Improving dizziness & balance with acoustic neuroma
Acoustic neuroma, also known as vestibular schwannoma, is a rare benign tumour involving the inner ear. Acoustic neuromas cause problems with hearing and balance.
Elizabeth Crawford and Shaleen Sulway presented a poster at the 2024 Acoustic Neuroma Association of Canada symposium in Toronto, about the role of vestibular rehabilitation in helping vertigo, dizziness, and imbalance. They presented a case series demonstrating physiotherapy treatment outcomes with retrospective chart review data from patients with acoustic neuroma seen in our clinic. Read on to learn more about how vestibular rehab has helped our patients.
What is the vestibular system?
The vestibular system includes the:
Balance organs of the inner ear - the semicircular canals & otoliths
Vestibulocochlear nerve (CN VIII) - acoustic neuroma is a noncancerous tumour involving this nerve
Areas of the brain that process balance information - particularly the cerebellum & brainstem
Signals from our vestibular system are relayed to the muscles that move our eyes - this is the vestibulo-ocular reflex or VOR. Vestibular signals are also relayed to the muscles in our body and neck to maintain upright posture, through the vestibulospinal and vestibulocollic reflexes.
What does the vestibular system do?
Maintains posture & balance
Keeps vision steady and in focus during movement (gaze stability)
Spatial orientation
Common symptoms of vestibular dysfunction:
Vertigo and dizziness
Imbalance and falls
Blurry or unsteady vision when you move
“Vestibular rehabilitation has been and continues to be crucial in my medical journey and recovery process. I can’t express enough how it improved the difficult situation. The improvement in symptom management could not have been achieved without their expertise, knowledge and guidance. Their understanding of my symptoms made me feel like I am not alone. I am eternally grateful and believe that this therapy should be a staple in symptom management and recovery for patients who suffer from a vestibular disorder to provide them with a better quality of life.”
Acoustic neuroma causes vestibular dysfunction
52 patients with acoustic neuroma participated in vestibular rehabilitation with our clinic from 2020 to 2024.
Average age: 59.63 years (range of 29 to 88 years)
Gender: 41% female, 59% male
Affected side: 42% right, 56% left, 2% bilateral
Most patients had vestibular dysfunction identified on inner ear testing. 88.9% had abnormal VNG, 76.9% had abnormal VEMP, and 89.3% had abnormal vHIT.
Most patients had signs of VOR impairment and gaze instability. 90% had abnormal Dynamic Visual Acuity at initial assessment.
Most patients experienced imbalance. The average score on the Activity Specific Balance Confidence Scale was 69% (moderate), but there was a wide range of scores (from 23% very low confidence/falls risk, to 100% complete confidence). 42.4% were at risk for falls based on their dynamic balance scores at initial assessment (Dynamic Gait Index & Functional Gait Assessment).
Most patients experienced dizziness. On average, patients reported moderate perceived disability due to dizziness/unsteadiness, with a mean score of 35.74/100 on the Dizziness Inventory, however there was a large variability with scores (from 0 none/mild to 86 severe).
“The vestibular rehabilitation directions and exercises shown to me by my physiotherapist was a significantly important step in returning to my “new normal” life. The exercises were key in assisting me in my recovery after surgery. The rehabilitation assists me to this day in understanding how my body and brain work together to accomplish the tasks I undertake.”
What is vestibular rehab?
Vestibular rehabilitation is an exercise-based program designed to facilitate central nervous system compensation for vestibular loss. These exercises train your brain to recalibrate how it interprets vestibular signals, to improve your symptoms and function through neuroplasticity.
Goals of vestibular rehab:
Reduce vertigo and dizziness
Improve gaze stability
Improve balance
Improve mobility
Prevent falls
Help you return to your activities
What does vestibular rehab involve?
Therapy starts with a comprehensive assessment. You start by talking with the physiotherapist so they can understand your symptoms and priorities. The physical examination involves clinical tests of inner ear and neurological balance function, and evaluation of your balance and walking abilities.
Treatment is guided by the assessment & your goals. Therapy is individualized, active and exercise-based, and is focused on meaningful activities and improving your function. You are given a home exercise program to complete, and the physiotherapist will monitor your progress and adjust your exercises.
Types of vestibular rehab exercises:
VOR adaptation exercises → to improve gaze stability
Balance training → to improve balance and decrease falls risk
Habituation/desensitization exercises → to decrease dizziness with movement
Gait training and a walking program → to improve mobility and decrease fatigue
Support for returning to your usual physical activities → to get you back to your life!
“When I first started physiotherapy, I wasn’t even sure if I could walk a straight line, let alone find a golf ball after a shot! But my physiotherapist not only got me back on my feet, she also gave me the confidence to tackle everyday activities with ease. She explained things about my balance and vision that my doctors couldn’t figure out—she seemed to know exactly what I was thinking before I did! Thanks to her, I’m now back on the golf course, with my balance in check… although my swing still needs some work!””
Is vestibular rehab effective?
