ARTICLE
Tracking Recovery of Vestibular Function in Individuals
With Blast-Induced Head Trauma Using Vestibular-Visual-
Cognitive Interaction Tests
Kim R. Gottshall, PT, PhD, ATC, and Michael E. Hoffer, MD, CAPT MC USN
Background and Purpose: Traumatic brain injury secondary to
blast exposure is a significant international concern and a growing
rehabilitation issue. Our objective was to determine whether a novel
battery of vestibular-visual-cognitive interaction tests provides ob-
jective data to document functioning, and the changes in functioning
associated with vestibular physical therapy (VPT) treatment, in
individuals with blast-induced balance disorder.
Methods: Eighty-two individuals with blast-induced mild traumatic
brain injury were evaluated at baseline using a set of vestibular-
visual-cognitive tests. Testing was repeated at 4-week intervals after
beginning VPT. The tests included static visual acuity, perception
time, target acquisition, target following (TF), dynamic visual acuity
(DVA), and gaze stabilization tests. The VPT program consisted of
exercise procedures that targeted the vestibulo-ocular reflex, cer-
vico-ocular reflex, and depth perception. Somatosensory balance
exercises, dynamic gait, and aerobic function exercises were also
included. Participants attended VPT twice weekly for 1-hour ap-
pointments and were instructed to perform the exercises at home on
other days. Mean test values were determined and compared with
normative values previously collected in our laboratory from indi-
viduals without vestibular dysfunction.
Results: Mean participant pre-VPT measures for perception time
and target acquisition were similar to normative values, and there
was no significant change in these measures. Initially, TF and DVA
scores were below normative levels but returned to normative levels
after 8 weeks of VPT. Gaze stabilization scores were below norma-
tive levels pre-VPT but improved by the time of the week 8
evaluation.
Conclusions: This battery of vestibular-visual-cognitive tests seems
to be reasonable to establish initial status and to evaluate participant
progress associated with participation in VPT. Our data suggest
meaningful improvement in TF and DVA after 8 weeks of treatment.
A treatment period of 12 weeks or longer may be required for gaze
stabilization scores to return to normative values.
Naval Medical Center, San Diego, California.
Correspondence: Kim R. Gottshall, E-mail: Kim.gottshall@med.navy.mil
The views expressed in this article are those of the author and do not
necessarily reflect the official policy or position of the Department of the
Navy, Department of Defense, or the United States Government.
Copyright © 2010 Neurology Section, APTA
ISSN: 1557-0576/10/3402-0094
DOI: 10.1097/NPT.0b013e3181dead12
94
Key words: concussion, traumatic brain injury, balance
(JNPT 2010;34: 94–97)
INTRODUCTION
M ild traumatic brain injury (mTBI) secondary to blast
exposure and blunt head trauma is the most common
battlefield injury seen in Iraq and Afghanistan, and is an
increasingly important injury pattern in the civilian world.
Blunt and blast mTBI are common causes of vestibular
disorders.1–3 Our group at Naval Medical Center San Diego
has described the patterns of dizziness from both blunt and
blast injury in the past.1–3 Awareness of these patterns is
useful in several ways, including guiding diagnosis and
management, and predicting prognosis. Vestibular physical
therapy (VPT) is an important tool for restoring function in
this group of individuals. The objective outcome measures
are vital to the evaluation of programs designed to promote
functional improvement in balance and gait stability. The
purpose of this study was to determine whether a novel
battery of vestibular-visual-cognitive interaction tests pro-
vides objective data to assess functioning and document
change in functioning after a VPT program in soldiers with
blast-induced mTBI.
METHODS
We studied 82 participants (79 men and 3 women;
mean age ⫽ 24 years, range ⫽ 19 –34 years) with mTBI who
were treated with VPT. All participants were soldiers who
had mTBI secondary to blast injuries sustained in Iraq or
Afghanistan, with no other associated physical injuries. The
participants were diagnosed as having 1 of 4 vestibular
disorders: (1) benign paroxysmal positional vertigo, (2) ex-
ertion-induced dizziness, (3) blast-induced disequilibrium,
and (4) blast-induced disequilibrium with vertigo. Diagnostic
characteristics for each classification are shown in Table 1.
All participants underwent a comprehensive physical therapy
and neurologic history and physical described elsewhere.1–3
We used a rotary chair as the objective test of vestibular
function. This study was approved by the institutional review
board at Naval Medical Center San Diego (IRB S2003.0143).
All subjects consented to participation in the study.
