Indian J Otolaryngol Head Neck Surg

(Oct–Dec 2017) 69(4):431–442; https://doi.org/10.1007/s12070-017-1236-9

INVITED ARTICLE

Specific Organ Targeted Vestibular Physiotherapy: The Pivot

in the Contemporary Management of Vertigo and Imbalance
Anirban Biswas1 • Bibhas Barui1

Published online: 20 November 2017

Ó Association of Otolaryngologists of India 2017

Abstract were found to be defective in vestibulometry. Specially

Introduction Advancements in our understanding of made Virtual reality programs were used in patients suf-
vestibular physiology and how it is changes in different fering from psychogenic balance disorders. The pre and
diseases have established that of the three therapeutic post therapy status was evaluated by different standard
approaches to treat disorders of the vestibular system viz. scales to assess balance and dizziness.
pharmacotherapy, surgery and physical therapy, it is the Results Very promising results were obtained. Organ tar-
later i.e., physical therapy which is the most efficacious geted physiotherapy where defective sense organs were
modality in the management of balance disorders. The specifically stimulated showed remarkable improvement in
futility of vestibular sedatives in the correction of different measures. Virtual reality exercises too showed
vestibular disorders and in the restoration of balance and very promising results in patients of psychogenic vertigo.
the very limited role of surgery has now been recognised.
Advancements in vestibulometry now enable us to localise Keywords Vestibular physiotherapy

any lesion in the vestibular system with utmost precision Management of balance disorders

and also determine the exact cause of the balance disorder. Physical therapy for vertigo
The site of lesion and the specific organ that is defective
can now be very precisely identified. Treatment modalities
especially that for physical therapy hence have to be organ Introduction
specific, and if possible, also disease specific.
Aims and Objectives The study aims at evaluating the Physiotherapy or physical therapy is defined as the treat-
efficacy of physiotherapy in the management of balance ment of disease, deformity and/or disability by physical
disorders and also assesses the efficacy of organ targeted methods such as massage, heat treatment, and exercise or
physical therapy, a new concept in restoring balance after physical workouts rather than by medicines or by surger-
vestibulometry has identified the offending organ. y. The essence of physiotherapy is to improve and enhance
Materials and Methods The study was conducted in the the functionality of a dysfunctional or malfunctioned body
specialised physical therapy unit for balance and gait dis- part and to stimulate and boost the residual function of a
order patients which is a part of Vertigo and Deafness damaged organ and thereby provide a better quality of life.
Clinic in Kolkata, India. Special instruments for physical Physical therapy adapts the body to overcome challenges
therapy devised by the first author were used for stimula- that are limiting daily physical activities necessary for
tion of specific sense organs in the vestibular labyrinth that sustenance of normal life. Vestibular physiotherapy is
physical therapy that helps in the correction of vestibular
disorders (that present as vertigo/imbalance/unsteadiness)
& Anirban Biswas and in the improvement of body’s balances mechanism.
[email protected]
Some ailments respond to medical treatment, some to
1
Vertigo & Deafness Clinic, BJ-252, Salt Lake, Kolkata, surgery and some to physical therapy. Vestibular disorders
West Bengal 700091, India respond best to a two pronged therapeutic approach viz.

