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19
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Vestibular Balance
Therapy for Children
Jennifer B. Christy
Vestibular dysfunction in the developing child can
have a devastating effect on gross motor development
(De Kegel, Maes, Baetens, Dhooge, & Van Waelvelde,
2012; Janky, Thomas, High, Schmid, & Ogun, 2018;
Kimura, Masuda, & Kaga, 2018; Maes et al., 2017; Rine
et al., 2000), balance (Cushing et al., 2009; Cushing,
Papsin, Rutka, James, & Gordon, 2008; Janky & Givens, 2015; Karltorp et al., 2014; Oyewumi et al., 2016;
Rine, Braswell, Spielholz, & Buchman, 2001), gaze stability (Christy, Payne, Azuero, & Formby, 2014; Rine
& Braswell, 2003), and potentially spatial orientation
(Wiener-Vacher, Hamilton, & Wiener, 2013). These
impairments ultimately affect life participation. Children at risk for peripheral vestibular hypofunction
include children with severe to profound sensorineural hearing loss with and without cochlear implants,
children with chronic otitis media, inner ear malformation, acute vestibular syndrome, post-meningitis, and
genetic syndromes such as Pendred, Usher, CHARGE,
and Waardenburg (Rine & Wiener-Vacher, 2013; Wiener-Vacher, 2008; Wiener-Vacher, Quarez, & Priol,
2018). Evidence is emerging that high dose aminoglycoside therapies commonly used for children with cystic fibrosis (Handelsman, Nasr, Pitts, & King, 2017) or
cisplatin chemotherapy (Prayuenyong et al., 2018) may
be ototoxic, damaging vestibular receptors. Children
with a diagnosis of unilateral or bilateral hypofunction
should be referred to a physical therapist for evaluation
so that vestibular balance therapy can be initiated as
soon as possible.
Some pediatric conditions may affect central integration of vestibular information in the presence of
normal peripheral vestibular reflexes, leading to dizziness and balance disorders and warranting a physical therapy referral. These diagnoses include pediatric
migraine equivalent, benign paroxysmal vertigo of
childhood and vestibular migraine, and post-concussion or head trauma (Wiener-Vacher, 2008; WienerVacher et al., 2018). Central vestibular integration
dysfunction may also exist in children with cerebral
palsy (Almutairi, Christy, & Vogtle, 2018; Almutairi,
Cochrane, & Christy, 2019), congenital muscular torticollis (Hallberg, Standring, & Ahsan, 2013), attention
deficit hyperactivity disorder, developmental coordination disorder, adolescent idiopathic scoliosis, and
autism (Christy, 2018). These children will most likely
already be referred to physical therapy for concomitant neuromusculoskeletal impairments but may need
referral to the audiologist for vestibular function testing and may also benefit from vestibular balance therapy (VBT).
Studies have demonstrated the effectiveness of
VBT to improve vestibular-related impairments in
children with sensorineural hearing loss and confirmed
vestibular hypofunction (Braswell & Rine, 2006; Ebrahimi, Jamshidi, Movallali, Rahgozar, & Haghgoo, 2017;
Rine et al., 2004), sensorineural hearing loss without
vestibular testing (Rajendran, Roy, & Jeevanantham,
2013), cerebral palsy (Tramontano et al., 2017), attention deficit hyperactivity disorder (Lotfi et al., 2017),
and concussion (Alsalaheen et al., 2010, 2016; Schneider et al., 2014; Storey et al., 2018). In a randomized
crossover design including 21 children with sensorineural hearing loss and vestibular hypofunction,
479
480 BAlAnCE FunCtion AssEssmEnt And mAnAgEmEnt
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Rine et al. determined that VBT done three times per
week in 30-minute sessions for 12 weeks significantly
improved outcomes (i.e., the Peabody Developmental
Motor Scales [PDMS] and the Sensory Organization
Test [SOT]) more than the control group (p ≤ 0.02) and
promoted alternate strategies for postural control (Rine
et al., 2001, 2004). In a similar study, Ebrahimi et al.
