sebastian Cooksey (1906 – 1989) was an English physiatrist who also trained at King’s College, London. Within a few years of each other they published work (Cawthorne 1944; Cooksey 1946) regarding rehabilitation of vestibular deficits. Collectively these are sometimes designated Cawthorne-Cooksey exercises.

These and related treatments, such as gaze stabilization exercises (Meldrum and Jahn 2019), have been studied for a variety of vestibular deficits, including vestibular weakness. Meta-analyses have concluded that there is strong evidence that such therapy is effective for unilateral vestibular hypofunction (Arnold et al. 2017; McDonnell and Hillier 2015). The Neurology Section of the American Physical Therapy Association views such therapy as the standard of care for unilateral vestibular hypofunction (Hall et al. 2016), and subsequently also recommended it for bilateral vestibular hypofunction (Hall et al. 2022).

Physiology and neuroanatomy

Vestibular hair cells in the labyrinth generate signals that are transmitted through the vestibular nerve to the vestibular nuclei in the brainstem. Damage of the end-organ (such as in labyrinthitis) can prevent vestibular signals from being generated at all. Even if the end organ is intact and generating normal vestibular signals, transmission of those signals to the vestibular nuclei can be impaired by damage to the vestibular nerve (such as in vestibular neuritis). Either lesion (end-organ or vestibular nerve) may reduce vestibular input reaching the vestibular nuclei. In view of this neuroanatomy, there are several mechanisms by which recovery from impaired vestibular function could occur.

The first mechanism would be recovery of damaged vestibular hair cells, and there is some evidence that this can occur (Katsarkas and Outerbridge 1981); presumably this reflects recovery of vestibular hair cells that were damaged (but not dead). The second mechanism would be repair of the damaged vestibular nerve. The third mechanism would be central compensation (Curthoys and Halmagyi 1995, 1999; Deveze et al. 2015; Helmchen et al. 2009; Imate and Sekitani 1993; Imate et al. 1993), which refers to upweighting of gain on remaining incoming vestibular signals. This third mechanism (central compensation) is thought to be leveraged by vestibular rehabilitation therapy for vestibular hypofunction.

The neural plasticity underlying this third mechanism is uncertain, but some experimental observations suggest that it requires integrity of the commissural connections between the vestibular nuclei (Galiana et al. 1984; Graham and Dutia 2001). This recovery is probably not monolithic; it likely that static and dynamic vestibular input have different compensatory mechanisms (Minor and Lasker 2009; Newlands et al. 2005). It is not yet clear whether the neural plasticity mediating recovery from unilateral vestibular hypofunction is identical to that mediating recovery from bilateral vestibular hypofunction (McCall and Yates 2011); thus, while some vestibular therapists may use similar exercises for unilateral and bilateral vestibular hypofunction, it is possible that each should have its own treatment strategy, but additional research is required to clarify this.

It should be emphasized that vestibular rehabilitation therapy for vestibular weakness should not be a “one size fits all” approach.  Rather, a vestibular therapist will tailor the treatment, choosing particular exercises that target a given patient’s specific deficits (Im et al. 2025).

References

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