Essential Equipment for a Vestibular Rehabilitation Clinic

Whether you’re starting a vestibular rehab program on your own or joining a team of vestibular clinicians, you’ll want to make sure that you have equipment that is reliable, affordable, and works for your space. When I brought vestibular rehab to a small, previously ortho focused clinic, I complied a list of items that I felt would be essential to a successful vestibular program. Now I’m sharing that list with you!

© National Museum of Health and Medicine

Keeping your equipment up to date is an important part of excellent patient care!

© National Museum of Health and Medicine

Basic Needs

These elements are your bare-necessities for any vestibular clinician.  The items listed below include essential exam items such as infrared video goggles as well as treatment tools like make-your-own Brock strings for convergence.  Think we missed something? Please email helena@vestibularfirst.com so I can share your ideas!

Most of the items below you can find on Amazon or at specialty stores linked below. If you would like to see the complete list of items from Amazon, check out our Ideas List for Essential Equipment for Vestibular Rehabilitation . Items purchased though these links directly support our innovation research to provide affordable vestibular technology to clinicians, educators, and researchers worldwide.

Post-It Notes

Post-it notes are the mainstay of the tool box for many vestibular therapists. With a clearly written, reading size letter (or larger, depending on the patient’s vision and the goals of the activity), the post-it is a solid target for active eye and head movements (also known as gaze substitution or shift) and gaze stabilization exercises (VORx1 or x2). You can have the patient hold the post-it or stick it to the wall (which is handy if they have shoulder issues particularly). 

Oakworks Pt 300 Lift Table

Hi Lo Lift Table

A hi lo lift table is necessary for assessment and treatment of everything from BPPV to neck issues to habituation of position changes. The adjustable height feature is important for both patient safety (getting on/off the table) as well as for proper body mechanics for the clinician. I like tables that are on the wider side, if your clinic can accommodate them, along with those that have a weight capacity to accommodate a variety of patient body types. Wider tables also allow more room for movement without the already dizzy and possibly anxious patient feeling like they might fall off of the table edge!

Timer

Set this timer for 30 sec, 1 min, or any time you’d like and have it countdown to ring when the patient should stop performing exercises such as active eye and head movements (gaze substitution), VORx1 or x2, and habituation or balance activities. In addition, it is has a magnetic back, stand, and hook, so there’s always a way to keep it upright and close by. At $10, it’s a low cost useful tool!

Beads for Convergence/Brock String

Using a Brock string can be important for treating those with impaired convergence (normal: 5-7 cm from the nose), which may be seen in those with post-concussive syndrome, migraine/headache, or other central vestibular disorders. At 1.2 cm, I like the size of these beads for visualization as well as the color variety in the mix. For those with a neuro program, sorting the beads also makes for a great fine motor and/or reaching activity with or without a standing balance challenge.

String for Convergence/Brock String

Instead of spending $5-10 per string, I just make my own with the above beads and this sturdy string. I like the fact I can cut the string to any size I like and give patients a string for their home exercise program. If your time for making your own strings is limited, I’ve made some strings in advance of patient care or trained staff on how to make them, so I have a stack of them waiting for me when they’re needed!

Cost: $7 for 100 beads and $8 for 109 yards (327 feet) of string. If you put 5 beads per string and made each string 10 ft long (I honestly make mine about 2 ft long to start, as my focus is near convergence for non-athletes), that’s $0.60 per Brock string. Not a bad deal!

Infrared Video Goggles

If you are performing positional BPPV tests, head shake tests, or a hyperventilation test in room light, you are likely missing abnormal eye movements you would see in the dark.  Traditional Frenzel lenses have been shown to be only 33% accurate in showing displaying abnormal eye movements in those with known vestibular dysfunction.

With infrared video goggles, you have removed visual fixation and can visualize abnormal eye movements with the same accuracy as ENG (the gold standard that uses signals from electrodes on the face to track eye movements). Video goggles also allow recording of eye movements for self or peer review or student/patient education.

Previously cost-prohibitive for many at $8,500-10,000, an affordable option is Vestibular First’s Insight Infrared Video Goggles ($950 new customer offer).

