ARTICLE
The Use of Optokinetic Stimulation in
Vestibular Rehabilitation
Marousa Pavlou, PhD, BA, MCSP
Abstract: Individuals with vestibular dysfunction may experience
visual vertigo (VV), in which symptoms are provoked or exacer-
bated by excessive or disorienting visual stimuli (eg, supermarkets).
Individuals with VV are believed to be overly reliant on visual input
for balance (ie, visually dependent). VV can significantly improve
when customized vestibular rehabilitation exercises are combined
with exposure to optokinetic stimuli. However, the frequency of
treatment sessions (twice weekly for 8 weeks) and the equipment
used (expensive and space consuming) make it difficult to incorpo-
rate these techniques into everyday clinical practice where exercises
may be practiced unsupervised. The aim of this focused review is to
provide an overview of recent findings investigating (a) responses of
individuals with vestibular deficits to a customized exercise program
incorporating exposure to optokinetic stimuli via a high-tech
visual environment rotator or a low-tech DVD with and without
supervision, and (b) the mechanism of recovery. Optokinetic stim-
ulation will also be discussed in relation to other new innovations in
vestibular rehabilitation techniques and future work.
Key words: visual vertigo, optokinetic stimulation, visual depen-
dency, vestibular rehabilitation
(JNPT 2010;34: 105110)
INTRODUCTION
T he use of exercise in the form of appropriate movements
and sensory exposure (ie, vestibular rehabilitation) is
currently considered the standard of care for individuals with
peripheral vestibular disorders regardless of age and symp-
tom duration.13 Customized vestibular rehabilitation pro-
vides greater benefit compared with a generic exercise pro-
gram (eg, Cawthorne-Cooksey exercise) with significant
improvements in subjective symptoms, dynamic visual acu-
ity, gait, and postural stability.2,4 9 Approximately 50% to
80% of individuals completing a customized vestibular reha-
bilitation program show improvements in symptoms and pos-
tural stability.10 12 However, complete recovery is less common
and occurs in approximately-of all cases.12,13 The reasons why
some individuals with peripheral vestibular disorders do not
fully recover are not entirely clear.
Division of Physiotherapy, School of Biomedical Sciences, Kings College
London, United Kingdom.
Correspondence: Marousa Pavlou, E-mail: marousa.pavlou@kcl.ac.uk
Copyright 2010 Neurology Section, APTA
ISSN: 1557-0576/10/3402-0105
DOI: 10.1097/NPT.0b013e3181dde6bf
JNPT Volume 34, June 2010
Individuals with a peripheral vestibular disorder may
experience discomfort, postural instability, and symptoms of
dizziness, light headedness, and/or disorientation in situations
involving visual-vestibular conflict or intense visual motion
stimulation (ie, supermarket aisles, crowds, watching moving
scenes, and driving on highways). This phenomenon has been
referred to as visual vertigo (VV),14 space and motion dis-
comfort,15 visual vestibular mismatch,16 and motorists dis-
orientation syndrome.17 Studies have shown that visual mo-
tion stimuli (tilted or rotating visual surroundings) have a
stronger influence on verticality perception and postural sta-
bility in individuals with VV than in individuals with vestib-
ular dysfunction but without VV.14,18,19 Thus, individuals
with VV are overly reliant on visual cues for both perception
and postural responses (ie, visually dependent). This exces-
sive reliance on visual cues is believed to be 1 of the factors
underlying poor vestibular compensation, especially in situ-
ations causing visual-vestibular conflict in which there is a
mismatch between visual and vestibular input regarding
movement and orientation (ie, 1 sensory system is indicating
movement and the other is not).14,18
One of the aims of vestibular rehabilitation is to desen-
sitize the patients through progressive, structured exposure to
symptom-provoking movements and situations. When the
ability to select appropriate sensory input for postural stabil-
ity is disrupted, exercises focus on asking the individual to
maintain balance in situations in which the availability and
accuracy of 1 or more sensory inputs are varied. For those
individuals with visual dependency, the approach involves ex-
ercises where visual input is incorrect, conflicting, or absent, so
that the individual learns to rely more on proprioceptive and
available vestibular cues.20 Guerraz et al18 suggested that
rehabilitation programs promoting desensitization and in-
creased tolerance to visual stimuli through exposure to visual
motion (ie, optokinetic stimulation) would be specifically
beneficial for individuals with VV.
