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J Neurol Phys Ther. 2010 June ; 34(2): 111–116. doi:10.1097/NPT.0b013e3181deca01.

The effects of habituation and gaze-stability exercises in the

treatment of unilateral vestibular hypofunction – preliminary
results

Richard A. Clendaniel, PT, PhD

Duke University Medical Center, Doctor of Physical Therapy Division, Durham, NC, Phone:
919-681-1008, Fax: 919-684-1846, [Link]@[Link]

Abstract
Background and Purpose—The efficacy of both habituation and adaptation exercise
interventions in the treatment of unilateral vestibular hypofunction has been demonstrated by prior
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studies. The purpose of this paper is to describe the preliminary results of an ongoing study that
compares the effects of these two different exercise approaches on outcomes related to vestibular
function.
Methods—Seven participants with unilateral vestibular hypofunction have completed a 6-week
exercise intervention after randomize assignment to either habituation (H) exercises, or gaze-stability
(GS) adaptation exercises. The following measures were taken pre-treatment and post-treatment:
Dizziness Handicap Inventory (DHI) to measure the symptom impact, motion sensitivity quotient
(MSQ) to assess sensitivity to head movements, and the dynamic visual acuity test (DVA) as a
measure of gaze-stability during head movements.
Results—Following the 6-week intervention there was an overall improvement in the DHI, the
MSQ, and both the active and passive DVA. The H and GS intervention group participants each
demonstrated similar improvements in both the MSQ, as well as the active and passive DVA
measures.
Discussion and Conclusions—The improvement in the MSQ for the GS group and the
improvement in the DVA measures for the H group were unexpected findings. Head movement,
which is required by both exercise interventions, rather than the specific type of exercise may be the
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critical factor underlying the observed improvements in motion sensitivity and dynamic visual acuity.

BACKGROUND AND PURPOSE

There are numerous studies that have documented the efficacy of exercises to alleviate the
symptoms and physical limitations associated with loss of vestibular function.1–4 The exercise
approaches have generally fallen into one of two categories, either adaptation or habituation
exercises. The adaptation exercises are based on the demonstrated ability of the vestibular
system to modify the magnitude of the vestibulo-ocular reflex (VOR) in response to a given
input (head movement). The adaptation of the VOR has been demonstrated in individuals with
normal vestibular function and those with unilateral vestibular hypofunction.5, 6 One of the

Richard Clendaniel, PT, Ph.D. is an Assistant Professor in the Doctor of Physical Therapy Division, Duke University Medical Center,
and Director of the Vestibular Testing Lab
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 Clendaniel Page 2

signals that induces adaptation of the VOR is retinal slip combined with head movement.7 This
is the basis for what has traditionally been considered adaptation exercises. These exercises
require the individual to perform rapid, active head rotations while watching a visual target,
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with the stipulation that the target remains in focus during the head movements.8 If the target
is stationary, then the exercises are referred to as x1 viewing exercises. If the target is moving
in the opposite direction of the head movement, then these exercises are referred to as x2
viewing exercises. While these exercises have been shown to improve dynamic visual acuity,
the actual mechanism behind this improvement is not known.9 As such, it may be more
appropriate to refer to these exercises as gaze-stability exercises.

In contrast with adaptation exercises, habituation exercises are based on the idea that repeated
exposure to a provocative stimulus (e.g. head movements) will lead to a reduction of the
motion-provoked symptoms.3, 10 This change is thought to be due to long-term changes within
the nervous system, and there is clinical evidence indicating that the habituation exercises can
lead to long-term changes in symptoms.11 The actual neural mechanism behind the
effectiveness of the habituation exercises is not understood.

While there is support for the two different intervention approaches, there are no studies to
date that have compared the two interventions in terms of changes in symptoms, motion
sensitivity, and dynamic visual acuity. What is reported herein are the preliminary results of a
study designed to investigate this issue in individuals with an identified unilateral vestibular
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loss. The underlying hypotheses for this study are that: 1) individuals who perform gaze
stability exercises will have a greater improvement in dynamic visual acuity compared to those
who perform the habituation exercises, and 2) individuals who perform habituation exercises
will have a greater reduction in their motion sensitivity compared to those who perform the
gaze stability exercises.

