VIDEO: VRT with Diagnosis Based Strategies using Hybrid Protocols

Vestibular Rehabilitation Therapy (VRT) is recognized as the gold standard for the non-medical, non-surgical management of this often-debilitating condition. Its usefulness has been demonstrated with children to adults, military pilots, and even astronauts, for whom its scientific advancement in the 1980’s was intended. It is most useful for patients who may have experienced any of the following:

• Vestibular neuritis or labyrinthitis
• mTBI and Labyrinthine Concussion
• Presbyastasia – age based disequilibrium
• Labyrinthine ablation or end-stage Meniere’s Disease or post surgical removal of Neuroma

In order to produce successful and measurable outcomes, the VRT protocols must be challenging and allow the brain to systematically see the error signals. More importantly, they much be context specific to the patient’s functional impairment. For example, if the patient has oscillopsia (blurred vision with head movement) produced with horizontal head movement at 1-3 cycles per second (cps), then the protocol must include the patient reading at these velocities with increasing difficulty in a step-wise progression. Without a quantifiable outcome measurement (a percentage score), the treatment efficacy cannot be determined. This is not only critical in moving the patient forward but in making decisions regarding discharge and ability to return to work or activities, as in post-concussion patients.

In this video you will see the patient undergoing a hybrid protocol, which incorporates both gaze stabilization (reading) with a complex stimuli of controlled (measurable cps) horizontal head movement, vertical perturbation (physio-ball) and aspects of habituation secondary to the head movement. The protocol can be progressed in difficulty by decreasing the font size to be read and increasing the velocity of the head movement, which may be actuated with a metronome or verbal command. The reading and attention to the metronome/command also provides increased attention and concentration, which has been shown to improve outcomes.


1.  Use context specific protocols that are specific to the patient’s functional impairments.

2. Use a step-wise progression that challenges in difficulty.

3. “If you didn’t measure it, It didn’t happen.” Quantify variables such as font size and velocity of head movement to demonstrate outcomes.


Gans, R. “Vestibular Therapy” (2014) In Katz, J. (Ed.) Handbook of Clinical Audiology, 7th Edition, Wolters Kluwer, 2015

Gans, R. “Vestibular Rehabilitation Therapy” (2013) In Dispenza, F. and
De Stefano, A., Textbook of Vertigo: Diagnosis and Management, JP Brothers Medical Publishers, 2014.

Gans, R. Vestibular Rehabilitation: Programs and Protocols (2010), AIB Education Foundation Press