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(1) Medical therapy directed to treat the underlying merely helped in partly and temporarily reducing the
medical disorder that is causing the vertigo/imbal- symptom of head spinning without correcting the under-
ance e.g., steroids for vestibular neuritis, diuretics lying cause of the disorder in any way [4]. As for patients
for Meniere’s disease, psychotropic drugs SSRIs/ with the imbalance, the vestibular sedatives did not help at
benzodiazepines for psychogenic vertigo, migraine all. Rather, by sedating and reducing the sensitivity of the
prophylactic drugs for Vertiginous migraine etc. [1]. balance organs/vestibular system they actually aggravated
(2) Diligent physical therapy that is directed to restora- the patient’s imbalance. Vestibular sedatives neither cor-
tion of the normal balance function after it has been rected the underlying disease causing the balance disorder
deranged by disease. This again acts in different nor restored the balance function that had been deranged by
ways. Some physical therapies just improve the the disease. As for physiotherapy in the management of
general balance function and sharpen the balancing balance disorders, the therapy was (and still is) limited to
skills of the subject, some enhance the vestibular non-specific Cawthrone Cooksey exercises.
compensatory mechanism (elaborated below) and The balance organs are special sense organs where dead
some enhance the functionality of a damaged part of cells do not regenerate; yet then, after the balance organs
the vestibular labyrinth or that of a deranged have been damaged by disease, most (but not all) patients
mechanism in the vestibular system. [2]. slowly re-gain their normal or near normal balance func-
tion. This happens not because the damaged cells regen-
erate, but because we have an in-built system called
the vestibular compensatory mechanism [5] which brings
Literature and Review
about some functional changes in the brain by virtue of
which a patient having a damaged balance organ at least
The Unique Challenges in Treating Balance
partly if not wholly gets back normal balance function.
Disorders
This is a unique system of the human body and the best part
of it is that it is a completely natural process. Medicines do
Vestibular disorders [3] cause extreme morbidity and
not enhance this process of vestibular compensation.
induce a severe impact on the quality of life of the patient
Rather, most, if not all vestibular sedatives that are used for
suffering from it. Disorders of the vestibular system are
symptomatic relief in vertigo depress this natural process
very incapacitating and cripple the patient not only phys-
of restoration of balance that is ingrained in our biological
ically but also mentally. Unfortunately, however, the bio-
system. But, physical therapy in different forms does
logical mechanism of maintenance of balance and how
enhance and expedite this natural mechanism of vestibular
different diseases of the balance system modify this normal
compensation in a very big way. Herein lies the importance
functioning of the balance system was ill-understood till
of physical therapy in the management of balance
about a decade back. This is due to the inherent complexity
disorders.
of the mechanism of maintenance of balance which
becomes still more complex when afflicted by disease as a
Contemporary Consensus on Solutions
huge lot of internal adjustments take place when the bal-
and Strategies for Effective Management of Balance
ance system starts malfunctioning.
Disorders
Head spinning or vertigo and imbalance or unsteadiness
is only the external manifestation or just the symptom of
It is only in the last 10 years that a paradigm shift has taken
some internal disease which needs to be diagnosed first for
place in the management of vestibular disorders. The cur-
effective treatment. But as the understanding of the
rent approach in management of balance disorders is to
pathophysiology was poor in the not so distant past, the
diagnose the underlying disease that is causing the balance
diagnosis of the underlying causative disease could not be
disorder and then to localise the exact site of lesion and
confirmatively made in most patients till a few years back.
identify which specific organ or system is at fault. Once
Consequently, treatment meted out to these patients was
this is done, specific drug therapy to treat the underlying
illogical, irrational and empirical and what the medical
disorder and specific physiotherapy to stimulate specifi-
community was doling out under the guise of treatment of
cally the damaged organ or the dysfunctional system is
vestibular disorders was actually an utter disservice and
instituted. It is now known that most if not all of the
mismanagement of these hapless patients.
vestibular sedatives that are/were used for treating
The common practice of treating balance disorders all
vestibular disorders actually jeopardise the natural process
these years was hence limited to prescribing anti-vertigo
of restoration of balance function and the use of such
drugs or vestibular sedatives (like betahistine/cinnarizine/
medicines is now unanimously denounced and long term
meclizine/prochlorperazine/dimenhydrinate etc.) that
use is universally abhorred. In fact, some of these drugs