METHODS
Participants in this study were recruited from the clinical practice of the author. All participants
had a documented unilateral vestibular hypofunction based on surgical history, caloric test
results, or clinical examination, and had an abnormal clinical dynamic visual acuity test.12,
13 Individuals were excluded from the study if they had a central nervous system disease or
cause of dizziness, orthopaedic problems that precluded performance of the exercises, if they
were legally blind, or if they suffered from dementia. Informed consent was obtained, and the
institutional review board for human subjects protection at Duke University approved all
aspects of the study.

The computerized Dynamic Visual Acuity Testing apparatus was similar to devices reported
previously in the literature.14 An optotype (the letter E) was displayed on 25-inch, high
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resolution computer monitor; the orientation and size of the optotype was under computer
control. The orientation of the optotype was randomly altered, and the size of the optotype was
progressively decreased in 0.1 logMAR increments (logarithm of the minimal angle of
resolution). For each optotype size, five orientations of the optotype were presented. Static
visual acuity was determined first. When the participant was unable to correctly identify all
trials at a given acuity level, the test was stopped, and the number of missed optotypes was
recorded. For determination of dynamic visual acuity (DVA), the optotype was presented every
time the horizontal head velocity was between 120 deg/s and 180 deg/s (determined with a rate
sensor) Within each trial, the optotype was presented 5 times before the participant was forced
to determine its orientation. When the participant was unable to correctly identify all trials at
a given acuity level, the test was stopped. The participant’s DVA was determined by subtracting
the number of optotypes missed under the static visual acuity test from the number of optotypes
missed under the dynamic component of the test. The DVA test was performed under both

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active (self-generated head movements) and passive (examiner generated head movements)
conditions. The test was performed separately for ipsilesional and contralesional head rotation.
Since the ipsilesional DVA test was the item of interest in this study, the contralesional passive
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DVA test was always run first to account for any learning effects that might occur. This method
of DVA testing has been shown to be reliable with good sensitivity and specificity.14

The Dizziness Handicap Inventory (DHI) was administered to measure the participant’s
perception of how the symptoms are interfering with their lives.15 This tool is used routinely
in clinical settings, and has been shown to have greater sensitivity to change than global health
surveys.16 Motion-provoked dizziness was measured using the Motion Sensitivity Test
(MST). The MST measures the perceived intensity and duration of symptoms provoked by16
rapid changes in head or body position. An overall score, the motion sensitivity quotient
(MSQ), is determined from the results of each of the movements. The MST has been shown
to be both a reliable and valid measure of motion-provoked dizziness.17

Participants were randomly assigned to either the gaze-stabilization (GS) exercise group, or
the habituation (H) exercise group using a program that generated a randomized block
assignment to group based on the order in which the participant was enrolled in the study. The
participants in the GS group performed a series of exercises designed to improve gaze-stability
during head movements (Table 1) as well as balance and gait exercises. The participants in the
H group performed a series of exercises designed to decrease their sensitivity to head
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movements (Table 1), as well as balance and gait exercises similar to those performed by the
GS group. The exercises used in each group are used routinely in clinical practice and are often
referred to as either adaptation exercises (the GS group), or habituation exercises (the H group).
The participants were instructed to perform the exercises three times a day over a 6-week
period. The participants returned to the lab once a week for clinical assessment and progression
of the exercise program. The exercise progression was based on clinical experience treating
patients with acute and subacute vestibular disorders. The exercise program was devised so
that the participants could successfully complete each phase of the program. Static and dynamic
visual acuity tests, MST, and the DHI were administered at the start of the program and at the
end of the 6-week intervention period. The author performed all testing and treatment
interventions.