BPPV Vibrating Massager

I don’t use vibration to treat BPPV often, but every once in a while, I add it to a treatment for those very stubborn cases. Vibration is required if you’re going to use the maneuver that involves vibration at the mastoid of the affected side plus the BBQ (modified canalith repositioning maneuver for horizontal canal) for horizontal canal cupulolithiasis. This vibrating massager is small, inexpensive at $18, and just takes one C battery to operate (so keep extra C batteries on hand, just in case).

ETDRS-R Eye Chart

Testing dynamic visual acuity is easy with this eye chart (24.5 in x 25.5 in at $65). You can choose the type you like depending on the room you have in your clinic – I prefer the one set to be accurate when the patient is standing 10 ft from the chart. You can print an eye chart for free instead of buying one, but it’s important that the patient stand at the distance appropriate for that specific chart, while it can be challenging to determine and ensure consistency of letter size between an online version and a printed one. Also, I prefer this chart because unlike a Snellen chart, there is the same number of letters on every line – in order to be counted as accurate, the patient has to read every letter on a line correctly.

Tape Measure

Every clinic likely has several tape measures floating around for assessing everything from leg length discrepancy to swelling. For a vestibular therapist, you will want to keep one handy, as you’ll need it to measure convergence, accommodation, and the distance from the rotation point of your patient’s head to a joint position error target (see more on tools for joint position error below). 

Cones

This is a gold standard for a neuro or balance program, so most clinics should already have them. You can use them for cone taps to promote single limb stance balance, weaving with coordination tasks for that athletic post-concussive patient, or practicing turns for the person with vestibular loss. At $35 for 30 cones, you won’t break the bank either.

Stairs or Aerobic Step

Stairs allow for assessment and treatment of an important functional task as well as serving as an element of the Functional Gait Assessment, a useful outcome measure for dynamic balance. Balance training for activities such as a step tap for single limb balance or safe negotiation when looking down may also be important for those with vestibular dysfunction. If your clinic has zero stairs available in-house and you can’t afford the space and/or cost of a wooden staircase ($900-2,000), then an aerobic step is better than nothing!

Airex Pad

A staple for any balance program, a medium density foam pad is essential for testing the mCTSIB (modified clinical test for sensory interaction in balance). It is also useful for various balance activities including stepping on/off of the foam to promote effective anticipatory and reactive control when standing or walking on uneven surfaces such as a sandy beach or a grassy yard. At $50, it won’t last forever, but it does the job well.

Printable Checkerboard Pattern

Various patterned backgrounds provide an opportunity for habituation for those with visual vertigo as well as adding a level of complexity or challenge for VOR exercises or active eye/head movement (AKA gaze substitution) training. I like this checkerboard because it’s free to print, printable on standard 8.5 x 11 in paper, and easy to provide to a patient for home exercise program use as well.

Joint Position Error Target

This target is free and printable from the Skillworks website for your assessment of joint position error, which if problematic may indicate possible cervicogenic dizziness. In order to be accurate, you must follow the proper protocol for target placement on the wall. This includes having the patient sit so that the rotation point of the patient’s head is 90 cm from the wall upon which you will be placing the chart, which should be eye level and centered per the patient’s report. Green and yellow are considered normal, while red and anywhere outside the target is considered abnormal.

© 2018 Skillworks

Joint Position Error Laser (DIY)

It is necessary to have the laser at eye level for joint position error testing and treatment of those with cervicogenic dizziness. The do-it-yourself set-up on this website offers two very inexpensive options for both clinic and home exercise program use, although I couldn’t find the Nitecore head strap they mention on Amazon. The ball cap version is particularly easy as almost everyone has the items needed, but be sure that the laser pointer you use is the type you can be turned on in such a way that it stays on without you having continuously hold down the button.

© 2018 Skillworks

Joint Position Error Laser

At $28, this is not a significant expense if you are going to be testing joint position error for cervicogenic dizziness often. It is a very easy-to-use device and doesn’t require any fiddling with aligning the laser as it sits at midline. Its strap is thick to keep it more securely in place and comes with waist/extremity strap if you’re interested in using it for visual feedback of somatosensory positioning for other joints.