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like betahistine and cinnarizine are not even approved by by adapting them to different types of challenging situa-
the FDA of USA which is a regulatory body for use of tions [8].
medical products/devices respected and followed interna- In patients with disorders of the vestibular system,
tionally. The current medical consensus is that if at all physical therapy restores the balance function by three
these anti-vertigo drugs [6] are ever used, then, the use different physiological mechanisms all of which are linked
must be restricted to just 3–5 days never ever beyond that. to each other viz
The scope of medical treatment in balance disorders is
(1) Enhancing and expediting the vestibular compen-
strictly confined to treating the underlying causative dis-
satory mechanism by exercises like (a) standing and
ease after it has been confirmatively diagnosed by a thor-
walking on uneven surfaces or soft surfaces so that
ough history taking, clinical tests and by the current
the proprioceptive input is reduced and the patient
investigative modalities i.e., modern vestibulometry. The
learns to manage balance by utilising the vestibular
medical treatment is augmented by physical therapy for the
and visual inputs; (b) standing and walking first on
best treatment outcome. But for this the physical therapies
hard even surfaces and then on soft uneven surfaces
for improving the balance functions need to be customised
with eyes closed so that the patient learns to maintain
for each patient. Each balance disorder patient has different
balance without visual input and with reduced
needs which require to be addressed by the team of neu-
proprioceptive input;
rotologist, vestibular physiotherapist and neuro-rehabilita-
(2) Improving general balance function by exposing the
tion specialist.
patient to different types of challenging situations
like walking unsupported with eyes closed, trying to
The Unique Role of Physical Therapy in Balance
balance on one leg, playing easy games like catching
Disorders
a ball standing on a pliable surface like a trampoline,
trying to sit and balance on a gym ball etc. Different
Physical therapy is currently considered the mainstay of
centres for vestibular physiotherapy can have its own
treatment in balance disorder patients especially for
protocols for increasing the balance capability of the
restoring the normal balance function and bringing back
patient and depending on the special requirements
the patient to mainstream. It has been found to be extre-
and physical capabilities of the patient the exercises
mely beneficial and effective for the restoration of balance
need to be customised;
function after the balance organs have been damaged by
(3) Specifically and individually stimulating the defec-
disease. Advancements in our understanding of the mech-
tive sensors in the vestibular labyrinth in the ears
anism of balance in normal persons and also when affected
(like the utricle/saccule/semi-circular canals) to
by disease have established the supreme efficacy of phys-
sharpen and augment their sensitivity after the defect
ical therapy in the management of balance disorders [7].
has been identified by the modern vestibular function
Physical therapy is beneficial in augmenting the physical
tests e.g., moving the head in the plane of the semi-
stability of any individual; not only balance disorder
circular canal that has been identified to have been
patients, but also in normal persons who do not have a
damaged [9, 19].
balance disorder. The balance system has an inherent
plasticity by virtue of which the balance faculty can be
augmented by physical training i.e., by physiotherapy and
decreased by disuse. Acrobats who perform highly skilled Materials and Methods
balance acts like tight rope walking are all normal persons
like any of us whose balance systems have been sensitised 53 patients diagnosed with different types of vestibular
and sharpened by intensive physical training only. This disorders and thoroughly investigated with all requisite
training is nothing but physical therapy. Hence, in a person vestibular function tests viz, VNG including oculomotor
with a compromised balance function due to any disease, tests, VHIT, ocular and cervical VEMP, Subjective Visual
the functionality or the capacity of the balance system can Vertical Test (SVV), Dynamic Visual Acuity (DVA) and
definitely be enhanced substantially just by physical ther- Craniocorpography (CCG) were enrolled for the study to
apy. Physiotherapy for balance improvement and aug- assess the role of pure physical therapy in improving the
menting general stability in challenging balance situations balance disability and physical impairment. The patients
is used in fall prevention too and is hence immensely useful were evaluated pre-therapy by Activity Balance Confidence
in improving quality of life of aged patients. Some special Scale, Burg Balance Scale and the Dizziness Handicap
forms of physical therapies like those employing virtual Inventory scale and re-evaluated post therapy on these
reality systems also help patients overcome the fear of fall scales after 10 sessions. The study was carried out in the
physiotherapy unit of Vertigo and Deafness Clinic at BJ-

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Fig. 1 a, b A set-up for stimulation of the saccule. In this much as possible. The chair stimulates the saccule at a low frequency
hydraulically operated electromechanical system (a) the patient can of stimulation. Once the patient is comfortable with the low frequency
be made to move up and down while seated on a chair. This is done stimulation the patient is made to jump on a trampoline (b) for high
first with eyes open and then with eyes closed such that the sensing of frequency stimulation of the saccule after being anchored properly by
the linear movement in the vertical axis is done by the saccule as harnesses (not shown here) attached to the walls or to the roof