provided vestibular balance therapy for 24 students,
aged 7 to 12 years with sensorineural hearing loss and
vestibular hypofunction. The intervention was completed three times per week in 45-minute sessions over
8 weeks. The treatment group significantly improved
on SOT and limits of stability scores (p < 0.05) but the
control group did not improve significantly (Ebrahimi
et al., 2017). More studies are needed to determine the
effectiveness of gaze stabilization training and the optimal dose of VBT for children with central and peripheral vestibular dysfunction.
Vestibular balance therapy programs are typically
delivered by a physical therapist and taught to the family members, who perform the exercises at home and
in the child’s natural environment. The exercises are
tailored to each child based on the child’s impairments,
life situation, and goals. The types of exercises include
a combination of gaze stabilization training, static and
dynamic balance training, habituation exercises, and
gross motor training. It is important that the exercises
be done every day and incorporated into the daily life
of the child. The exercises must challenge the children
but enable success, and of course, the exercises must be
fun and engaging.
GAZE STABILIZATION TRAINING
The purpose of gaze stabilization training is for the
child to keep the eyes stable while the head is moving.
The goal is to improve dynamic visual acuity, a test of
how well a child uses the vestibulo-ocular reflex (VOR)
to see during head movement. Dynamic visual acuity
(DVA) can be tested in cooperative children aged 4
years and up using a Lea symbols chart (Christy et al.,
2014; Rine & Braswell, 2003). DVA is the difference in
acuity with the head stable versus moving in the yaw
plane at 2 Hz. A decrement of more than two lines (10
optotypes) between static and dynamic is considered
abnormal. A minimal detectable change score of 8
optotypes can be used to determine that gaze stabilization training improved DVA by more than expected by
chance in children with sensorineural hearing loss and
vestibular hypofunction (Christy et al., 2014). A computerized version of the DVA test is sensitive to deter-
mine if an asymmetry exists but can probably not be
completed by young children (e.g., under 7 years of
age) due to the concentration required. If DVA is abnormal, gaze stabilization exercises may help to improve
it. Gaze stabilization exercises involve fast head movements in yaw and pitch as the child focuses on a visual
target of interest.
Four types of gaze stabilization exercises can be
done to improve DVA: (1) X1 (times 1) viewing, (2) X2
(times 2) viewing, (3) gaze shifting, and (4) remembered targets. All the exercises require head movement
with subsequent visual focus. The stimulus that drives
the neural change is retinal slip. Therefore, the head
movements must be quick enough to cause retinal slip,
but slow enough so that the child can see the target.
Gaze stabilization exercises are based on theories of
adaptation and substitution. Historically, X1 and X2
viewing were prescribed to promote adaptation at the
level of the vestibular nuclei for patients with remaining vestibular function. Gaze shifting and remembered
targets were prescribed to promote substitution of
compensatory saccades for patients with bilateral vestibular loss. However, studies have determined that
patients employ different and unique compensatory
mechanisms to improve DVA and VOR, regardless of
whether they have a unilateral or bilateral lesion. Using
a scleral coil and bite block paradigm, Schubert et al.
showed that some adult patients improved DVA by
increasing angular VOR gain, while others increased
the numbers and efficiency of compensatory saccades
(Scherer, Migliaccio, & Schubert, 2008; Schubert, Migliaccio, Clendaniel, Allak, & Carey, 2008). Therefore,
all four gaze stabilization exercises can be prescribed
for children with DVA deficits, regardless of whether
the child has unilateral or bilateral hypofunction, or
degree of loss.