Disco Ball

Party time in therapy! This disco ball is useful for those visual vertigo patients whose symptoms are provoked by busy backgrounds or visual movement, like a patterned carpet or cars moving past them. You can have them simply view the steady pattern (disco ball turn action off) or moving lights, perform a balance challenge while watching, or perform gaze stabilization or active eye and head movements while viewing the background. I like this disco ball in particular because I can move it between rooms (unlike the ceiling mounted options) and adjust the light to change the intensity of the pattern, how much of the wall the pattern covers, and the color of the light. At $30, it’s worth forgiving the fact that you need a D battery for the ball (the light plugs into the wall).

aVOR iOS App for Education

Free to download, this app provides an opportunity for patient, self, student, or new vestibular clinician education. It has a visual representation of the vestibular apparatus including its location and size relative to the head. It allows you to see which canals are activated and inhibited with certain directions of head movements as well as what types of abnormal eye movements you may see with dysfunction (acute or compensated lateral canal loss, for example). The app also has a “quiz” setting for self-testing: view the eye movements, then predict the vestibular issue(s). 

Adjustable Cane

Sturdy, reliable, and basic, this $13 cane is a great tool not only for the obvious gait training but also for training stepping over an object (tree root simulation!) as long as you guard your patient closely for safety. If you have a neuro population (peripheral neuropathy etc.), you may also want to get Loftstrand crutches – these are my favorite, with a decent $120 price tag: Loftstrand crutches

Rolling Walker

Unfortunately, vestibular issues can become so significant that a patient may need more than a cane to ensure safety while walking. This is a basic $30 walker – if long term symptoms require ongoing use for several months or years, you can guide them through the selection of the most appropriate device (rollator with or without seat and so forth) if the basic walker does not meet their long-term needs. Consider gliders or the tried-and-true tennis balls on the back two legs of the walker, but note that the tennis balls can wear out and will need replaced if used often. 

Floor Mounted Parallel Bars

Essentially, parallel are a safe place for balance training when the patient is more challenged. This includes higher level balance training, for example an athletic person on a BOSU half-dome. Your clinic’s space, the needs of your clinic (heavy neuro population requires the bars to be wide enough for a wheelchair to fit in between), and your budget will likely determine which bars to purchase; the example I’ve provided in the link above is $1,200, not including the cost of installation.

Spot It! Cards

At $13, these cards have been one of my best investments. They provide a great way to train both visual saccades (scanning to find matching objects) and left and right head turns during a balance challenge (when the cards are held by the patient with arms in a wide “V”). I have the patient reach for the cards to add another dynamic component. Not does this game make balance training less boring, but it also provides a concurrent cognitive challenge which is great for many of my patients including those with post-concussive syndrome.

Playground Ball

I like the $5 light playground balls they have at most pharmacies in the spring and summer, but if you want a sturdier ball, this $15 one does the job. It’s great for the patient to ball toss/catch to self or to staff for anticipatory and reactive balance training. I like to walk next to my patients, alternating sides, while tossing the ball to them and having the toss it back to me, so they have to frequently turn their head while walking. It’s also perfect for the patient to toss the ball behind them, have it bounce on the wall, then they catch it, alternating sides for frequent left/right head and body turns. Increase the speed for your higher level patients, and you’ve got some significant vestibular stimulation there!

Busy Backgrounds (e.g. wrapping paper)

If you’re ready to go beyond the checkerboard when progressing the treatment program of your patients with visual vertigo, an inexpensive way to go is wrapping paper. There are many options of varying level of challenge, from lines (vertical or horizontal depending on how you place the paper) to complex patterns. You can cover piece of cardboard for a more “permanent” use in your clinic, and you can cut off pieces for home exercise use. Another option is YouTube videos (free as long as you allow an ad to run), which can provide more challenging moving patterns, like this very difficult option: Moving Lines Video

Treadmill

Although a higher priced item at $1,000-2,000, a treadmill is a standard for progressing gait training, side stepping or backwards walking for a higher level patient, and completing the Balke Treadmill test. The Balke is an exertional test for patients after concussion, and it can help set heart rate limits as a patient initiates light aerobic activity with the goal of avoiding significant provocation of symptoms. I like this treadmill because it has a 15% incline (required for the Balke), but do your own research and read recent reviews, as treadmills definitely vary in quality even among the same brand/model year to year.

Recumbent Bike

Most patients need aerobic activity, particularly your patients after concussion, but they may not be safe, physically able, or tolerate the movement required on a treadmill. This is especially true with vestibular patients if they are provoked by self-motion. The recumbent bike is a great option for these patients. Again, do your own research on this one, as the brands and models seem to vary in quality year to year. I’ve had good luck with the NU step for my neuro patients (elliptical rather than circular pedal motion and can buy one with straps to secure the feet for those with a flaccid leg etc.), but they’re pricey at $3,000-5,000. 

