Ai Chi-Based Rehabilitation for Peripheral Unilateral Vestibular Dysfunction

Unilateral peripheral vestibular hypofunction is a clinical condition characterized by reduced vestibular function due to inner ear or vestibular nerve pathology. It presents with symptoms such as dizziness, imbalance, visual instability, and impaired postural control, significantly affecting functional independence and quality of life. Diagnosis is typically established by the otorhinolaryngology clinic and supported by vestibular function tests such as videonystagmography (VNG) and video head impulse testing (vHIT).

Vestibular rehabilitation is an evidence-based therapeutic approach aimed at promoting central compensation through mechanisms of adaptation, substitution, and habituation. These mechanisms contribute to the improvement of vestibulo-ocular reflex function, postural stability, and overall functional performance.

Ai Chi is an aquatic exercise program derived from Tai Chi and Qi Gong principles, consisting of slow, continuous, and controlled movements coordinated with breathing. The aquatic environment provides unique therapeutic properties such as buoyancy, hydrostatic pressure, and viscosity, allowing safe movement, reducing fall risk, and enhancing proprioceptive and sensory input. These features may support multisensory integration and facilitate central compensation in patients with vestibular dysfunction.

Although aquatic therapy has been increasingly used in rehabilitation, there is limited evidence regarding the effectiveness of Ai Chi specifically in patients with unilateral peripheral vestibular hypofunction. To the best of our knowledge, no randomized controlled study has specifically evaluated the effects of Ai Chi in this patient population.

In this randomized controlled study, participants will be allocated into two groups. Both groups will receive a standardized home-based vestibular rehabilitation program. In addition, the intervention group will participate in supervised Ai Chi sessions conducted in an aquatic environment over a 4-week period, consisting of a total of 10 sessions. All sessions will be delivered by a certified therapist, and adherence will be monitored using exercise logs.

Assessments will be performed at baseline, immediately after the intervention, and during the follow-up period by a blinded evaluator. The findings of this study are expected to contribute to the development of alternative rehabilitation strategies and provide additional evidence for the management of patients with vestibular disorders.

• Ai Chi-based exercise program (Behavioral): Ai Chi-based exercise program is a structured aquatic therapy approach consisting of slow, continuous, and controlled movements combined with breathing techniques. The program will be conducted in a pool environment over 4 weeks, with a total of 10 sessions delivered as group sessions under the supervision of a certified therapist. The exercises are designed to enhance balance, postural control, proprioceptive input, and multisensory integration, thereby supporting central compensation in patients with vestibular dysfunction.
• Home-Based Vestibular Rehabilitation (Behavioral): Participants will receive a structured home-based vestibular rehabilitation program including gaze stabilization, head movement, balance, and postural control exercises. The program aims to promote vestibulo-ocular reflex adaptation, improve postural stability, and reduce dizziness-related symptoms. Participants will be instructed to perform the exercises regularly, and adherence will be monitored using exercise logs.

Primary outcomes

• Change in balance performance assessed by Berg Balance Scale [Baseline, immediately after the 4-week intervention, and 2 months after the end of treatment]: Change in balance performance will be assessed using the Berg Balance Scale (BBS). The BBS consists of 14 items scored from 0 to 4, with a total score ranging from 0 to 56. Higher scores indicate better balance performance. balance performance will be assessed using the Berg Balance Scale in participants receiving Ai Chi-based exercise program in addition to home-based vestibular rehabilitation, compared with participants receiving home-based vestibular rehabilitation alone.

