Vestibular Rehabilitation Therapy: The Ins and Outs

Those familiar with the healthcare industry know that there are several different types of medical therapy. These include various interventions, from massage and occupational therapy to respiratory and behavioral therapy approaches. While each is quite well-known, vestibular rehabilitation therapy is one form that just doesn’t get as much attention. 

If you’re a physiotherapy practice owner, you could be missing out on boosting your revenue by not offering this service. Vestibular rehabilitation is undoubtedly a type of therapy you should be aware of. This modality could serve your current patient panel and even draw in some new ones, as the symptoms and conditions it treats are very common. 

So, keep reading to learn more about vestibular rehabilitation therapy and figure out whether it makes sense for your business. 

What Is Vestibular Rehabilitation Therapy?

Before we immediately jump into what this treatment is, let’s first break down a keyword in this term: vestibular. This word means “of, relating to, or affecting the perception of body position and movement.” Simply put, it refers to someone’s experience of their sense of balance. Stability issues are often associated with the inner ear, which is where the vestibular system is located. 

Therefore, vestibular rehabilitation therapy, or VRT for short, is a practice that addresses balance issues caused by primary and secondary problems of vestibular disorders. It is a very distinct form of physical therapy that incorporates exercises to aid with symptoms of unsteadiness. 

These disorders often cause permanent deficiencies, as the body’s ability to restore vestibular function is modest. However, physical therapists can help patients decrease symptoms and improve function with vestibular compensation despite the damage. 

Understanding Acute and Chronic Vestibular Compensation

Vestibular compensation occurs when the body compensates for a vestibular injury by remedying the part of the brain that controls balance. There are immediate and long-term compensation responses, which we’ll discuss below. 

Acute Vestibular Compensation

Let’s first look at acute vestibular compensation. If someone experiences an abrupt unilateral injury to a balance organ, they’ll likely experience dizziness. This is because the brain interprets the suddenly impaired spatial orientation signals as constant movement. 

It’s theorized that within a few hours, the brain realizes that the signals coming from the ears are inaccurate and reduces them via a process called the cerebellar clamp. This initial compensation response improves the symptoms mentioned above. However, the patient may still feel unsteady when standing, making head movements, or performing other activities, which puts them at risk of falls.

Chronic Vestibular Compensation

After a few days, the cerebellum clamp steadily decreases, permitting more signals from the inner ear to reach the brain. The brain recalibrates signals from injured and uninjured vestibular organs at this stage. Finally, once the process of chronic compensation is complete, most patients can return to their normal activities with little to no symptoms. 

Those with fully functional recovery are deemed well compensated. However, in circumstances where this doesn’t occur, vestibular rehabilitation therapy exercises should be implemented. The term for patients with partial recovery is poorly compensated, while decompensation is used to describe those who experience a near-total relapse. 

What Is the Goal of Vestibular Rehabilitation? 

As one study explains, the primary aim of VRT is to “capitalize on the innate plasticity of the balance system to advance the natural compensation process.” This is achieved by a few interventions. 

1. Enhancing Gaze Stability

Gaze instability, also called movement-induced dizziness, occurs when there’s a decreased gain in vestibular response to head movements. Or, in simple terms, head and eye movements are out of sync. The best intervention for promoting the gain of the vestibular response is the error signal influenced by retinal slip, but other methods can also be implemented. 

2. Bettering Postural Stability

The main approaches to postural recovery are boosting dependence on visual and somatosensory cues (substitution) and enhancing vestibular responses (adaptation). 

3. Improving Vertigo

Physical therapists can better vertigo by habituation of abnormal vestibular responses to fast movements. In other words, repeating certain exercises reduces how much certain movements impact them in the future. 

4. Restoring the Ability to Complete Daily Living Activities

Once patients can return to normal work or are adequately resettled, it’s determined that they’ve completed vestibular rehabilitation therapy. They must be safely and slowly exposed to different sensory and motor environments to accomplish this. Eventually, their nervous system will learn to identify strategies to fulfill their functional goals. 

What Conditions Does Vestibular Rehabilitation Therapy Treat?

If you’re considering adding VRT services to your physical therapy practice, you’d first need to clarify which patients would benefit most from them. 

Based on current research, vestibular rehabilitation therapy is appropriate for the following conditions and circumstances: 

• Vertigo
• Ménière’s disease
• Elderly with dizziness
• Benign paroxysmal positional vertigo (BPPV)
• Labyrinthitis
• Vestibular neuritis
• Migraine headache
• Stroke
• Head injury, such as a traumatic brain injury (TBI)
• Those at risk of falls

Dizziness is a common symptom in each of the above conditions and can greatly affect one’s quality of life. This is why VRT is often introduced to help remedy the balance issues that result from it. 

In a study on balance disorder trends in the United States, researchers found that there is a significantly increasing prevalence of dizziness and balance issues. To give you an idea, approximately 24.2 million people reported balance problems in 2008, which jumped to about 36.8 million in 2016. While often overlooked, patients with dizziness and vertigo may endure a tremendous cost burden, costing more than $48 billion annually in medical expenditures. 

Given this seemingly growing problem, why not help your physical therapy practice step up and offer a solution to patients in need?  

Vestibular Rehabilitation Therapy Exercises 

As you know, no two patients are the same, and treatment approaches aren’t one-size-fits-all, either. It’s crucial that physical therapists create a customized program of vestibular rehabilitation therapy exercises for each patient they encounter to optimize their results. 