Given the preliminary nature of this report, between-group statistical analyses were not
performed. With the small sample size, pre-treatment to post-treatment changes across all
participants were assessed with the Wicoxon Signed Rank Test. Based on the initial studies of
the DHI, an 18-point change is considered to be statistically significant.15 This value was based
on test-retest results of a small sample (n=14), and raises the question of how to measure
improvement in individuals whose pre-treatment DHI score is <18. Despite these limitations,
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the DHI changes of each individual will be compared to this 18-point value. While there have
been demonstrated changes in computerized DVA with treatment, neither a mimial clinically
significant difference, nor statistically significant change scores have been reported for
computerized DVA.9 Earlier work by Herdman and colleagues14 documented the normal
values of the DVA by age. In subsequent studies, they refer to a reference value for
documenting individual improvement in DVA.9 This is reported to be a change of 6 or more
optotypes (personal communication). The DVA changes of each participant were compared
to these values. To our knowledge, there are no reports that have determined significant clinical
or statistical change scores for the MSQ.

RESULTS
Eight participants with unilateral vestibular hypofunction have been enrolled in the study to
date. Seven of the participants have completed the study. One participant was unable to

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complete the study due to having to return to work. The mean age of the participants was 43.9
years (range 27–65 years). Six of the seven participants were female. The time since onset of
the symptoms ranged from 2 weeks to 6 months, and the causes of the unilateral vestibular
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hypofunction included vestibular nerve resection, labyrinthectomy, and vestibular neuritis.

Three of the participants were enrolled in the GS group and four were enrolled in the H group.
These data are summarized in Table 2. Compliance with the exercise program (based on weekly
exercise logs) averaged 69.7% (range 34% – 90%).

Taken as a group, the participants demonstrated improvements in DHI scores, MSQ, and both
active and passive ipsilesional DVA. The DHI scores improved with intervention (pretreatment
mean=55.71, sd=19.34; post-treatment mean = 8.0, sd=7.30). This change was significant
based on the Wilcoxon Signed Rank Test (p < 0.01). The number of optotypes missed during
the active ipsilesional DVA also decreased (pre-treatment mean=14.7, sd= 9.35, post-treatment
mean=8.3, sd= 9.37), and this change was also significant (p < 0.05). In a similar manner the
number of optotypes missed during the passive ipsilesional DVA decreased (pretreatment
mean=14.3, sd=10.0, post-treatment mean=8.7, sd=9.71), which was also a significant change
(p < 0.05). There was a marked reduction in the measure of motion sensitivity post-treatment
(pre-treatment mean=25.21; post-treatment mean=1.85), but due to the small sample size and
the large variability, this was not statistically significant.

Since the number of participants was low, between-group statistical comparisons could not be
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performed. Observation of the individual data points for the different measures, however, is
illuminating, as there are clear trends in the preliminary data. Figure 1A and 1B demonstrate
the individual changes in DHI and MSQ, respectively, by intervention group across the six
week intervention session. For the DHI, all participants demonstrated a reduction in their scores
(Fig 1A). The three participants in the GS group each had decreases in the DHI score of >18
points. Three of the four participants in the H group also demonstrated decreases in their DHI
scores of >18 points. The one individual that did not demonstrate an 18-point change had a 10-
point decrease from 22 to 12. Regardless of intervention group, the majority of the participants
had improvements in DHI that are considered to be significant based on current understanding
of the test metrics.15

Due to symptom severity at the time of the initial assessment, not all participants were able to
complete the MST. Three of the five participants who were able to complete this test
demonstrated a reduction in the MSQ (Fig 1B). For two of the individuals in the H group, there
was a marked reduction in their motion sensitivity from values >40 to values <2. The other
individual in the H group had a pre-treatment MSQ score below 10 and demonstrated a mild
increase in MSQ score; the post-treatment value, however, was still <10. For the two
participants in the GS group, the MSQ decreased from 10.98 to 0.73 in one individual, and
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increased from 0.05 to 0.44 in the other. For the first individual this represents a change from
a motion sensitive condition to one with little motion sensitivity. For the other individual, there
was little motion sensitivity either pre-treatment or post-treatment.

The individual changes in ipsilesional active and passive DVA by intervention group are
depicted in Figure 2A and B. For the majority of the participants there was an improvement in
both active and passive DVA. For the participants in the GS intervention group the results were
mixed. For participant S1, even though the clinical DVA test was abnormal, the computerized
DVA was normal. There was an improvement of 2 optotypes during the passive DVA;
however, this is not a significant change. Participant S3 had a markedly abnormal active and
passive DVA at intial testing, neither of which showed improvement with the exercise
intervention. There were significant improvements in the active and passive DVA for
participant S4. The active DVA improved by 11 optotypes, and returned to a normal level. The
passive DVA improved by 8 optotypes, but did not return to a normal level.