Earlier studies in individuals with a unilateral or
bilateral peripheral vestibular disorder showed significant
improvements in both postural stability and optokinetic
nystagmus after 6 weeks of exposure to optokinetic stimula-
tion.21,22 These studies, however, did not have a control group
and did not assess either symptom severity or type. Further-
more, patients were in the subacute phase from which the
majority of individuals will recover either spontaneously or
with conventional therapy.23 Consequently, it was not possi-
ble to ascertain whether exposure to optokinetic stimulation
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Pavlou JNPT Volume 34, June 2010

provided any greater benefit compared with customized ves-
tibular rehabilitation alone, and, if so, which subset of indi-
viduals would benefit most from this type of treatment.
Essentially, the clinical efficacy of visual motion and visual-
vestibular conflict stimulation remained unknown. These is-
sues were addressed in a study that compared patients
responses with a customized regimen versus a customized
regimen that also incorporated exposure to optokinetic stim-
ulation via whole-body or visual environment rotators.24 The
findings showed that customized vestibular rehabilitation
incorporating optokinetic stimuli was more beneficial for
improving dizziness, postural instability, and particularly VV
symptoms in individuals with chronic peripheral vestibular
symptoms.24 However, the 8-week, twice-weekly therapy
sessions and the equipment used (ie, custom made, expen-
sive, and space consuming) made it difficult to transfer this
rehabilitation method from a research setting into everyday
clinical practice. Furthermore, visual dependency measures
were not obtained, and the mechanism of recovery could
not be identified.
The purpose of this focused review is to provide an
overview of recent work addressing (a) the use of high-tech
versus low-tech optokinetic stimulation and the role of supervi-
sion and (b) the mechanism of recovery. Optokinetic stimulation
is also discussed in relation to other new innovations in vestib-
ular rehabilitation techniques and future work.
HIGH-TECH VERSUS LOW-TECH
OPTOKINETIC STIMULATION AND THE
ROLE OF SUPERVISION
High-tech visual motion stimulation in previous work
has included approaches such as exposure to optokinetic
disks with multicolored circles, an optokinetic drum with
rotating chair and striped curtain, and moving rooms.20,22,24,25
Many clinicians do not have access to these types of high-
tech equipment. Wrisley and Pavlou26 reported that similar,
although less intense, stimulation could be provided by a busy
screen saver (eg, mazes), a head-mounted display, or a DVD
including visual stimulation recorded from the available clinical
equipment. However, the individual effectiveness of any of
these low-tech methods had not been investigated.
A recently completed study, Pavlou et al27 compared
responses three groups to a customized vestibular exercise
regimen in three groups of individuals with chronic periph-
eral vestibular disorder. Participants received either: (1) su-
pervised exposure to optokinetic stimuli via a high-tech
full-field visual environment rotator, (2) supervised exposure
to optokinetic stimuli via a low-tech DVD, or (3) practiced
customized vestibular exercises and the low-tech DVD at
home without supervision.
The high-tech stimulus (Stimulopt; Framiral, Cannes,
France) is commercially available (Fig. 1A and B), provides
full-field visual motion in the y- and z-axes, and the direction
and speed can be controlled. The DVD stimuli include indi-
vidual 2-minute sequences of an optokinetic disk (Fig. 2A) or
drum (Fig. 2B) moving in a clockwise, counterclockwise, ver-
tical, or sinusoidal direction at varying speeds within a limited
field of view. A full description of the DVD is included in
Pavlou et al.24
Parameters such as the frequency, velocity, type of
texture, stimulus area, and position of the stimulus within the
visual field can influence the amplitude of visual evoked
postural responses and perception of self-motion (ie, vec-
tion).25,29 32 However, preliminary data analysis from the
aforementioned study27 indicates significant improvements
for subjective VV, vestibular, and autonomic symptoms for

FIGURE 1. A and B, Apparatus used for the high-tech simulator-based intervention. A, The visual environment rotator apparatus
(Stimulopt; Framiral, Cannes, France). B, Participants are asked to stare ahead while the visual environment rotator provides a full-
field stimulus moving in different directions and at differing speeds. Participants practice exercises in sitting and standing positions
and walking either toward and away from the stimulus or alongside it with or without sagittal or horizontal head movements.