Secondary outcomes

• Change in dizziness-related disability will be assessed using the Dizziness Handicap Inventory (DHI). The DHI consists of 25 items with a total score ranging from 0 to 100. Higher scoredizziness-related disability assessed by Dizziness Handicap Inventory [Baseline, immediately after the 4-week intervention, and 2 months after the end of treatment]: Change in dizziness-related disability will be assessed using the Dizziness Handicap Inventory.
• Change in dizziness severity assessed by Vertigo Symptom Scale-Short Form [Baseline, immediately after the 4-week intervention, and 2 months after the end of treatment]: Change in vestibular symptoms will be assessed using the Vestibular Symptoms Scale (VSS). The VSS consists of 15 items evaluating the frequency of vestibular symptoms. Each item is scored from 0 to 4, with a total score ranging from 0 to 60. Higher scores indicate more severe symptoms. dizziness severity will be assessed using the Vertigo Symptom Scale-Short Form.
• Change in kinesiophobia assessed by Tampa Kinesiophobia Scale [Baseline, immediately after the 4-week intervention, and 2 months after the end of treatment]: Change in kinesiophobia will be assessed using the Tampa Scale for Kinesiophobia (TSK). The TSK consists of 17 items scored from 1 to 4, with total scores ranging from 17 to 68. Higher scores indicate greater fear of movement.
• Change in quality of life assessed by Short Form-36 [Baseline, immediately after the 4-week intervention, and 2 months after the end of treatment]: Change in quality of life will be assessed using the Short Form-36 Health Survey (SF-36). The SF-36 consists of 8 subscales scored from 0 to 100, with higher scores indicating better health status.
• Change in balance confidence assessed by Activities-specific Balance Confidence Scale [Baseline, immediately after the 4-week intervention, and 2 months after the end of treatment]: Change in balance confidence will be assessed using the Activities-specific Balance Confidence Scale (ABC). The ABC includes 16 items scored from 0% to 100%, with higher scores indicating greater balance confidence.
• Change in functional mobility assessed by Timed Up and Go Test [Baseline, immediately after the 4-week intervention, and 2 months after the end of treatment]: Change in functional mobility will be assessed using the Timed Up and Go Test (TUG). The time required to stand up, walk 3 meters, turn, and sit down is recorded in seconds. Lower times indicate better performance.
• Change in tandem balance performance assessed by tandem stance/walking duration [Baseline, immediately after the 4-week intervention, and 2 months after the end of treatment]: Change in dynamic balance will be assessed using tandem walking performance. The duration or number of steps maintained in tandem stance is recorded. Higher performance indicates better balance.
• Change in perceived benefit assessed by Vestibular Rehabilitation Benefit Questionnaire [Baseline, immediately after the 4-week intervention, and 2 months after the end of treatment]: Change in perceived benefit will be assessed using the Vestibular Rehabilitation Benefit Questionnaire (VRBQ). The questionnaire evaluates symptom severity and quality of life related to vestibular dysfunction. Raw scores are converted to percentage values ranging from 0 to 100. Higher scores indicate greater symptom severity and poorer quality of life.

Sex: Female, ages: 18 Years to 70 Years

Inclusion Criteria:

* Age between 18 and 70 years
* Diagnosis of unilateral peripheral vestibular hypofunction
* Presence of dizziness symptoms for at least 3 months
* Ability to participate in Ai Chi and aquatic exercise program
* Berg Balance Scale score ≥21
* Willingness to participate in the study

Exclusion Criteria:

* Inability to complete assessment tests and questionnaires
* Severe systemic disease that may interfere with exercise participation
* Central vestibular disorders
* Berg Balance Scale score ≤20
* Severe visual or hearing impairment
* Initiation or change of psychiatric medication within the last 3 weeks
* Severe cardiopulmonary disease
* Contraindications to hydrotherapy, including water phobia, behavioral disorders, dyspnea at rest, incontinence, known chlorine allergy, open wounds, acute systemic illness, epilepsy, tracheostomy, permanent drainage devices, immunodeficiency, or known neurological disorders

• Kurt EE, Buyukturan B, Buyukturan O, Erdem HR, Tuncay F. Effects of Ai Chi on balance, quality of life, functional mobility, and motor impairment in patients with Parkinson's disease<sup/> Disabil Rehabil. 2018 Apr;40(7):791-797. doi: 10.1080/09638288.2016.1276972. Epub 2017 Jan 13. PMID 28084851
• Covill LG, Utley C, Hochstein C. Comparison of Ai Chi and Impairment-Based Aquatic Therapy for Older Adults With Balance Problems: A Clinical Study. J Geriatr Phys Ther. 2017 Oct/Dec;40(4):204-213. doi: 10.1519/JPT.0000000000000100. PMID 27490823
• Pereira CMM, Pinheiro do Vale JS, de Oliveira WP, Pinto DDS, Cal RVR, de Azevedo YJ, Bahmad F Jr. Aquatic physiotherapy: a vestibular rehabilitation option. Braz J Otorhinolaryngol. 2021 Nov-Dec;87(6):649-654. doi: 10.1016/j.bjorl.2019.12.003. Epub 2020 Jan 13. PMID 32035856
• Elbar O, Tzedek I, Vered E, Shvarth G, Friger M, Melzer I. A water-based training program that includes perturbation exercises improves speed of voluntary stepping in older adults: a randomized controlled cross-over trial. Arch Gerontol Geriatr. 2013 Jan-Feb;56(1):134-40. doi: 10.1016/j.archger.2012.08.003. Epub 2012 Aug 28. PMID 22951028