The testing and VPT were the same for all participants
regardless of diagnosis. We applied a standardized battery of
JNPT • Volume 34, June 2010
JNPT • Volume 34, June 2010 Tracking Recovery of Vestibular Function

TABLE 1. Classification of Dizziness in Participants With Blast-Induced, Mild Traumatic Brain Injury
Classification Symptoms Physical Examination Vestibular Test Results
Positional vertigo Vertigo with change of head position Nystagmus on Dix-Hallpike Test or No abnormalities
modified Dix-Hallpike Test
Exertional dizziness Dizziness during and immediately after Abnormalities in challenged No abnormalities
exercise walking test
Blast-induced disequilibrium Constant feeling of unsteadiness when standing Abnormalities in challenged Abnormal posturography
and walking, worse with challenging walking tests
environments
Constant headache Abnormalities in tandem Romberg Abnormal target acquisition, dynamic
test visual acuity, and gaze stabilization
Abnormalities with quick head VOR gain, phase, and/or symmetry
motions abnormalities
Blast-induced disequilibrium Constant feeling of unsteadiness when standing Abnormalities in challenged Abnormal posturography
with vertigo and walking, worse with challenging walking tests
environments
Constant headache Abnormalities in tandem Romberg Abnormal target acquisition, dynamic
test visual acuity, and gaze
stabilization
Episodic vertigo Abnormalities with quick head VOR gain, phase, and/or symmetry
motions abnormalities
Participants with blast-induced mild TBI fell into 1 of 4 classifications. The rotary chair test was used as the vestibular function test for gain and symmetry of the VOR.
Abbreviations: TBI, traumatic brain injury; VOR, vestibulo-ocular reflex.

accurate recognition by the subject. TA was the time required

TABLE 2. inVision Tunnel Standard Scores for Vestibular-
Visual-Cognitive Testing for the eyes to make a saccade from the center of the screen
to the new optotype position up, down, right, or left; TA did
Age (y)
not involve measuring eye velocity. TF was a functional
Test 20–29 30–39 40–49 measure of smooth pursuit speed in degrees per second. The
PT (msec) 20–30 20–40 30–50 subject was asked to track a symbol when the velocity of the
TA (msec) target was fixed (horizontally or vertically); TF did not
Horizontal 175–250 175–250 175–250 involve measuring eye velocity. DVA was measured in log-
Vertical 250 250 250 MAR DVA loss (ie, change in function from stable acuity to
TF (degrees/sec) 12 10 10 head motion acuity as measured in logarithm of the minimal
DVA loss in logMAR 0.1–0.2 0.1–0.2 0.1–0.2 angle of resolution) with active horizontal or vertical head
GS (degrees/sec) 200 190 180 motion. A GST was the speed in degrees per second at which
Normative data for vestibular function tests as a function of age range. Normative the subject could accurately hold a visual target and maintain
data were obtained from 80 participants without vestibular dysfunction (55 men and 35 recognition while performing active horizontal or vertical
women; mean age 30.6 years, range 20 –39 years); data were collected in the same
laboratory and under conditions similar to this study.
head motion. For each of the vestibular-visual-cognitive tests,
Abbreviations: PT, perception time; TA, target acquisition; TF, target following; participants gave a verbal response and the answer was
DVA, dynamic visual acuity; GS, gaze stabilization. entered by the operator.
The aim of the study was to assess performance on
SOT, MCT, DGI, PT, TA, TF, DVA, and GST at the initial
physical therapy visit, week 4, and week 8 visit. Group mean
tests at baseline and follow-up for all participants referred for
VPT after blast injury. These tests included computerized values were compared with normative data previously col-
dynamic posturography (CDP) in which the sensory organi- lected in the laboratory (but not previously published) as part
zation test (SOT) and motor control test (MCT) were admin- of another study of individuals without vestibular dysfunc-
istered.4 The dynamic gait index (DGI) test was performed to tion.6 The sample for the normative data set was 80 partici-
assess overall dynamic gait function and fall risk.5 Tests of pants (55 men and 35 women), mean age 30.6 years (range,
vestibular-visual-cognitive function were administered using 20 –39 years); therefore, the normative data group contained
the Neurocom inVision Tunnel. The vestibular-visual-cogni- a higher proportion of men and was slightly older than the
tive battery of tests was performed in a darkened room with current study sample. Normative values are summarized in
an effective viewing distance of 10 feet. The test battery Table 2. In participants whose scores were outside the range
included static visual acuity, perception time (PT), target of normative scores at week 8, additional testing was per-
acquisition (TA), target following (TF), dynamic visual acu- formed at subsequent 4-week intervals after completing more
ity (DVA), and gaze stabilization tests (GSTs). PT was therapy. In all cases, the final measurements represent that
measured by calculating the time, in milliseconds, that a point in time when the participant’s scores were within the
randomly presented target must be on the screen before range of normative values and rehabilitation was terminated.