252 Salt Lake Kokata, India which is equipped with all

modern diagnostic and therapeutic equipment related to
balance and hearing disorders owned and run by the
authors.
The physical therapies were carried out by some new
tools devised by the first author and by some standard
available tools most of which were specifically improvised
in-house at Vertigo and Deafness Clinic Kolkata. Some of
the tools used were:
(1) Hydraulically operated linear vertical movement
generator at low frequency stimulation of saccule
(Fig. 1a)
(2) Trampoline for generating high frequency linear Fig. 2 A hydraulically operated electromechanical device to specif-
ically stimulate the utricle. The platform moves in the linear plane
vertical movement for stimulation of the saccule horizontally. The patient stands on the moving platform first with eyes
(Fig. 1b) open holding on to the railings and then without holding the railing
(3) Hydraulically operated linear horizontal movement with eyes open and then with eyes closed. The speed of movement
generator for stimulation of utricle at low frequen- can be slowly increased and the task made more difficult by making
the patient stand on a soft surface first on two legs then on one leg
cies (Fig. 2)
(4) Mechanically operated angular head movement
(8) Stability and Balance improving exercises using a
generator for anterior and posterior canals (Fig. 4)
Trampoline (Fig. 6a, b), a Bosuball (Fig. 6c) and
(5) Electromechanically operated lateral angular
Foam pads (Fig. 6d)
movement generator of lateral semi-circular canals
(9) Body Weight Support unweaning System impro-
at low frequencies (Fig. 3)
vised in the clinic for gait disorder patients and
(6) Stability Trainer from Theraband—Blue, Green
patients with a psychological fear of walking
and Black foams of different grades of firmness/pli-
(Fig. 7)
ability for different grades of gradually varying
(10) Virtual Reality Software(s) made in-house through
proprioceptive stimulus (Fig. 5a)
NeuroEquilibrium Diagnostic Systems for training
(7) Gym Balls from Theraband for stability improving
in Virtual Reality environment (Fig. 8)
exercises like lifting one hand and one leg while
sitting on the gymball (Fig. 5b) and activities like If vestibulometry diagnosed a patient has a defect in the
catching a ball while balancing on the gymball anterior semi-circular canal, of the left side the patient was

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subjected to specific physical therapy that precisely stim-

ulates the anterior semi-circular canal of the left side. If
there was a defect in the saccule the patient was subjected
to up-down movements in a hydraulic chair and after the
patient became comfortable with this low frequency stim-
ulation, then the patient is made to jump on the trampoline
after securely anchoring the patient with specially made
harnesses for high frequency stimulation of the saccule. If
there was a defect in the utricle, then the utricle is stimu-
lated by side to side and front–back movements in a
hydraulic platform. There are very special gadgets for
stimulating each different sensor in the vestibular system
all devised by the first author with the help of engineering
fabricators.
Some patients were diagnosed by the first author to have
a psychic overlay causing a sense of imbalance and fear of
falls but showed more or less normal findings in vestibu-
lometric tests. These patients were made to undertake,
some customised virtual reality programs (Fig. 8) to
expose the patient to different mentally challenging bal-
Fig. 3 Set up for precisely stimulating the lateral semi-circular canals ance situations so that the sense of insecurity and the
only. The electromechanical device rotates the platform in clockwise/ apprehension of losing balance or undue fear of falling is
anti-clockwise manner to specifically stimulate the left and the right
lateral semi-circular canals. The patient stands on the revolving
overcome. These modalities actually are a form of Cog-
platform first holding on to the handles then without holding to the nitive Behavioural Therapy and act by a process of
handles and then with eyes closed and finally with eyes closed on a Exposure and Response Prevention and bring back such
foam pad to eliminate visual and proprioceptive inputs patients to mainstream.

Fig. 4 a, b Targeted physiotherapy for specifically stimulating the circular canals and b is the position for stimulating the left anterior
anterior (superior) and the posterior semi-circular canals. a Is the and right posterior semi-circular canals
position for stimulating the right anterior and left posterior semi-

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Results

Subjects Vestibulometry Physical therapy Abc (%) pre Abc (%) post Bbs(_/56) Bbs(_/56) Dhi pre Dhi post
intervention treat treat pre treat post treat treat treat