X1 (Times One) Viewing
The goal of the X1 viewing paradigm is to have the
child identify words or pictures while the head moves
in yaw or pitch planes. To complete this exercise, the
child must be cognitively able to communicate with the
adult, who must be able to discern whether the child
sees the visual target. The reason that it is called X1
viewing is that the eyes must move one time as much
as the head in the opposite direction. To complete the
exercise, the adult (e.g., therapist, parent) will stand
behind the child, hold the head, and turn the head in
yaw or pitch approximately 30 degrees to each side at a
frequency of up to 2 Hz. A metronome (or metronome
app) can be used to help with speed of head movement.
19. VESTIBULAR BALANCE THERAPY FOR CHILDREN 481
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During the head movement, the child will be asked to
identify static visual targets that change periodically.
The visual targets can be pictures, words, or groups
of words on flash cards or in books. The therapist can
create PowerPoint presentations with words, groups of
words, or pictures that will automatically advance, or
create “book videos” that the child can read as the head
is being moved. The visual target must be interesting
and engaging to the child. The exercise should be done
for at least 30 seconds, progressing to two minutes. The
therapist will progress the exercise by decreasing the
size of the words/pictures or including more words/
pictures on the page, changing the background so that
it is busier, increasing the speed of head movement,
increasing the time of the exercise, or increasing the
balance challenge (e.g., standing instead of sitting).
The therapist will work with the parent and child to
determine how and when to progress the exercise. See
Table 19–1 for examples of how to progress. Other methods to achieve head movement during visual focus are
to show the child the visual target (i.e., words or pictures) as he/she jumps on a mini trampoline, bounces
on a stability ball, walks or jogs on a treadmill, spins on
a sit-n-spin, or swings as the therapist or parent shows
the child words or pictures that he/she identifies.
X2 (Times Two) Viewing
The X2 viewing paradigm (times two) is a progression of X1 viewing and requires that the visual target
move opposite of the head. The reason that it is called
X2 is that the eyes must move twice the distance of the
head, since the target is moving in the opposite direc-
tion. This can be difficult to complete with young children and would most likely require a second person
to move the target while one adult moves the head.
This should be completed at a slower speed than X1
viewing due to the difficulty of the exercise. This exercise can be progressed by moving the target and head
faster, increasing the time, changing the background so
that it is busier, or changing the balance challenge (see
Table 19–1).
Gaze Shifting
Gaze shifting involves a saccade to a visual target, followed by a quick head movement toward the target
while keeping the visual target in focus. This is a functional activity that is done during many daily activities — for example, when turning the head to look both
ways to cross the street; when looking down at a paper,
then up at the front of the room in school; while walking down the hall at school and moving the head to
look around; while playing tennis and trying to follow
the ball to the racket. One way to teach this exercise
is to have the child standing 10 feet from a wall, eyes
and head focused on one visual target (e.g., a picture).
The adult stands to the side of the target holding flash
cards. When the adult says “go,” the child quickly
turns the eyes and head to identify the word or picture
on the flash card, then returns the eyes and head to
the first visual target. This is repeated several times,
then the adult will move to the other side and repeat
the exercise in pitch plane. This exercise can also be
completed using a laser target attached to a hat. The
therapist/parent can place words or pictures on a wall.
Table 19–1. Example of Progression of Gaze Stabilization Exercises
Background Plain:
Balance challenges Sitting or standing with
Target size
Speed of head
movement
Time 30 sec to 1 minute 1.5 min 2 minutes
Easy Medium Difficult
Busy:
white or soft color
feet together
Large (2.5 cm or larger) Medium (2 cm) Small (1 cm or smaller)
Slow (1 Hz) Medium (1.5 Hz) Fast (2 Hz)
checkerboard, wallpaper,
busy floor
Standing with feet in
tandem; standing on
foam pad; standing on
one foot
Moving background: TV;
in front window looking at
traffic
Walking on a treadmill;
jumping; bouncing on a
stability ball; standing on
one foot on foam pad
482 BALANCE FUNCTION ASSESSMENT AND MANAGEMENT
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The child wears a hat with a laser pointer on it, then
tries to point the laser target at the word or picture on
command. Another way to complete this exercise is to
place word or black and white picture cards all over
a large room or space. The adult will show the child
a word or picture, then see how quickly he/she can
find the matching card. As the child is searching for the
card, he/she will be moving the eyes and head to try
to find it. The therapist/parent can also place the cards
on either side of a long hallway and have the child turn
the head right and left to identify all the pictures as
he/she is walking forward. Time the child and see if
he/she can go quicker with each repetition. The therapist/parent can also place word/picture stickers on a
large poster board, sit behind the child, turn the child’s
head quickly to one side then the other, and have the
child point to a picture that he/she is told to identify
(e.g., “point to Mickey Mouse” then turn the head
quickly toward the sticker of Mickey Mouse). The exercise can be progressed by increasing the speed of head
movement, decreasing the size of the visual targets, or
increasing the time of the exercise (see Table 19–1).