© 2010 Neurology Section, APTA 95

Gottshall
Vestibular Rehabilitation
The VPT program consisted of exercise procedures that
targeted the vestibulo-ocular reflex, cervico-ocular reflex,
depth perception, somatosensory retraining, dynamic gait,
and aerobic function. The vestibulo-ocular reflex, cervico-
ocular reflex, and depth perception exercises were graded in
difficulty, based on velocity of head and object motion, and
progression of body positioning from sitting to standing to
walking. The SS exercises were graded in difficulty by
narrowing the base of support, making the surface uneven, or
changing the surface from firm to soft. Walking exercises
were graded in difficulty by changing direction, performing
with the eyes closed, increasing speed, walking on soft
surfaces, or navigating stairs. The aerobic exercise home
program was progressively increased by adjusting the time,
speed, or distance. All subjects were encouraged to work at
their maximum tolerance while performing the VPT. These
exercises have been described in detail elsewhere.7 Partici-
pants attended VPT twice weekly for 1-hour sessions and
were instructed to perform the exercises on a home program
basis the other days.
Statistical Analysis
Group mean pretreatment scores on SOT, MCT, DGI,
PT, TA, TF, DVA, and GST were compared with group mean
posttreatment scores using a 2-way analysis of variance with
standard statistical software (GB-STAT). Significance was
defined as P ⱕ .01.
RESULTS
Group mean PT, TA, TF, and DVA values achieved
normative or near-normative levels after 4 weeks of VPT.
Group mean PT decreased from 43 msec to 27 msec (nor-
mal ⫽ 20 msec). TF increased from 9 degrees/sec to 13
degrees/sec (normal ⫽ 12 degrees/sec). Horizontal TA time
decreased from 350 msec to 260 msec, whereas vertical TA
time decreased from 360 msec to 280 msec (normal ⫽ 250
msec). DVA logMAR loss decreased from 0.33 logMAR
right to 0.2 logMAR right; 0.36 logMAR left to 0.2 logMAR
left; 0.28 logMAR down to 0.18 logMAR down, and 0.27
logMAR up to 0.18 logMAR up, (normal ⫽ 0.20 logMAR or
less). However, GST did not return to the normed levels (ie,
horizontal GST: 140 degrees/sec left and 144 degrees/sec
right; vertical GST: 136 degrees/sec down and 135 degrees/
sec up) until completing an additional 4 weeks (ie, 12 weeks
total) of VPT. Anecdotally, we noted a return to running 3
miles without symptoms in those soldiers that had normal
values of vertical GST at week 12.
SOT test results revealed a reduced vestibular profile
(mean CDP SOT score of 58) in participants on initial testing.
Similarly, MCT also revealed a significantly higher percent-
age of prolonged latencies to translation in a portion of our
cohort (n ⫽ 30) on initial testing. Mean DGI increased from
21 to 23 points at the week 8 test point. Although this was not
statistically significant, the DGI tasks that consistently im-
proved were walking with horizontal head motion and with
vertical head motion, so we believed the difference to be
clinically meaningful. Full performance of the DGI achiev-
96
JNPT • Volume 34, June 2010
ing 24 points was attained by all participants after 12
weeks of VPT.
DISCUSSION
Vestibular symptoms are the most frequent sequelae of
blast-induced mTBI.1 VPT is an important treatment modal-
ity for individuals with this diagnosis when the goal is return
to duty status. Nevertheless, there is little work objectively
documenting the impact of VPT on this group. Previous
studies have used clinical measures such as the Glasgow
Coma Scale as a general assessment of recovery of con-
sciousness after TBI.8 However, there remains a lack of
studies aimed at examining the adequacy of vestibular tests
for tracking recovery of vestibular function. Scherer and
Schubert9 reinforced the need for “best practice” vestibular
assessment for formulation of appropriate VPT treatment
strategies. The application of vestibular testing and rehabili-
tation in individuals with vestibular dysfunction is needed to
provide information on objective outcome measures.10 Al-
though we and others have developed VPT procedures that
apply a best practice approach for individuals with blast-
induced mTBI, these therapies must be customized for the
individual based on initial level of function and expected
level of recovery.5
Knowledge of the patient’s diagnosis and disability is a
critical foundation for planning interventions with the goal of
return to activities of daily living, work, or sport. The value
of the CDP SOT score as a guide for exercise selection and
progression has been established;4 and the DGI has been
identified as a useful a diagnostic tool.5,11,12 However, these
studies have not included individuals with blast-induced
mTBI injury, who tend to have a different type of vestibular
profile than those tested in previous studies. The blast-in-
duced mTBI population also represents a younger population
compared with participants in most previous studies. Simi-
larly, although there are several studies examining the GST as
an outcome measure and correlating these scores with pos-
tural stability,13–16 the sample sizes were small and were
different from our sample of participants with blast-induced
mTBI both in terms of vestibular dysfunction and age. Al-
though the entire suite of vestibular-visual-cognitive tests
provides valuable information, our data indicate that the
vertical GST is the last measure to improve in our population.
