Not All Eye Exercises Are the Same: VOR Training vs. Oculomotor Training in Vestibular Dysfunction and Concussion
- Ana Souto
- 6 days ago
- 4 min read
The visual and vestibular systems work in tight coordination to keep the world stable as we move through it. When this integrated system is disrupted, whether through peripheral vestibular hypofunction or after a traumatic brain injury (TBI), patients commonly experience dizziness, blurred vision, difficulty reading, visual fatigue, and challenges with balance.
Although some rehabilitation programs for these conditions may appear similar on the surface, the underlying mechanisms and evidence-based treatment strategies differ dramatically. A common clinical error is assuming that all eye exercises target the same functions or are interchangeable across disorders. In reality, VOR training and oculomotor training serve distinct purposes, and applying them incorrectly can delay recovery.
This article outlines why these two forms of training are distinct and why understanding their differences is critical for effective rehabilitation.
1. VOR Training in Peripheral Vestibular Hypofunction
In cases of unilateral or bilateral peripheral vestibular hypofunction, the primary issue is the impaired Vestibulo‑Ocular Reflex (VOR). The deficit originates in the damaged peripheral vestibular end organs, leading to reduced gaze stability during head movement.
VOR Adaptation: Recalibrating the Reflex Through Retinal Slip
Exercises such as VORx1 and VORx2 aim to restore normal VOR gain by generating a controlled “retinal slip” signal that drives central neuroplasticity. Key principles include:
The patient maintains visual focus on a stationary or moving target while the head moves.
Movement must be fast enough to induce retinal slip without overwhelming symptoms.
Repetition, duration, and progression are essential for long‑term neural adaptation.
This approach improves:
Dynamic visual acuity.
Motion‑provoked dizziness.
Overall gaze stability during daily activities.
Substitution Strategies When Adaptation Is Not Enough
When VOR recovery is incomplete or less likely, rehabilitation shifts toward substitution mechanisms, such as:
Pre‑programmed compensatory saccades.
Heavier reliance on visual and somatosensory cues.
Predictive and anticipatory eye movements.
These strategies support gaze stability but do not directly train or restore the VOR.
As an example, in this video, the subject is performing saccadic eye movements followed by head Movements for eye-head-neck coordination training. This can be performed with VR or using the second monitor.
Why Isolated Oculomotor Exercises Should Not Be Used in Vestibular Hypofunction
Clinical practice guidelines clearly state that isolated pursuits and saccades (without head movement) do not improve gaze stability in patients with peripheral vestibular loss.
These exercises:
Do not induce retinal slip.
Do not drive VOR adaptation.
Do not improve dynamic visual acuity.
May delay appropriate treatment.
Can increase costs by investing time in ineffective interventions.
2. Oculomotor Training in Concussion and Traumatic Brain Injury
Visual dysfunction is extremely common following concussion and TBI. Research reports that a significant number of individuals experience visual disturbances and show oculomotor deficits, such as:
Poor pursuits.
Saccadic dysfunction.
Convergence insufficiency.
Visual tracking difficulty.
Reduced visual attention.
The key difference here is that these deficits arise from central neural network disruption, not peripheral vestibular organ damage.
Targeted Oculomotor Exercises Are Appropriate and Often Necessary
Unlike in peripheral vestibular disorders, isolated oculomotor exercises play an important role in TBI rehabilitation. Structured protocols usually target:
Smooth Pursuits.
Saccades.
Vergence and convergence.
Accommodation.
Evidence shows improvements in:
Reading speed.
Smooth pursuit accuracy.
Binocular coordination.
Symptom reduction (headaches, fatigue, visual strain).
The Neurobehavioral Impact of Eye‑Movement Training
Saccadic and pursuit training in TBI is not purely motor. Many patients experience concurrent impairments in:
Attention.
Executive function.
Mental endurance.
Information processing speed.
Oculomotor rehabilitation can indirectly enhance these functions because eye‑movement tasks stimulate wide, interconnected brain circuits, not just the eye-movement centres. As a result, patients often report improvements in:
Brain fog.
Cognitive fatigue.
Slowed thinking.
Conclusion: Two Conditions, Two Different Rehabilitation Needs
VOR training and oculomotor training serve different purposes and are based on different mechanisms.
Peripheral vestibular hypofunction: The primary deficit is VOR dysfunction. Treatment must focus on VOR adaptation and head‑movement–based exercises.
Concussion/TBI: The deficits are primarily central and oculomotor in nature. Treatment should include targeted oculomotor training and cognitive‑visual rehabilitation.
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Ana Souto
Meet Ana, a physiotherapist with a master's degree in human physiology and certified by the American Institute of Balance.
Ana currently serves as the clinical specialist at PhysioSensing, a cutting-edge Balance Assessment and training device. Her approach is firmly rooted in the latest scientific findings, ensuring that PhysioSensing users receive the most effective and up-to-date care. In addition to her role in designing tailored programs, Ana plays a pivotal role in guiding new clients through the learning process of using PhysioSensing. She also provides advanced training and support to existing customers seeking to further deepen their clinical practice knowledge and stay on top of the latest scientific advancements.
References
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Berryman, A., Rasavage, K., Politzer, T., & Gerber, D. (2020). Oculomotor Treatment in Traumatic Brain Injury Rehabilitation: A Randomized Controlled Pilot Trial. The American Journal of Occupational Therapy, 74(1), 7401185050p1-7401185050p7. https://doi.org/10.5014/ajot.2020.026880
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