1 Ab lateral canal Specific organ therapy, 40 86 28 50 30 8

balance training
2 Bilateral Specific organ therapy, 20 80 12 48 40 12
vestibulopathy balance training, gait
training
3 Normal Virtual reality 60 90 38 52 18 8
4 Ab utricular Specific organ therapy, 50 86 38 46 22 10
balance training
5 Ab lateral canal Specific organ therapy, 20 30 32 36 56 48
balance training
6 Normal Virtual reality 54 88 38 48 22 10
7 Normal Virtual reality 58 90 40 50 20 8
8 Ab lateral canal Specific organ therapy, 60 96 40 52 18 8
balance training
9 Ab utricular Specific organ therapy, 62 92 38 50 24 10
balance training
10 Ab utricular Specific organ therapy, 30 90 38 56 30 12
balance training
11 Normal Virtual reality 58 94 40 52 24 10
12 Normal Virtual reality 54 92 39 50 22 8
13 Ab lateral canal Specific organ therapy, 40 90 28 54 28 8
balance training
14 Ab utricular Specific organ therapy, 50 90 36 52 20 10
balance training
15 Normal Virtual reality 70 94 48 54 22 8
16 Normal Virtual reality 36 86 36 50 18 10
17 Ab lateral canal Specific organ therapy, 50 96 40 54 24 12
balance training
18 Ab lateral canal Specific organ therapy, 56 88 36 50 22 8
balance training
19 Normal Virtual reality 60 92 42 54 16 8
20 Ab lateral canal Specific organ therapy, 54 86 34 50 24 10
balance training
21 Ab lateral and Specific organ therapy, 48 84 34 48 28 14
posterior canal balance training
22 Ab lat, ant and Ab lat, ant and post, saccule 40 60 32 46 34 16
post, saccule
23 Normal Virtual reality 60 88 38 56 18 10
24 Normal Virtual reality 64 90 40 56 16 8
25 Ab lateral canal Specific organ therapy, 50 84 34 48 28 12
balance training
26 Ab lateral and Specific organ therapy, 46 82 32 48 36 12
posterior canal balance training
27 Ab utricular Specific organ therapy, 52 90 34 50 24 8
balance training
28 Ab lateral canal Specific organ therapy, 38 86 38 52 40 10
Balance training
29 Ab lateral canal Specific organ therapy, 44 88 34 50 36 12
balance training

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Subjects Vestibulometry Physical therapy Abc (%) pre Abc (%) post Bbs(_/56) Bbs(_/56) Dhi pre Dhi post
intervention treat treat pre treat post treat treat treat

30 Ab lateral canal Specific organ therapy, 46 90 32 50 40 16

balance training
31 Ab utricular Specific organ therapy, 54 90 36 54 36 12
balance training
32 Normal Virtual reality 58 88 39 55 40 12
33 Normal Virtual reality 56 92 42 54 18 8
34 Ab lateral and Specific organ therapy, 48 89 32 52 24 6
posterior canal balance training
35 Ab lateral canal Specific organ therapy, 46 92 33 51 18 8
balance training
36 Normal Virtual reality 60 90 41 53 28 8
37 Ab lat, ant and Ab lat, ant and post, saccule 38 86 39 54 26 10
post, saccule
38 Ab lateral canal Specific organ therapy, 45 91 38 53 20 8
Balance training
39 Normal Virtual reality 42 96 45 54 14 6
40 Normal Virtual reality 52 88 42 52 28 8
41 Ab lateral canal Specific organ therapy, 38 78 30 46 44 16
Balance training
42 Normal Virtual reality 50 90 40 54 28 8
43 Normal Virtual reality 48 89 40 55 26 10
44 Ab lat, ant and Specific organ therapy, 45 88 38 52 24 12
post, saccule balance training
45 Ab utricular Specific organ therapy, 46 90 39 52 28 10
balance training
46 Ab lateral canal Specific organ therapy, 52 91 40 51 26 8
balance training
47 Normal Virtual reality 44 88 42 54 22 6
48 Ab lateral canal Specific organ therapy, 46 90 40 54 24 8
balance training
49 Normal Virtual reality 52 90 44 56 20 6
50 Ab utricular Specific organ therapy, 50 92 43 55 30 8
balance training
51 Ab utricular Specific organ therapy, 62 94 45 54 22 6
balance training
52 Normal Virtual reality 34 96 48 56 18 4
53 Normal Virtual reality 42 95 46 56 16 6

Discussion Of these three, though the Cawthrone-Cooksey exercises

are more widely practised and have stood the test of time,
Physical therapy is basically of two forms viz: yet the other modalities of non-specific balance improving
Non-specific physical therapy To improve the general exercise i.e., Yogic asanas and Taichi have been found to
balance function and also expedite the process of vestibular be more efficacious. These exercises, including the Caw-
compensation. As these are generalised, non-specific throne-Cooksey exercises need to be taught and demon-
exercises, they are not targeted to improve the function of strated by trained and qualified physical therapists and
any particular balance organ that has been damaged by experts in yoga and tai chi (Fig. 9). The common practice
disease. This are of doctors giving some tear-away sheets of the Cawthrone-
Cooksey exercises to patients (circulated by some phar-
(a) Cawthrone-Cooksey exercises.
maceutical companies with the names of some anti-vertigo
(b) Yogic asanas.
products advertised therein) is farcical and defeats, if not
(c) Tai Chi exercises.
makes a joke of the purpose of these exercises. These