There is moderate to strong research evidence - meaning high quality randomized controlled trials - that vestibular rehab is a safe and effective treatment for vestibular hypofunction (1). We have a clinical practice guideline that provides recommendations to optimize care and outcomes (2).
A systematic review identified 23 studies that looked at vestibular rehabilitation for people with vestibular schwannoma, and concluded that multimodal physiotherapy consistent with clinical practice guidelines (i.e. including gaze stability, habituation, balance training, gait training) demonstrated potential for improvement in dizziness, balance, and vestibular function, but more high quality studies are needed (3).
Physiotherapy can improve your vestibular symptoms
Our patients with acoustic neuroma attended an average of 4 vestibular rehab sessions (range of 1 to 15 sessions). The average vestibular rehab treatment duration was approximately 6 months.
82% of our acoustic neuroma patients had improvement in gaze stability as measured by Dynamic Visual Acuity at end of treatment.
89% of our acoustic neuroma patients had improvement in balance & gait at the end of treatment.
“I underwent gamma knife for a tumour near my left ear canal. Unfortunately in my case all did not go as well as predicted and expected. Within 3 days I had severe vertigo and was readmitted to the hospital. I returned home the following day in a wheelchair. One month later, I began physiotherapy. Slowly I started to notice an improvement to the vertigo and eventually used a walker and then walking poles. Today I use one walking pole only and infrequently thanks to the physio treatment. Physiotherapy gave me back quality of life and being able to manage my disability. It is important to remember to not give up, have courage, know you are not alone in this journey, do the prescribed exercises, and have faith. You will get better.”
Vestibular rehab and your acoustic neuroma journey
Our patients participated in vestibular rehab across all stages of acoustic neuroma treatment options.
At all stages, vestibular rehabilitation can help:
Facilitate compensation for vestibular loss
Address symptoms of dizziness and imbalance
Improve balance and functional mobility
Increase physical activity levels
Support return to physical and functional activities
Being physically active pre-surgery is associated with better balance compensation post-surgery (4,5). Gaze stability exercises may speed up post-surgery vestibular compensation (6,7). Early vestibular rehabilitation facilitates recovery of balance post-surgery, particularly in people over 50 years of age (8).
Dizziness, vertigo, or imbalance can occur at a delay after radiosurgery. If you have vestibular symptoms prior to gamma knife, you may be more likely to experience vestibular symptoms within 6 months post-treatment (9,10).
For resources and support for people with acoustic neuroma, visit the Acoustic Neuroma Association of Canada.
Ready to get started? Book an appointment with us!
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1. McDonnell MN, Hillier SL. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane ENT Group, ed. Cochrane Database of Systematic Reviews. Published online January 13, 2015. [link]
2. Hall CD, Herdman SJ, Whitney SL, et al. Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Updated Clinical Practice Guideline From the Academy of Neurologic Physical Therapy of the American Physical Therapy Association. Journal of Neurologic Physical Therapy. 2022;46(2):118-177. [link]
3. Yap J, Palmer G, Graving K, Stone S, Gane EM. Vestibular Rehabilitation: Improving Symptomatic and Functional Outcomes of Persons with Vestibular Schwannoma: A Systematic Review. Physical Therapy. Published online July 10, 2024:pzae085. [link]
4. Gauchard GC, Parietti-Winkler C, Lion A, Simon C, Perrin PP. Impact of pre-operative regular physical activity on balance control compensation after vestibular schwannoma surgery. Gait & Posture. 2013;37(1):82-87. [link]
5. Parietti-Winkler C, Lion A, Frère J, Perrin PP, Beurton R, Gauchard GC. Prediction of Balance Compensation After Vestibular Schwannoma Surgery. Neurorehabil Neural Repair. 2016;30(5):395-401. [link]
6. Enticott JC, O’Leary SJ, Briggs RJS. Effects of Vestibulo-ocular Reflex Exercises on Vestibular Compensation after Vestibular Schwannoma Surgery: Otology & Neurotology. 2005;26(2):265-269. [link]
7. Herdman S, Clendaniel R, Mattox D, Holliday M, Niparko J. Vestibular adaptation exercises and recovery: Acute stage after acoustic neuroma resection. Otolaryngology - Head and Neck Surgery. 1995;113(1):77-87. [link]
8. Vereeck L, Wuyts FL, Truijen S, De Valck C, Van De Heyning PH. The effect of early customized vestibular rehabilitation on balance after acoustic neuroma resection. Clin Rehabil. 2008;22(8):698-713. [link]
9. Bojrab DI, Fritz CG, Lin KF, et al. Pre-existing Vestibular Symptoms Are Associated With Acute Vestibular Symptoms After Gamma Knife Therapy for Vestibular Schwannoma. Otology & Neurotology. 2021;42(6):912-917. [link]
10. Lee DY, Lerner DK, Naples JG, et al. Vestibular Schwannoma Tumor Size Is Associated With Acute Vestibular Symptoms After Gamma Knife Therapy. Otology & Neurotology. 2019;40(8):1088-1093. [link]