Remembered Targets
The remembered targets exercise requires that the child
focus on a visual target, close the eyes and imagine to
still be looking at the target, make a quick head turn,
then open the eyes to see if the target is still being
looked at. The child then returns the head back to
center, focuses on the word, closes the eyes, turns the
head the other way, then opens the eyes. To make this
exercise interesting and fun, the therapist or parent can
change the picture or word after the child closes the
eyes. The words can string together to make a story.
Progress this exercise by increasing the number of head
turns after closing the eyes or increase the balance chal-
lenge. This exercise may be difficult to complete with
young children under age of 7 years who may not
understand why they are closing the eyes.
Dose
The clinical practice guidelines developed for adults
with vestibular hypofunction acknowledged that
more research is needed to determine the effectiveness
of vestibular rehabilitation in children. The guidelines
recommend that gaze stabilization exercises should
be completed a minimum of three times per day for
a total of 12 minutes per day for patients with acute
or subacute vestibular hypofunction, and a minimum
of three times per day for a total of 20 minutes total
per day for patients with chronic vestibular hypofunction (Hall et al., 2016). Therefore, it is critical that the
therapist teach and empower the parents and children
to do the exercises at home. The physical therapist
will design the home program, which will dictate the
exercises to do each day. An example of a home program for gaze stabilization training, done three times
per day for 15 minutes total is included in Table 19–2.
The optimal intensity or duration of training to
improve DVA with gaze stabilization training in children is unknown. There is limited evidence that children with bilateral areflexia from birth will need more
intense and longer duration of treatment than a child,
for example, with acquired unilateral hypofunction or
remaining function bilaterally (Braswell & Rine, 2006).
Studies are needed to determine factors that predict
recovery in children with varying degrees of hypofunction. No one has studied the effect of gaze stabilization
training on children with central integration–related
DVA deficits (e.g., children with cerebral palsy who
have normal peripheral vestibular reflexes but abnormal DVA).
Table 19–2. Example of a Home Program for One Day of Gaze Stabilization Training
Session Exercises Time
1 X1 viewing in yaw (1 min), rest, X1 viewing in pitch (1 min),
rest. Do three times
2 Gaze shifting matching game (find cards around room) 5 min
3 X 1 viewing in yaw (1 min), rest, X1 viewing in pitch (1
min), rest. 2 min of gaze shifting to quick head movements
(adult turns head right to left as child identifies pictures or
words placed on either side of a poster board)
Total Time 15 min
6 min
4 min
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habituation training
Habituation training should be included in VBT programs if the child complains of dizziness during
head movement or dizziness with visual stimuli (e.g.,
watching action movies, playing video games, visual
vertigo). The goal of the exercise is to repeat the symptom-provoking movement or stimulus so that the central nervous system decreases its abnormal response. In
any patient complaining of dizziness related to changes
in head position, the therapist must first test for benign
paroxysmal positional vertigo (BPPV). Although rare
in children, BPPV can occur following head trauma
or concussion, or concurrent with vestibular migraine
(Brodsky, Lipson, Wilber, & Zhou, 2018; Yao, Song,
Wang, Shi, & Yu, 2019). If, following testing for BPPV, it
is determined that BPPV is not the cause of symptoms,
habituation exercises may help.