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Surprisingly, there were substantial reductions in the number of missed optotypes for the
participants in the H intervention group. Participant S2 demonstrated an improvement of 16
optotypes for the active DVA and an improvement of 8 optotypes for the passive DVA. This
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also represents a change from an abnormal pre-treatment DVA to a normal result post-
treatment. Participant S5 had an improvement of 8 optotypes for the active DVA, and an
improvement of 15 optotypes for the passive DVA. While this change is significant, this
individual did not attain normal levels for either active or passive DVA post-treatment. The
third participant in the H group, S7, did not demonstrate a significant in improvement in active
DVA and did not attain normal levels for this test condition. For the passive DVA, however,
there was an improvement of 3 optotypes, which improved performance to a normal level.
Since participant S8 was too symptomatic to perform the active DVA tests at the pre-treatment
assessment, only the passive DVA was measured. There was an improvement of 4 optotypes
with the passive DVA, which represents a change from an abnormal DVA pre-treatment to a
normal DVA post-treatment.

DISCUSSION
The improvements observed across participants were not unexpected based on prior studies.
2–4 Both intervention groups demonstrated similar improvements in the DHI, which suggests
that there was a decrease in the impact of the symptoms on the participants’ lives, and that the
type of exercise intervention was not an important factor. Participant S3 presents unusual
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findings; there was a significant decrease in the DHI score, yet no change in either active or
passive DVA. In addition, the MSQ was <1 on both the pre-treatment and post-treatment
assessments. According to the self-report exercise log, participant S3 was compliant with the
exercise program (73%). A possible explanation for the disparity between the DVA and DHI
scores is that this participant avoided movements and activities for fear of symptom
provocation, which would be reflected in the pre-treatment DHI score. With initiation of the
exercise program, the participant may have discovered that he was able to move and function
without symptoms (as reflected in the low MSQ scores), which would lead to decreases in the
DHI scores. It is not clear why participant S3 demonstrated no improvement in DVA. It could
be due to improper performance of the exercises at home, or some other factor. Exercise
intervention in the treatment of vestibular hypofunction has been shown to not be beneficial
in all cases.18 In that study, the percentage of participants who felt the rehabilitation program
was of benefit was greater than the percentage of participants who demonstrated improvements
in gait measures, which is consistent with the disparity between physiologic measures and
patient reported outcome measures observed in participant S3.

Given the small number of participants in this preliminary report, one must be cautious to not
over-interpret the results. That said, the present results demonstrate two somewhat unexpected
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results that bear further discussion and exploration. The first result is the reduction of the MSQ
in the Gaze-Stability group. This intervention group did not perform exercises designed to
specifically alleviate their sensitivity to large amplitude, rapid head movements. The one
participant in this group that had a pre-treatment MSQ score >10 had a marked reduction in
the MSQ to a value <1. While there are several possible explanations for this, one must keep
in mind that of the two participants in the Gaze-Stability group that completed the MST, only
one had measurable motion sensitivity. One possible explanation for the reduction in motion
sensitivity is that the gaze-stability and balance exercises, as well as the participant’s daily
activities, included sufficient provocative stimuli to cause habituation of the motion-provoked
symptoms. Another possible explanation for the reduction in the motion sensitivity is that the
GS intervention led to adaptation of the vestibular system. This adaptation would result in
resolution of the sensory mismatch between vestibular, visual and somatosensory inputs. With
the loss of the sensory mismatch, which is thought to produce the symptoms of motion
sensitivity, there would be no motion-provoked dizziness. The efficacy of the gaze stabilization