 

Additional tools to consider

The below list includes bonus items that will further improve your clinic.  You can save this list for months or a year or two down the road, if budget is strapped after the purchase of the essential items above.

Fluid Apparatus - Grey_Web

Fluid-Filled Model of Vestibular System

Showing how the otoconia move through the semicircular canals can be quite the challenge–but not anymore!  Check out our new model that has crystals floating in fluid-filled canals with realistic timings, accurate anatomy, and cupulas that represent what happens during positional vertigo.

Playing Cards

Not expensive at $5 (maybe less at the dollar store?) but another option for reaching, picking up a flat object from the ground, cognitive training during balance activities, and tapping your toe to cards arranged in different directions on the floor for single limb balance training. My patients who like to go to the casino or play card games with friends really engage with activities involving cards. Just keep the betting out of it to avoid legal issues!

Bosu Balance Trainer

The BOSU is an industry standard for higher level balance training. This is great for athletes or your more physically able patients. I like to have patients stand on the flat side, reach or toss a ball vertically or between hands to themselves, then step to turn 90 degrees and repeat. Flip the BOSU to have them stand on the round side to crank up the challenge!

Balance Disc

This is a great addition to a balance program when you’re looking to diversify your uneven surfaces. I like to have my patients stand with one foot on the Airex pad and the other on the balance disc to provide a more varied challenge, then reverse the placement, all while the patient catches and tosses a ball or plays a reaching game. At $17, this is a reasonably priced item that comes in a variety of colors too.

Memory Game

While not as versatile as the Spot It! cards, a memory game is another great way to create a cognitive challenge while having a patient perform a balance exercise such as standing tandem on foam. You can select as many or few cards as you want to use, matching the game’s length to how long you want the activity to last. You can also have the patient play alone or against you or a staff member, depending on how much challenge to memory you want to provide.

Exercise Sliders

Place this flat disc under one foot to promote single limb balance on the opposite leg. The patient can simply slide the other leg on the floor forward/backwards or laterally then toward midline, or you can increase the challenge by having them trace letters on the floor. Backwards alphabet or spelling out words can really increase the cognitive aspect!

 

Nice to have for the A+ Clinic

There’s no way to be an overachiever like having this swag below.  Get it now while your boss still is being nice to you

Vestibular Apparatus Ball Maze

Learn by doing with this interactive vestibular apparatus/labyrinth ball maze that shows the basic functions of the semi-circular canals, otoconia, and cupulas.  Perfect for use with patients, students, and educators!   

Poster of Inner Ear

A picture is worth a thousand words, and this $15 poster is an affordable way to provide your patients with a better understanding of the vestibular system and their vestibular issues. Hang it in your office for patient education, or photocopy pictures from your vestibular textbook for the truly curious patients to take home with them as a bonus.

Balance Disc (Large)

At 24 cm diameter, this $40 disc is twice as large as the regular discs and very uneven, so it is best for patients who really need a highly challenging surface such as those high level athletes post-concussion. It’s a bonus in a clinic where you’re looking to increase the diversity of your balance surface options beyond the traditional BOSU. 

RiverStones Obstacle Balance Course

I love these river stones ($60) because they are great for walking across and around as a high level balance challenge, particularly for my patients who live downtown where negotiating curbs, cobblestone paths, and uneven sidewalks are real issues. They’ve also come in handy for outdoorsy patients who may be walking over rocky ground or into and along creeks for fishing. The real key is to cue the patients not to look down the entire time as that can be provoking to dizziness, but rather to pause while they have their balance to look ahead before looking down to continue walking.

Accommodation Ruler

For a formalized means of measuring convergence and accommodation, this ruler hits the mark. It’s pricey at $81, which is why I keep it in my “nice to have” category. I currently measure convergence and accommodation informally with a measuring tape, which takes a bit more manual skill but is doable.

EMI Eye Occluder for Eye Exams (Model # EMI-OCC)

Eye Occluder

I just use my hand to block the vision of one eye when testing for skew deviation. However, if you want a formalized tool, here’s an inexpensive eye occluder that can do the job. At $9, it’s affordable as well as durable and easily cleaned between patients.