Computerized game-based vestibular rehabilitation: assessment of feasibility and motor learning

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Damage to the vestibular system is a common problem that often leads to substantial disability. For most cases, there is no effective medication to restore vestibular function. Instead, the mainstay of treatment is vestibular rehabilitation to promote central motor learning that will enhance impaired vestibular reflexes and compensate for the vestibular deficit. Vestibular therapy consists of a program of exercises that are performed at home and in the clinic, supervised by a trained vestibular therapist. Gaze stability exercises target the vestibulo-ocular reflex and improve vision during head movement; balance exercises help to restore good postural control. Although vestibular therapy is effective, there are several key limitations as it is currently practiced. First, the difficulty of exercises cannot be precisely calibrated to each patient's specific level of impairment. Second, compliance with therapy cannot be easily monitored. Finally, standard exercises may not be sufficiently engaging to encourage continued practice. The objective of this project is to test the feasibility of a customized interactive vestibular game for gaze stability exercises. The game is based on a visual discrimination task that tests visual acuity during rotations of the head. The difficulty of the task can be customized and adjusted incrementally based on the patient's initial level of function and progress over time with treatment. There are two aims of this pilot study. The first aim will test the ability of the game to induce plasticity in the vestibulo-ocular reflex in healthy individuals with normal vestibular function. The approach will be based on prior studies of vestibular adaptation, in which a mismatch of vestibular (head motion) and visual (motion of the scene being viewed) inputs leads to a change in the gain of the vestibulo-ocular reflex. In the same group of subjects, the change in VOR gain provoked by an incremental increase in the degree of visual-vestibular mismatch will be compared to that induced by the more traditional approach of single-step adaptation. The hypothesis is that the game will lead to a change in vestibulo-ocular reflex gain, and that this change will be larger with the incremental strategy. The second aim will be to test the feasibility and playing experience of the vestibular game in a group of veterans with peripheral vestibular hypofunction, who are undergoing or who have recently completed standard vestibular rehabilitation therapy. Each patient will play the game and will provide feedback of their experience. We will also record the same physiological data (vestibulo-ocular reflex gain before and after playing) to assess short term motor response. The patients will play the game once a week for four sessions each; this will provide us with preliminary data regarding improvements in gaze stability over time. The data from this aim will support a future application for a multisession clinical trial of our game in comparison to conventional therapy.