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exercises to reduce motion sensitivity needs to be confirmed with continued enrollment of

participants in the study.
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The most interesting finding in the study is the improvement in the active and passive
ipsilesional DVA in the participants performing the habituation exercises. This improvement
was seen across all participants in the H intervention group, who did not perform exercises
designed to improve their visual acuity during head movements. The improvements in both
the GS and H groups are similar (except for one participant in the GS group who showed little
to no improvement). There are several possible explanations for this improvement in DVA in
the H intervention group. One, it is possible that the balance exercises and the participants’
daily activities provided sufficient stimuli to induce improvements in DVA. However, in a
study by Herdman and colleagues9, wherein the participants performed either gaze
stabilization and balance exercises, or a placebo (saccadic eye movements) and balance
exercises, the group performing the placebo and balance exercises showed no improvement in
their DVA measures. Another possible explanation is that the head movements used in the H
intervention enabled, or facilitated, the central compensations that resulted in the improvements
in DVA. It may be that the head movements pose a challenge (sensory mismatch) to the central
nervous system, which then attempts to resolve the challenge. As the CNS learns to compensate
for the sensory mismatch, it may also learn strategies for improving visual acuity during head
movements. The common factor in the exercises performed by both the GS and H groups is
the head movement, which may be the enabling factor in the compensation process. A similar
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result was described by Cohen and Kimball.19 These investigators demonstrated

improvements in measures of ataxia, as well as static and dynamic postural stability, in
individuals with unilateral vestibular hypofunction following a rehabilitation program
consisting solely of habituation exercises. This explanation, that head movement enables the
compensation process, is also supported by the clinical observation that those individuals with
a vestibular deficit who move tend to improve (decreased symptoms and increased functional
levels) without intervention.

The actual mechanisms underlying the improved DVA for either intervention are not known.
Analysis of the eye movements during the DVA test both pre- and post-intervention may help
elucidate these mechanisms. These data are currently being collected, but are beyond the scope
of this report.

CONCLUSIONS
Gaze-stability and habituation exercises have previously been shown to decrease symptoms of
dizziness and increase function in individuals with vestibular disorders. The preliminary results
of this study indicate that both exercise interventions lead to a reduction in the self-report
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measure of the impact of symptoms on the ability to function, a decrease in the sensitivity to
movements, and an improvement in the ability to see clearly during head movements.
Continued investigation is needed to determine if these results will hold, to determine if there
are different effects of the two interventions, and to determine the mechanisms of improved
visual acuity.

Acknowledgments
This work was supported by NIH (NCMRR) grant R03HD049885

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hypofunction. [Link] Head Neck Surg 2003;129(8):819–824. [PubMed: 12925338]
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11. Clement G, Tilikete C, Courjon JH. Retention of habituation of vestibulo-ocular reflex and sensation
of rotation in humans. Exp Brain Res 2008 Sep;190(3):307–315. [PubMed: 18592226]
12. Halmagyi GM, Curthoys IS. A clinical sign of canal paresis. Archives of Neurology 1988;45:737–
739. [PubMed: 3390028]
13. Longridge NS, Mallinson AI. The dynamic illegible E-test. A technique for assessing the vestibulo-
ocular reflex. Acta Otolaryngol (Stockh) 1987;103(3–4):273–279. [PubMed: 3577760]
14. Herdman SJ, Tusa RJ, Blatt P, Suzuki A, Venuto PJ, Roberts D. Computerized dynamic visual acuity
test in the assessment of vestibular deficits. Am J Otol 1998;19(6):790–796. [PubMed: 9831156]
15. Jacobson GP, Newman CW. The development of the Dizziness Handicap Inventory. Archives of
Otolaryngology Head and Neck Surgery 1990;116:424–427. [PubMed: 2317323]
16. Enloe LJ, Shields RK. Evaluation of health-related quality of life in individuals with vestibular disease
using disease-specific and general outcome measures. Physical Therapy 1997;77(9):890–903.
[PubMed: 9291947]
17. Akin FW, Davenport MJ. Validity and reliability of the Motion Sensitivity Test. [Link]
2003;40(5):415–421. [PubMed: 15080226]
18. Krebs DE, Gill-Body KM, Parker SW, Ramirez JV, Wernick-Robinson M. Vestibular rehabilitation:
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19. Cohen HS, Kimball KT. Decreased ataxia and improved balance after vestibular rehabilitation.
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Fig 1.
Pre-treatment and post-treatment values for the Dizziness Handicap Inventory (A) and motion
sensitivity (B). The individual DHI scores for the participants in the gaze-stability intervention
group (GS) are plotted in 1A with solid lines and those in the habituation intervention group
(H) are plotted with dashed lines. The individual motion sensitivity quotient (MSQ) values are
plotted in 1B.