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Fig. 5 a, b Exercises that augment the balance faculty. The patient is exercises on each pad starts with the patient first standing on both legs
made to stand on especially made foam pads of varying firmness with eyes open then with eyes closed then on one leg etc. such that the
commercially available called balance trainers (front Theraband). The exercises become gradually more challenging in every step. Balance
exercises start initially on firm pads and then on pads of increasing enhancing exercises using the gym ball available from fitness
softness so that the proprioceptive input is gradually deceased step by equipment stores
step to vary the proprioceptive input in a graded fashion. The

exercises are beneficial only if properly done and for this effective than SSRIs and counselling in these patients
focussed first hand training from trained experts who where there is a psychic overlay compounding the balance
understand the physiology of balance and can interpret problem and in patients of psychic balance disorders like
vestibulometric findings is mandatory. Phobic Postural Vertigo (PPV) and Persistent Perceptive
Now modern technology like virtual reality [10] is also Postural Dizziness (PPPD) [11]. Though there are some
being used to restore stability in balance disorder patients published studies comparing vestibular physiotherapy like
and is instrumental in improving the plight of balance the Cawthrone exercises with VR therapy in patients of
challenged patients in a big way. Virtual reality programs vestibulopathies, these studies do not bring out the true
especially made for balance disorder patients entails pre- efficacy of VR therapy as VR is not the best modality for
senting to the patient’s senses a computer generated virtual patients with vestibulopathy [12]. For patients who have
environment that isn’t really there, but from the patient’s purely a vestibular damage without any psychic involve-
perspective is perceived as real. Through virtual reality the ment, physical therapy is the best choice. VR therapy is
patient can be exposed to different situations that simulate best suited specifically for balance disorder patients with a
conditions where a normal person is expected to experience psychic overlay and fear of falls as in psychogenic vertigo.
somewhat frightening unsteadiness e.g., standing at the In such patients the efficacy of VR therapy is very high.
edge of a precipice or a cliff of a mountain and the Specific organ-targeted physical therapy Modern
vestibular system can be exposed to very challenging sit- research has unravelled many of the mysteries of the
uations. These exercises are very effective in allaying the functioning of the balance system and has advanced our
feel of insecurity and the crippling fear of fall that a lot of understanding of the mechanism of balance enormously.
balance disorder patients often experience. Correcting the We now know the exact function of each part of the
mental fear and anxiety/insecurity induced by these situa- balance system. The balance organs in the ear have dif-
tions is a very important part of therapy. Moreover such ferent and very specific and specialised sensors for iden-
challenging (virtual) exposures train the brain to evolve the tifying different types of body movement. Today we
right strategies for maintenance of balance in difficult and know that the saccule senses up-down movement in the
demanding situations. Many, if not most patients who have vertical axis, the utricle senses linear movement in the
balance disorders develop a severe sense of insecurity, lack horizontal axis i.e., side to side and front-back movement
of self-confidence and mental anxiety that compounds the and the three semi-circular canals sense angular move-
balance problem. The mental insecurity (e.g., fear of falls) ment in three different planes [19]. In diseases of the
and the unsteadiness perpetuate each other and the patient balance system, one or more of these sensors are often
goes downhill and ultimately becomes a psychological damaged. With the development of our understanding of
wreck with severe agoraphobia. This needs effective the finer aspects of the mechanism of balance, the science
management without which treatment is never successful. of vestibulometry i.e., medical investigations to evaluate
An unpublished ongoing study being carried out by the first the functional and structural integrity of the balance
author shows that virtual reality therapy is far more system when afflicted by disease has also been vastly

