Conventional Versus Virtual Reality Based Vestibular Rehabilitation; Effect on Dizziness, Gait and Balance

Unilateral vestibular disease results in vertigo, dizziness, dysequilibrium and gait problems. Recovery results from a process known as vestibular compensation where visual and proprioceptive inputs are upregulated, or remaining vestibular function is recalibrated and utilised more effectively (Curthoys, 2000). Patients who do not compensate remain significantly impaired. They benefit from specialised assessment and treatment techniques collectively referred to as vestibular rehabilitation (Hillier and McDonnell, 2011). This form of rehabilitation has its roots in the empirical work of Cawthorne and Cooksey, who in the 1940's first documented the important role of exercise in recovery after a vestibular injury (Cooksey, 1945) and more recently in studies investigating vestibular adaptation (Schubert et al., 2008). Vestibular rehabilitation programs can be considered as motor learning programs and thus require practice and feedback. In conventional rehabilitation it is difficult for patients to gain feedback of performance performing balance exercise which can be repetitive and boring. Force plate technology has been used in the clinical setting to provide visual and auditory feedback and has shown some promising results (Teggi et al., 2009). Virtual reality, defined as 'a high-end-computer interface that involves real time simulation and interactions through multiple sensorial channels' (Burdea and Coiffet, 2003) is also being investigated in laboratory settings. There is some support for the use of virtual reality in vestibular rehabilitation (Viirre and Sitarz, 2002) but these technologies are presently prohibitively expensive and are not universally available. They require considerable therapist time and are unlikely to be used with the frequency that is required for motor learning (particularly in vestibular rehabilitation where most programs entail daily exercise). Recent developments in the gaming industry have resulted in the Nintendo Wii ® Fit Plus, which combines a force platform with an accelerometer to provide visual and auditory feedback of subjects' centre of gravity during virtual reality exercises and games. It stimulates movement and perturbs balance in order to retrain it. Use of this low cost gaming system could easily be adapted to meet the requirements of a vestibular rehabilitation program. The system allows for accurate monitoring of use in terms of time and frequency which is an area that has proven difficult to monitor in both research and clinical applications due to inaccurate patient recall. It is fun to use and therefore may be motivating patients. The rehabilitation community is beginning to investigate this technology in the area of balance retraining (Nitz et al. 2009). Anecdotal reports indicate the Wii is being used in vestibular rehabilitation (Hain, 2011) but as yet no randomised controlled trials exist.

It is important to measure the effect of this technology which can easily be incorporated into the home environment and compare it to conventional treatment before it can be recommended for use. In tandem with this is also important to gain some insights into patient satisfaction with both treatments.

Aim To compare the outcome from conventional vestibular rehabilitation to virtual reality based vestibular rehabilitation in the treatment of unilateral vestibular disease.

Objectives To compare the effect of conventional vestibular rehabilitation and virtual reality based rehabilitation on gait.

To compare the effect of conventional vestibular rehabilitation and virtual reality based rehabilitation on subjective complaints of dizziness/vertigo.