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Fig 2.
Pre-treatment and post-treatment values for the active (A) and passive (B) ipsilesional dynamic
visual acuity tests. In both graphs the individual values for the participants in the gaze-stability
intervention group (GS) are plotted with solid lines and those in the habituation intervention
group (H) are plotted with dashed lines.

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Table 1
Exercise Progression
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Gaze-Stabilization Exercises Week Habituation Exercises

Horizontal and vertical x1 viewing 1 Large amplitude, rapid cervical rotation

exercise with near target, 1 minute (horizontal or vertical), each set of
duration, sitting exercise consisted of 5 complete
movements (cycles) and the individual
performed 3 sets, sitting

Horizontal and vertical x1 viewing 2 Large amplitude, rapid horizontal cervical

exercise with near target, 2 minute rotation (seated) and standing pivots, or
duration, sitting large amplitude, rapid vertical cervical
rotation (seated) and seated trunk flexion-
extension,3 sets of 5 cycles

Horizontal and vertical x1 viewing 3 Large amplitude, rapid horizontal and

exercise with near and far targets, 2 vertical cervical rotation (seated) and
minute duration, standing standing pivots, or large amplitude, rapid
horizontal and vertical cervical rotation
(seated) and seated trunk flexion-
extension,3 sets of 5 cycles

Horizontal and vertical x1 viewing 4 Large amplitude, rapid horizontal and

exercise with near and far targets, and vertical cervical rotation (seated), standing
targets located in front of a busy pivots, and seated trunk flexion-extension,
background, 2 minute duration, standing 3 sets of 5 cycles
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Horizontal and vertical x1 viewing 5 Large amplitude, rapid horizontal and

exercise with near and far targets, and vertical cervical rotation (standing),
targets located in front of a busy standing pivots, and seated trunk flexion-
background. Horizontal and vertical x2 extension,3 sets of 5 cycles
viewing exercise, plain background. All
exercises 2 minute duration, standing

Horizontal and vertical x1 viewing 6 Large amplitude, rapid horizontal and

exercise with near and far targets, and vertical cervical rotation (standing),
targets located in front of a busy standing pivots (180 degrees), seated
background. Horizontal and vertical x2 trunk flexion-extension, and Brandt-
viewing exercise, busy background. All Daroff exercise 3 sets of 5 cycles
exercises 2 minute duration, standing
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Table 2
Key: The DHI measures reflect the scores on the Dizziness Handicap Inventory, with lower scores indicating improvements in perceived handicap. The
DVA scores reflect the number of missed optotypes during the dynamic test condition (minus the number of optotypes missed during the static visual acuity
test). A decrease in the number of missed optotypes reflects improvements in the DVA. The MSQ values represent the results of the Motion Sensitivity Test.
Clendaniel

These values can range from 0 (no motion sensitivity) to 100 (severe symptoms in all test positions). A decrease in MSQ reflects improvement. Note: S7
was 3 years status post acoustic neuroma resection; she had an exacerbation of symptoms following childbirth.

ID Age Diagnosis Symptom Intervention DHI Active Passive MSQ

Duration Pre- / Post- Ipsilesional Ipsilesional Pre- / Post-
DVA DVA
Pre- / Post- Pre- / Post-

S1 40 Vestibular Neuronitis 2 mos GS 60 / 0 1/1 3/1

S3 65 Vestibular Neuronitis 3 mos GS 36 / 0 28 / 27 27 / 28 0.05 / 0.44

S4 54 Labyrinthectomy 1 mos GS 68 / 14 15 / 4 22 / 14 10.98 / 0.73

S2 56 Vestibular Neuronitis 1 mos Habituation 76 / 2 21 / 5 13 / 5 67.38 / 1.17

S5 32 Acoustic Neuroma 1 mos Habituation 64 / 18 14 / 6 24 / 9

Resection

S7 33 Acoustic Neuroma 4 mos Habituation 22 / 12 9/7 6/3 4.44 / 5.47

Resection

S8 27 Vestibular Neuronitis 1 mos Habituation 64 / 10 5/1 43.21 / 1.46

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