Combined Approach of Vestibular Physical Therapy with Therapeutic Virtual Reality for Visually Induced Disorientation - A Case Report

Research Objectives: To illustrate a combined approach of traditional vestibular physical therapy (VPT) and therapeutic virtual reality (VR) in the management of visually induced disorientation (VID).

Design: Case Report

Setting: Hospital-based outpatient

Participants: A 49-year-old male with VID worsening over 5 years. He reported standing at and looking up or down at heights as symptom triggers requiring external support for balance impacting his participation in social and work-related activities.

Interventions: This case demonstrates the use the specific environments via a therapeutic head-mounted display VR (HMD-VR) system with traditional VPT delivered over 11 sessions. Primary treatment strategies of habituation and sensory re-weighting were used to up-weight somatosensory and vestibular cues with VPT and down-weight visual cues with VR. Visual environments in VR progressed from linear optokinetic and optical flow to more complex and functional environments that simulated his real-world triggers (elevator, escalator). Treatment in VR progressed from sitting to standing on firm surfaces to dynamic force platform. Adjustable settings in the VR software allowed for varying speed and height in environments. Gradual environmental exposure to VR environments increased from 5 to 25 minutes as tolerated.

Main Outcome Measures: Dizziness Handicap Inventory (DHI), Activities-Specific Balance Confidence Scale (ABC), Subjective visual vertical (SVV) performed in rotatory chair and modified Clinical Test of Sensory Interaction and Balance (mCTSIB) were performed at initial evaluation (IE) and discharge (DC).
Sensory Organization Test (SOT) and vestibular function tests were performed on IE only.

Results: IE revealed normal balance scores (SOT=70) but abnormal visual dependence with normal vestibular function testing.

Disability scores (DHI) significantly improved (22% to 4%).
Activities scores (ABC) showed mild improvement (85.9% to 94.1%).
SVV normalized (-6.09° to -1.23°).
mCTSIB improved to normal (120s, minimal sway from 102.6s- 2 falls).

Conclusions: Persons who experience VID commonly present to VPT with a concurrent peripheral or central vestibular diagnosis. Current literature focuses on reducing VID as a secondary, not primary, diagnosis. Without significant clinical findings, these persons often do not seek out or receive care. Successful treatment of VID is challenging without the ability to apply a therapeutic dose of specific, complex and dynamic visual environments in HMD-VR which are now more commercially available. A combined approach of traditional VPT with specific and functional environments therapeutically dosed in HMD-VR can improve quality-of-life, participation in work and life activities, and physical performance in persons with VID.

Author(s) Disclosures: No conflicts of interest to disclose.