The utility of this finding in establishing return to military
work/duty status is unclear.16 Functional levels that might be
considered typical for an older individual with vestibular
dysfunction (eg, poststroke) would be unacceptable in a
young military population intent on returning to active duty.
We recommend that vestibular clinics establish their own
normative data sets to establish a basis of comparison to assist
return to duty/work status as well as return to physical
activity status.17
CONCLUSION
In soldiers with mTBI and vestibular disorders caused
by blast injuries, many aspects of vestibular-visual-cognitive
function recover with VPT. The time course of recovery
varies for different aspects of vestibular function. A battery of
© 2010 Neurology Section, APTA
JNPT • Volume 34, June 2010
vestibular-visual-cognitive tests is valuable for establishing
initial functional levels and can be used to document im-
provement. These outcome measures may also be useful to
determine return to duty/work status as well as return to
physical activity status for military personnel.
REFERENCES
1. Hoffer ME, Balaban C, Gottshall KR, Balough BJ, Maddox MR, Penta
JR. Blast exposure: vestibular consequences and associated characteris-
tics. Otol Neurotol. 2010;31:232–236.
2. Hoffer ME, Gottshall KR, Moore RJ, Balough BJ, Wester DC. Charac-
terizing and treating dizziness after mild head trauma. Otol Neurotol.
2004;25:135–138.
3. Gottshall KR, Drake A, Gray N, McDonald E, Hoffer ME. Objective
vestibular tests as outcome measures in head injury patients. Larygno-
scope. 2003;113:1736 –1750.
4. Nashner LM, Peters JF. Dynamic posturography in the diagnosis and
management of dizziness and balance disorders. Neurol Clin. 1990;8:
331–349.
5. Shumway-Cook A, Woolacott MH. Motor Control Theory and Practical
Applications. Baltimore, MD: Williams and Wilkins; 1995.
6. Gottshall KR, Cohen H, Hoffer M, Moore R. Active head movements
facilitate compensation for effects of prism displacement on dynamic
gait. J Vestib Res. 2006;16:29 –33.
7. Gottshall KR, Gray N, Drake AI. A unique collaboration of female medical
providers within the United Sates Armed Forces. Rehabilitation of a marine
with post-concussive vestibulopathy. Work. 2005;24:381–386.
© 2010 Neurology Section, APTA
Tracking Recovery of Vestibular Function
8. Drake AI, McDonald EC, Magnus NE, Gray N, Gottshall KR. Utility of
Glasgow Coma Scale-Extended in symptom prediction following mild
traumatic brain injury. Brain Inj. 2006;20:469 – 475.
9. Scherer MR, Schubert MC. Traumatic brain injury and vestibular pa-
thology as a comorbidity after blast exposure. Phys Ther. 2009;89:1–13.
10. Mishra A, Davis S, Speers R, Shepard NT. Head shake computerized
dynamic posturography in peripheral vestibular lesions. Am J Audiol.
2009;18:53–59.
11. Herman T, Inbar-Borovsky N, Brozgol M, Giladi N, Hausdorff JM. The
Dynamic Gait Index in healthy older adults: the role of stair climbing,
fear of falling and gender. Gait Posture. 2009;29:237–241.
12. Whitney SL, Marchetti GF, Pritcher M, Furman JM. Gaze stabilization
and gait performance in vestibular dysfunction. Gait Posture. 2009;29:
194 –198.
13. Goebel JA, Tungsiripat N, Sinks B, Carmody J. Gaze stabilization test:
a new clinical test of unilateral vestibular dysfunction. Otol Neurotol.
2006;28:68 –73.
14. Badaracco C, Labini FS, Meli A, Angelis ED, Tufarelli D. Vestibular
rehabilitation outcomes in chronic vertiginous patients through comput-
erized dynamic visual acuity and gaze stabilization test. Otol Neurotol.
2007;28:809 – 813.
15. Pritcher MR, Whitney SL, Marchetti GF, Furman JM. The influence of
age and vestibular disorders on gaze stabilization: a pilot study. Otol
Neurotol. 2008;29:982–988.
16. Gottshall KR, Gray NL, Drake AI, Tejidor R, Hoffer ME, McDonald
EC. To investigate the influence of acute vestibular impairment follow-
ing mild traumatic brain injury on subsequent ability to remain on active
duty 12 months later. Mil Med. 2007;172:852– 857.
17. Paige GD. Nonlinearity and asymmetry in the human vestibuloocular
reflex. Acta Otolaryngol. 1989;108:1– 8.
97