The therapist will first determine the stimulus that
triggers the symptoms of dizziness. Typically, the parent and child will be able to describe the situations that
provoke symptoms. If it is determined that symptoms
are motion provoked, the therapist will provide a home
program of doing the motion repetitively (i.e., three to
five repetitions) but only to the “edge” of symptoms.
The goal is to provoke symptoms, but not make the
child sick. For example, if the child becomes dizzy
with swinging on a playground swing, the exercise
might include sitting on a swing and doing one or two
swings, then stopping, letting the symptoms return to
baseline, then repeating several more times. The goal
is that as the child habituates, he/she will be able to
swing longer and higher. Habituation exercises are
prescribed three to five times per day. If symptoms are
provoked by visual stimuli, the therapist may search
for a computer video that provokes mild symptoms.
The child will view the video until symptoms begin,
then stop and let the symptoms return to baseline, then
repeat. The rule of thumb is that the symptoms should
not last for more than 15 minutes after doing the final
repetition. If symptoms last longer, or if the child is
unable to get through the rest of the day after doing
the exercise, the child should back off on the intensity
and/or duration. Keep in mind that gaze stabilization
exercises might also serve as habituation training.
statiC and dynamiC balanCe training
Although somatosensory effectiveness for balance control is mature by age 3 to 4 years, visual and vestibular
system effectiveness for balance matures slowly until
age 15 years (Ferber-Viart, Ionescu, Morlet, Froehlich,
& Dubreuil, 2007; Hirabayashi & Iwasaki, 1995). However, children with vestibular hypofunction may have
delayed development of all sensory systems for balance. When standing on a stable floor, the brain relies
primarily on somatosensory information, regardless of
what is happening in the visual environment. However, when the floor is unstable, or the base of support
is small (e.g., tandem standing, single legged stance),
the brain’s reliance should shift to the stable visual
environment (e.g., a stable object on the wall). Finally,
when the visual environment is absent (e.g., standing
or walking in the dark) or moving (e.g., standing or
walking in a crowded room, watching the waves at the
ocean) and the floor is unstable, the brain must rely
on the vestibular system to provide information about
head movement to trigger the appropriate balance
reaction. In the absence of vestibular function, especially from birth, children will have difficulty with balance situations that require the vestibular system. Since
the three sensory systems (i.e., vision, vestibular, and
somatosensory) are interdependent for development
of balance, the loss of one sense (e.g., vestibular) may
affect the development of the other two senses (Rine
et al., 2004). Therefore, the therapist will determine
which senses are inadequate for postural control and
will work to strengthen them. In the absence of vestibular function, the child will be taught to substitute visual
and somatosensory information.
For the purposes of this discussion, static balance is defined as the act of balancing while standing
still (i.e., stability). Examples of static balance include
standing on the floor or foam with eyes opened or
closed. Dynamic balance is the act of balancing while
weight shifting (i.e., controlled mobility) or while moving from one place to another (i.e., skill). Examples of
dynamic balance include walking on a balance beam or
on a line on the floor, shifting the weight over the base
of support to reach or pick something off the floor. The
overall goal of static and dynamic balance training in
a child with vestibular dysfunction is to train the central nervous system to integrate sensory information to
appropriately handle balance reactions in all situations.
The clinical tests that determine the need for and
effect of balance training to improve static balance
include the SOT and the Modified Clinical Test of Sensory Interaction on Balance (MCTSIB). If using the SOT,
the clinician can determine which sensory systems are
deficient for balance by looking at conditions 2 (eyes
closed, stable floor) and 3 (eyes opened, stable floor,
swayed surround) for somatosensory effectiveness;
condition 4 (eyes opened, swayed surface, stable visual
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