106 2010 Neurology Section, APTA

JNPT Volume 34, June 2010
FIGURE 2. A and B, Still images from DVD stimuli. A, Still
image from an optokinetic drum sequence rotating clock-
wise at 40 degrees per second. B. Still image from an opto-
kinetic disc sequence rotating counterclockwise at 60 de-
grees per second. Exercises while watching the DVD are
divided into a progressive sequence in which patients are
asked to focus on a particular area of the moving image
while sitting or standing at varying distances from the screen
or while walking toward and away from the screen with and
without head movements.
all 3 groups with no significant differences among groups.
Furthermore, improvements in postural stability and psycho-
logical status are specific to supervised intervention but not to
a particular visual motion stimulus. These findings suggest
that factors that were specifically different between the high-
and low-tech stimuli including texture, area, and position
within the visual field did not influence rehabilitation out-
come. Further work is needed to identify the most beneficial
parameters of optokinetic stimulation for rehabilitation out-
come; however, currently, the visual motion DVD could be
an economical and effective method of incorporating optoki-
netic stimulation into vestibular rehabilitation programs.
2010 Neurology Section, APTA
Use of Optokinetic Stimulation
Previous studies investigating the effect of supervision
on vestibular rehabilitation outcomes show mixed results,12,33
but it is generally advocated that some form of supervision is
beneficial.4,5,24,34 The data from Pavlou et al27 further support
this view as the findings indicate a direct relationship between
supervision, motivation, and compliance. There was an un-
acceptable 55% drop-out rate for the nonsupervised group,
compared with 10% for each of the 2 supervised groups.
Patients in each of the supervised groups attended once-
weekly therapy sessions for the duration of the study and
practiced a customized home exercise program, including the
visual motion DVD, on the days they did not attend the clinic.
Furthermore, supervision is believed to improve psycholog-
ical status by increasing patient confidence, providing reas-
surance, and emphasizing the positive effects of vestibular
exercises.5,34 Black et al5 also suggested that frequent assess-
ment of progress during supervised therapy allows the ther-
apist to introduce more challenging balancing tasks in a
timely fashion, and ensure that exercises are being performed
correctly. It is hypothesized that these factors are meaningful,
as significant improvement for psychological symptoms and
postural stability was observed only with supervised therapy.27 It is
clear that some form of supervision is necessary, but further
studies are required to determine the most appropriate type
and frequency of supervised sessions.
MECHANISM OF VESTIBULAR RECOVERY
Adaptation of specific vestibular parameters has been
noted after exposure to optokinetic stimulation including
changes in the gain of the vestibulo-ocular reflex in primates,
healthy individuals, and individuals with a chronic peripheral
vestibular disorder.4,21,35,36 Exposure to repetitive vestibular
or optokinetic stimulation also reduces the duration of
postrotational vestibular sensation in healthy individuals.37
However, although it is believed that improvements noted
in VV symptoms in individuals with a peripheral vestibu-
lar disorder after exposure to optokinetic stimulation are
due to a decreased reliance on vision for perceptual and
postural responses, no studies to date have investigated visual
dependency measures before and after rehabilitation.
A recently completed study aimed to further investigate
this issue by measuring visual dependency before and after
repeated exposure to optokinetic stimuli in healthy individu-
als.38 Participants were randomly allocated into either an
intervention group that underwent graded exposure to visual
motion stimuli for 5 consecutive days, or a control group that
did not receive any intervention. Static and dynamic aspects
of perceptual preferences for spatial orientation and postural
sway measures with eyes open and closed, and in the pres-
ence of visual motion stimuli, were obtained at baseline and
at the end of the intervention. Findings indicated significant
improvements for both perceptual and postural responses
only for the intervention group suggesting that short-term,
graded, repeated exposure to visual-vestibular exercises in-
duces plastic, adaptive changes that decrease the magnitude
of visual dependency.38 Possible neural sites of action for the
adaptive changes induced by visual-vestibular conflict and
optokinetic stimulation are numerous because of the exten-
sive convergence of these signals in the neuraxis. However,
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Pavlou
recent functional magnetic resonance imaging studies have
provided some insight into activation patterns during small-
field, horizontal, and vertical optokinetic stimulation.39 43
During small-field optokinetic stimulation, activation in cor-
tical areas related to visual motion processing and control of
eye movement are noted, along with deactivation of parieto-
insular vestibular cortices.39,40,41 Neuronal substrates in the
cerebellum and brainstem are also involved in the processing
of horizontal and vertical optokinetic stimulation.42,43
TREATMENT INTENSITY
Preliminary findings from Pavlou et al38 may have
important implications for the treatment of visual dependence
in individuals with and without vestibular dysfunction. It was
initially believed that daily and intense exposure to optoki-
netic stimuli would be too nauseogenic and almost certainly
intolerable for this client group.24 However, Corna et al44
compared intensive twice-daily (1 hour total) supervised
exposure with either sinusoidal support surface translations or
Cawthorne-Cooksey exercises for 5 consecutive days in a
similar client group. Participants in this study were not only
able to complete the training but also reported significant
improvements in objective and subjective outcome measures.