Doing so should involve carefully reviewing a patient’s medical history, examining any imaging studies or laboratory tests, and gathering details from the patients themselves. A clinical assessment incorporating the patient’s head, neck, and eye movements should also be conducted to evaluate their balance function. 

Below, we’ll share three types of VRT exercises. However, keep in mind that these exercises should be designed to accommodate your patients’ age, health, and interests. Therefore, some of our suggestions may not be appropriate for all patients. 

Adaptation Exercises 

Completing adaptation exercises helps the nerve impulses in the brain adapt to the inaccurate signals from the impaired vestibular system. Essentially, it resets the ear-eye-brain connection.

Research shows that adaptation exercises can improve postural stability and the diminished perception of disequilibrium in chronic and acute phases. 

Some examples of adaption exercises might include: 

• Ocular control. Looking up and down, side to side, or focusing on a finger moving from three feet to one foot away from one’s face. Usually, patients start by sitting down and then standing up to conduct their sessions once they’re more comfortable. 
• Horizontal and diagonal head movements. Patients start with their eyes open, bending forward and backward, and turning from side to side. Later, they close their eyes and do the same actions. 

Habituation Exercises

As mentioned earlier, these actions aim to reduce the gravity of a patient’s vestibular symptoms through repetition. 

A few of these vestibular rehabilitation therapy exercises might incorporate: 

• Balance. Patients doing ankle sways, touching a front wall, or conducting ball diagonals are options here. 
• Gait. Individuals might start off sitting to standing or doing walking movements. Later, it might include games that require stretching, stooping, and aiming. 

Substitution Exercises 

The primary purpose of these exercises is to utilize visual cues and those from the muscles and joints to compensate for the loss of vestibular cues. 

Examples of substitution exercises include: 

• Sitting. The patient may do shoulder shrugging and circling, throw a ball from hand to hand under the knee, or bend forward and pick up objects from the ground.

Manage Patient Expectations 

As a physical therapist, you must ensure your patients have realistic expectations about VRT services. Here are some reasons why. 

It’s not uncommon for patients to feel worse when they begin these balance exercises, which may make them want to quit. Reassure them that this isn’t a sign that something bad is happening or their condition is worsening. It actually means that the exercises are having an effect, so they should continue until they’re told to stop. Prematurely ending treatment may lead to a downward spiral, as the less they exercise, the worse their balance may become. 

Usually, treatment can stop once the patient doesn’t experience dizziness while performing the movement for at least two consecutive weeks. Achieving this requires six to eight weeks of PT sessions occurring at least one to two times weekly. 

3 Ways VRT Services Affect Your Physical Therapy Clinic

Adding vestibular evaluations and rehabilitation services to your PT clinic accomplishes three major things: 

• It provides a much-needed service to the millions of people who struggle with dizziness and stability issues. You’re essentially helping to restore someone’s quality of life, which is a major feat. 
• Your offering and professional expertise will differentiate you from your local competition. Partnering with other practitioners involved in this aspect of care could result in referrals. 
• Vestibular therapy gives you another revenue stream. 

What to Consider Before Offering Vestibular Rehabilitation

Anytime you’re thinking about offering a new service to your business, there are things you should consider and plan for. Here’s what we suggest if you’re thinking about taking the leap with VRT services.

Professional Skills and Education

Currently, the United States doesn’t require physical therapists to have any extra training or certifications to provide vestibular therapy. However, if you want to improve your competence in the field, there are online courses on the subject matter. There are also some post-graduate programs and courses specifically for vestibular rehabilitation.

Because dizziness is often a symptom related to neurologic disorders, physical therapists might stand out more if they become a Neurologic Clinical Specialist. This would demonstrate that you have advanced knowledge in the field of neurologic rehabilitation. 

Balance Equipment

One factor you can’t ignore is the equipment you might need to perform VRT and how much that equipment may cost. As a practice owner, understand that you don’t need everything but there are some essential balance tools your vestibular clinic should have. 

Some tools you might find in vestibular therapy clinics include: 

• Infrared video goggles
• ETDRS-R eye chart
• Balance pad
• Hi-lo lift table
• Aerobic step

CPT Codes for Vestibular Rehabilitation Therapy

It’s also essential that you know how to properly report the VRT services you and your team perform so that insurance companies can reimburse you. 

The most common CPT codes for vestibular rehabilitation therapy are: 

• 97112: Neuromuscular reeducation
• 97116: Gait training
• 97110: Therapeutic exercises
• 97140: Manual therapy techniques
• 92540: Basic vestibular evaluation, which includes four specific tests, with recording, to check balance disorders
• 92541: Spontaneous nystagmus test

CMS also lists vestibular testing codes and how and when to bill for them. However, these codes could differ by insurance provider, so always double-check.

To make it easier for you, consider physical therapy EMR tools that can make documenting a breeze while optimizing reimbursements, especially those with coding and billing functions. 

Collaborating with Other Practitioners

Like most things in healthcare, helping patients is a team effort, so you’ll probably interact with other practitioners, such as: 

• Audiologists 
• Dietitians
• Neurologists
• Nurses
• ENT doctors

Vestibular Rehabilitation Therapy Can Help You Serve Patients

If you’re looking for additional ways to provide more meaningful and impactful services at your physical therapy clinic, look no further than vestibular rehabilitation (VRT). Chances are, you already serve the patient population that would benefit from VRT and likely have some of the equipment to get started. Or maybe you’re a PT practice starting from scratch and thinking of providing this as your sole offering. 

In either scenario, VRT is a great way to serve more patients and increase your bottom line. We hope this resource proves valuable as you weigh what’s best for your physical therapy clinic.