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Fig. 6 a, b Other exercises to boost the patient’s balance capabilities. task of maintaining balance can be made more and more difficult.
In Fig. 3a, b the patient is standing on a trampoline first on two legs Many such easily available instruments can be improvised into very
then on one leg and is given tasks like holding a ball and swinging it effective gadgets for physical therapy of patients with balance
from side to side. In Fig. 6c the patient is asked to stand on an disorders. Figure 6d: the patient standing on a foam pad is made to
inflatable Bosuball available in fitness equipment stores. The Bosuball perform tasks like catching a ball. All these exercises enhance the
is connected to an electrical air-pump such that the contour of and balance powers of the patient
softness of the ball can be changed by operating the air-pump and the

refined. Advancements in diagnostic neurotology have Vestibulometry [19] today can so very precisely localise
sharpened the diagnostic techniques [13] to such an extent and quantify the dysfunction in the defective organ that a
that the modern vestibular function tests like videonys- modern neurotologist using the advanced vestibulometric
tagmography (VNG), cervical and ocular VEMP [14, 19] tests [18, 19] available today can specify that the saccule of
subjective visual vertical tests (SVV) [15, 19], video head one side is 56.2% defective or that the posterior semi-
impulse test (VHIT) [16, 19] the dynamic visual acuity circular canal of one side is 39.62% defective or that there
test (DVA) [17, 19]., etc (Fig. 10). can accurately and is a in a specific defect in the oculomotor function like that
very precisely identify the exact part or function of the the latency of saccadic eye movement is increased. In
balance system that has been damaged and specify which keeping with the advancements in diagnostic neurotology,
type of body movement is not being adequately sensed by therapeutic neurotology especially physical therapy has
the diseased balance organs or which particular mecha- also undergone great sophistication. Specific physical
nism is at fault. That specific part of the balance organ therapy to stimulate the functional status of the defective
can then be very precisely stimulated by physical therapy. sense-organ is now possible. If the cVEMP identifies that

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by the author. We can now specifically and individually

stimulate the utricle, the saccule and/or one or more of the
three semi-circular canals by organ targeted physical
therapy. The results of such physical therapy are extremely
promising. Just as physicians diagnose an infection, then do
a culture sensitivity to identify the offending infective
agent and then prescribe antibiotics to eradicate the
infection, in modern neurotology to the same road-map is
followed. The neurotologist today diagnoses the exact site
of lesion, unambiguously identifies the defective sense
organ and the extent and nature of lesion and prescribes
specific physical therapy to enhance the functionality of the
defective organ that has been identified by vestibulometry
along with specific medication targeted to treat the
underlying causative disease as and when required. Just as
non-specific medical therapy with anti-vertigo drugs is now
Fig. 7 Set up for therapy for patients of gait disorders like gait a thing of the past denounced by modern neurotologists,
apraxia, cerebellar ataxia and patients with paraplegia similarly non-specific physical exercises to improve gen-
eral balance function is being supplemented with rather
the saccule is partly damaged, it would imply that up-down than replaced by specific therapy targeted to stimulate the
movements are not being adequately sensed; physical dysfunctional sense organ/system in the vestibular system.
therapy to stimulate the saccule by repeatedly exposing the Experts in physical therapy for balance disorder patients
patient to movement in the vertical axis is then instituted. If and specialists in neuro rehabilitation work in coordination
the anterior semi-circular canal of the right side is found to with neurotologists to provide a much better quality of life
be malfunctioning then angular stimulation of the head in to most if not all balance disorder patients. This form of
the plane of the right anterior semi-circular canal is initi- physical therapy is very scientific and logical and stimu-
ated and so on. A huge lot of electro-mechanical gadgetry lates the residual function of any dysfunctional sense-organ
is now available for this some of which has been developed in the vestibular system. Advancements in physical therapy

Fig. 8 Screen shot from a virtual reality (VR) program specifically whereby the patient gets the feeling of walking on a wooden plank
developed through NeuroEquilibrium Diagnostic Systems under without railings or any support. If the patient looks down on the sides
instructions of the author. Many such are also available from he gets the visual feeling of the ground hundreds of feet below. The
different internet sites. The patient wearing the VR goggles is shown width of the plank can be changed from broad to narrow and very
in the inset and the visual surroundings all around as experienced by narrow and the height of the plank from the ground can be increased
the patient in all dimensions not merely 3D is shown two- in instalments gradually making the task more difficult for the patient.
dimensionally in the picture. The patient actually gets the multi- The patient may also be made to get the feeling of standing on the
dimensional visual effect. The patient is exposed to a virtual situation edge of a roof without railings