A study is currently under way at the Academic Department
of Neuro-Otology, Imperial College London, United King-
dom, to investigate whether individuals with a peripheral
vestibular disorder and VV symptoms are able to tolerate
short-term intensive, graded exposure to vestibular exercises
and optokinetic stimuli, and the impact of this exposure on
rehabilitation outcomes in both the short and long term.
OPTOKINETIC STIMULATION AND
OTHER INNOVATIVE VESTIBULAR
REHABILITATION TECHNIQUES
Vestibular rehabilitation is a continuously emerging
field with promising advances in treatment. In addition to
optokinetic stimulation provided via high-tech simulator-
based equipment and low-tech DVDs, various authors have
also discussed the potential benefit of virtual reality in ves-
tibular rehabilitation.45 48 They have recommend that virtual
reality can be a useful therapeutic tool to improve postural
stability and symptoms in situations that closely reflect con-
ditions found in everyday environments (ie, supermarket
aisles).46 48 It has also been suggested that wide field-of-view
devices may be more beneficial in improving postural re-
sponses, particularly in individuals with VV.46 However, 2
studies have showed that using a limited field-of-view head-
mounted device can also be beneficial in individuals with
vestibular disorders, with improvements noted in vestibulo-
ocular reflex gain and symptoms.49,50 Additional work is
needed for comparing the efficacy of vestibular rehabilitation
using virtual reality devices. Future studies should also com-
pare different types of optokinetic stimulation (eg, simulator-
based, DVD, virtual reality) to try to identify whether an
optimal stimulus exists both in regards to treatment outcome
and cost.
Other exciting advances include the use of balance
prostheses, which provides information regarding head or
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JNPT Volume 34, June 2010
body orientation through vibrotactile cues delivered to the
trunk,5153 head,54 or tongue.55,56 Studies have shown that
these devices can improve postural stability and reduce the
risk of falls in individuals with vestibular disorders while
standing on a compliant surface and during computerized
dynamic posturography, a standard clinical test of bal-
ance.5156 Most work has included participants with bilateral
vestibular hypofunction. The prosthesis works by translating
information normally sensed by the vestibular system (ie,
head movement and verticality) into a proprioceptive cue that
is then integrated with remaining sensory information to
improve standing balance.54,57,58 In most of the aforemen-
tioned studies training sessions are brief, no control group is
included, and carryover of improvements to task performance
without the tactile device is not assessed. Furthermore, no
randomized, controlled trials have been conducted to inves-
tigate the clinical usefulness of balance prostheses within a
vestibular rehabilitation program. It is clear that more studies
are needed in this area. Future work should also investigate
the potential benefit of combined techniques (ie, optokinetic
stimulation and balance prostheses).
CONCLUSION
Customized vestibular rehabilitation incorporating op-
tokinetic stimuli is more beneficial than the vestibular reha-
bilitation without optokinetic stimuli for improving dizziness,
postural instability, and particularly VV symptoms in indi-
viduals with chronic peripheral vestibular symptoms. How-
ever, the high-tech equipment used and the frequency of
treatment sessions make it difficult to transfer this rehabili-
tation method into everyday clinical practice The visual
motion DVD may be an economical, clinic friendly, and
effective method of incorporating optokinetic stimulation into
vestibular rehabilitation programs. It is suggested, however,
that some form of supervision is needed for greater compli-
ance and improvements in postural stability and psychologi-
cal state. It is hypothesized that improvements after exposure
to optokinetic stimuli are due to plastic, adaptive changes in
the magnitude of visual dependency at both perceptual and
postural levels. It is therefore suggested that the treatment of
visual dependency in individuals with and without vestibular
dysfunction incorporates exposure to visual motion stimuli.
However, future research is required to assess optimal treat-
ment duration, stimulus, and long-term benefit.
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