VOR exercises

[Jackie Gomes]

Hello Chrissy and fellow PTs,

This question is probably more relevant to PT practice than the NCS exam, but I would sure like some input as Vestibular Rehab is what I do have a lot on my caseload.
As per the Alsalaheen BA et al article of 2013, it was recommended that the VOR x1 be done for 2 MHz x 2min. I have however not seen that in any recent literature/guidelines. Also I am not really able to get patients to go beyond 20 sec to 1min at most, even when they are functioning well with subjective and with other outcome measures.
SO my question is whether the 2 min timeframe is still currently evidence based or not?

Thank you so much for your input!
Jackie

[Kyle Reedy]

Hi Jackie, good question.

Most of the vestibular patients i treat are concussion patients with a splash of chronic hypofunction. For these, I go by the vestibular rehab hypofunction guidelines in regard to volume of exercise. What i find more important than anything inregard to vestibular rehab interventions is the intensity. Symptoms should be increased with VOR exercises however should not be unbearable. whether this by symptom onset or gaze instability. For symptoms, their symptoms can increase by 1-2 above baseline and should subside after resolution of exercise and if they have any prolonged symptoms, it should be better <15min of resolution of total exercise. In regard to volume of exercise, i follow the CPG “Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Evidence-Based Clinical Practice Guideline” Home Exercise Program:
— Acute: > 3x/day for > 12 minutes total
— Chronic: >3x/day for > 20 minutes total

i break these exercises into 2-3 bouts. acute i give them 3x/day for 5-10min each.

For specific articles, i do not have ready to cite. They are based off the Medbridge courses i have taken as well as the recommendations from co-workers.

To be more specific with your question i pose 2 thoughts here that i do and do not agree with. First the frequency: 2mHz would be 120bpm. However the VOMS tests the VORx1 at 180bpm. So this study may not be getting the right intensity of what is considered normal. This could be due to decreased rate for increased time. I have personally favored increased rates over decreased time (focussing on 180bpm for 20sec at at time) given this is very flexible with patient presentation. My second thought is a personal opinion, is i do not find 2min of straight VOR to be function. VOR is not an enduruance reflex, it is a quick compensation reflex. So i would not do this for 2min.

I kind of went off on tangents. But thought this was good discussion question so i wanted to join in.

[Jackie Gomes]

Awesome reply Kyle, thank you so much! Such good points about the increased rate and functional vs endurance. Makes perfect sense! I do like to use the 2-3/day for 20 min guidelines and absolutely loved the MEdbridge Vestibular course.
My only concern question was about it taking upto 15min to resolve. But I guess it will be gradually decreasing all that time. From experience i did recently have a patient try the 2 min (was at 120max),he stopped at 1 min due to nausea and increase in symptoms so we did so some completely different supine neck/core exercises for a while and he got up saying he was better- than even when he came in. Never fails to amaze me how good well done VOR exercises provide almost immediate results!
Was nice to chat with a fellow Vestibular Therapist and good luck with your NCS exam!!

Thanks,
Jackie

[Chrissy Durrough Lugge]

Hi Jackie and Kyle!
This is a great discussion! For the latest recommendations, I read the updated peripheral vestibular hypofunction CPG that will be published in JNPT in April that Kyle referenced: https://journals.lww.com/jnpt/Abstract/9000/Vestibular_Rehabilitation_for_Peripheral.99697.aspx

This document outlines the timeframes Kyle mentioned for acute and chronic unilateral vestibular hypofunction (3-5x/day for 12-20 minutes), although the strength of the evidence for these general recommendations is weak.

On page 38 of the PDF, you can see the evidence updates for acute/subacute and chronic unilateral vestibular hypofunction. One individual study used a duration of 1.5 minutes for VORx1 viewing. Another study used a shorter episode of PT but increased frequency of VORx1 exercises (10x/day). I didn’t see clear guidelines regarding the rate of head turns in this document.

Basically, there is strong evidence to support VORx1 viewing for vestibular hypofunction and there is a trade-off for rate of head turns and duration. Like Kyle mentioned, long duration VORx1 viewing isn’t necessarily functional. I always consider functional complaints and assessments as I progress/modify my VORx1 recommendations (i.e., what are the patient’s scores on other objective measures, how is their reported balance during home/occupational/leisure activities, etc.).

Chrissy

[Kyle Reedy]

Thank you Chrissy. I think this is a good dive into the articles. I appreciate you looking into those and synthesizing the information. I like the recommendation of tie back to function at the end. some people may need that long duration at slower speeds

[Jackie Gomes]

Thanks Chrissy! As always thanks for going beyond and for the info and for providing the link.
Sure appreciate it!

Jackie

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