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Indian J Otolaryngol Head Neck Surg (Oct–Dec 2017) 69(4):431–442 441

possible in most if not all patients of vertigo/imbalance

today. Using the modern vestibulometric modalities
today’s neurotologists can accurately pin point whether
there is a defect in the utricle or in the saccule or in any of
the three semi-circular canals or in other parts/mechanisms
of the balance system. In many cases by modern vestibu-
lometry neurotologists can even diagnose whether a
specific organ is malfunctioning at a high frequency of
vestibular stimulation or at low frequencies of vestibular
Fig. 9 Different exercises for vestibular rehabilitation
stimulation. Once the defective sense organ in the balance
system is identified by the modern vestibulometric tests,
the patient can be subjected to very specialised organ tar-
geted vestibular physiotherapy using different modalities
of physical therapy that is targeted specifically to the
defective vestibular sense organ with very good outcomes.
The current study evaluates the effect of specific organ
targeted vestibular physical therapy using electromechan-
ical devices devised by the first author and carried out by
the second author. The results as evaluated by different
parameters like the Activity Balance Confidence Scale,
Burg Balance Scale and the Dizziness Handicap Inventory
scale have shown remarkable improvement.

Fig. 10 Tests to assess each part of the vestibular labyrinth. Modern

vestibulometry enables us to evaluate the functional status of each
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13. Wuyts FL, Furman J, Vanspauwen R, Van de Heyning P (2007) Past-president of the Neurotological and Equilibriometric Society of
Vestibular function testing. Curr Opin Neurol 20(1):19–24 India (1999–2001). Ex-editor of the Indian Journal of Otolaryngology
14. Akkuzu G, Akkuzu B, Ozluoglu LN (2006) Vestibular evoked and Head and Neck Surgery (2000–2005). Selected as member of
myogenic potentials in benign paroxysmal positional vertigo and Barany society for his contribution to the discipline of neurotology in
Meniere’s disease. Eur Arch Otorhinolaryngol 263(6):510–517 1997. This is the highest international academic recognition in neu-
15. Chetana N et al (2015) Subjective visual vertical in various rotology. President Indian Academy of Otolaryngology Head and
vestibular disorders by using a simple bucket test. Indian J Oto- Neck Surgery (2016–2017). Vice-President International Neuroto-
laryngol Head Neck Surg 67(2):180–184 logical and Equilibriometric Society (2016–2017). Recipient of Tato-
16. Miłoński J et al (2014) The use of videonystagmography head Claussen award for extraordinary achievements in the field of applied
impulse test (VHIT) in the diagnostics of semicircular canal neurotology and therapies of neurotological disorders—presented by
injuries in patients with vertigo. Int J Occup Med Environ Health the International Neurotological and Equilibriometric Society on 16th
27(4):583–590 April 2010 in Its 37th annual scientific conference held at Bad
17. Peters BT et al (2012) Dynamic visual acuity testing for Kissingen, Germany. Authored two university approved text cum
screening patients with vestibular impairments. J Vestib Res reference books on neurotology viz, Clinical Audiovestibulometry
22(2):145–151 which is now in its 5th edition and is popular internationally and An
18. McCaslin DL et al (2011) The influence of unilateral saccular introduction to neurotology now in the 2nd edition. Other books
impairment on functional balance performance and self-report authored are (1) Physical therapy for balance disorder patients, (2) A
dizziness. J Am Acad Audiol 22:542–549 holistic approach to balance disorders and its ethical management (3)
19. Biswas A (2017) Clinical Audiovestibulometry. 5th edn. Bha- Understanding hearing aids and (4) Contemporary hearing aids and
laniPublishing House, Mumbai, India related devices. Authored many patient education booklets, books and
educational CDs for doctors, articles in several national and inter-
national journals. Conducts the prestigious neurotology workshop
Anirban Biswas Practices in regularly every year in India which is a learning ground for upcoming
neurotology in Kolkata and is neurotologists in India and the neighbouring countries and is now the
well known for his contribution most popular neurotology course in this part of the world. Previously
in the development and popu- used to conduct an yearly workshop on Vertigo at London Whipp’s
larisation of medical audiology Cross Hospital. Delivered guest lectures and conducted panel dis-
and neurotology in India and cussions in numerous ENT and Neurotology conferences in India and
abroad. Books authored by him abroad. Runs a very sophisticated neurotology clinic in Kolkata -
are very popular among ENT VERTIGO and DEAFNESS CLINIC (www.vertigoclinic.in) which is
specialists, neurologists and equipped with all modern diagnostic and therapeutic gadgetry for
medical specialists who treat diagnosis and treatment of patients suffering from hearing and bal-
patients of vertigo and deafness. ance disorders.
Some of his achievements are
listed following: Past-President
of the Association of Otolaryn-
gologists of India (2010–2011).

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