Vestibular Therapy

What is Vestibular Rehabilitation?

Vestibular disorders may cause a variety of symptoms such as dizziness, vertigo, imbalance, hearing problems, nausea, fatigue, anxiety, concentration, and others. These symptoms can massively affect a person’s daily life, social relationships, and quality of life. 

A healthy individual most of the time takes their sense of balance for granted. Most do not find it difficult to walk across a gravel driveway, or transition from walking on a sidewalk to walking on grass, or getting out of bed at night without stumbling or feeling unsteady. The ability to balance depends on sensory information delivered from the vestibular system (inner ear), vision, and proprioception- sensory receptors from the muscles and joints (i,e your feet). 

Vestibular disorders are thought to be the common cause of dizziness in the elderly population, it is responsible for approximately 50% of the reported dizziness in the elderly. 

Causes of dizziness:

The vestibular system of the inner ear provides the brain with information about any changes in head movement. If the vestibular system is improperly functioning then dizziness, vertigo, imbalance, spatial disorientation, and other symptoms can result. 

Distress in the Vestibular-system can be caused by a variety of influences, including viral infections of the labyrinth of the vestibular nerve. Bacterial infections of either the middle ear or the brain coverings may spread to the inner ear. Vestibular disorders can also occur from exposure to drugs or chemicals that are harmful to the inner ear. 

Up until recently, relatively little was known about the consequences of aging for the vestibular system. Anatomical studies have shown that the number of nerve cells in the vestibular system becomes smaller with age, starting at age 55. As age progresses the loss of cells grows more severe. Degeneration of hair cells in the inner ear is due to aging as well which results in dizziness, vertigo and hearing loss.

Read about why it is important to consult a Physical Therapist when you experience dizziness. 

Why should you see a Physical Therapist for dizziness?

What is BPPV (Benign Paroxysmal Positional Vertigo)?

BPPV is one of the most common vestibular disorders. It is known to cause vertigo, dizziness, and other symptoms due to very small crystals that collect within a part of the inner ear. These crystals are composed up of calcium carbonate or “ear rocks”. Due to trauma, infection or even aging, these small crystals can detach from the utricle and collect within the semicircular canals. With any movement of the head, the displaced crystals can shift, which sends false signals to the brain causing dizziness and other symptoms. 

Getting out of bed and rolling over in bed are the two common “problem” motions that cause the symptoms of BPPV. Some people feel dizzy and unsteady when they tilt their heads back to look up.

Test for BPPV:

Dix-Hallpike Test:

1. Bring patient from a sitting to the supine position (flat on their back) with head turned to 45 to one side and extended about 20 backward.
2. Once supine, the eyes are typically observed for about 30 seconds. If no nystagmus (jumping of eyes) ensues, the patient is brought back to sitting.
3. After again observing for a reaction for 30-60 seconds, the other side may be tested.

Result: A positive test would consist of a burst of nystagmus (jumping of the eyes) or an increase in vertigo. Nystagmus may be small or difficult to discern with the naked eye.

Treatment for BPPV:

The Epley Maneuver is very effective in treating BPPV and can be performed by a physical therapist. The goal of this maneuver is to move the detached crystals out of the semicircular canals. Through a series of head position changes, the Epley Maneuver moves the crystal from the canal to the utricle.

The Epley Maneuver is very effective with an approximate cure rate of 80%. The recurrence rate for BPPV after the maneuvers is low. In some instances, additional treatment(s) may be required.

The Epley Maneuver Steps:

Start the patient in an upright position
The patient will slowly lie down and the therapist will turn head to the symptomatic side at a 45-degree angle for 30-60 seconds
The therapist will turn head to another side for 30-60 seconds
The patient will then roll in the same direction onto the side until the nose is pointed downward, 45 and maintain for 30 seconds.
The patient sits up, keeping his head tilted down for 15 seconds.

Treatment precautions:

Precautions for the days immediately after the Epley Maneuver have been performed:

1. Wait for 10 minutes after the maneuver is performed before getting up.
2. Sleep in a semi-recurrent position if possible the same evening, such as a recliner, or by using at least two       pillows.
3. During the day try and keep your head upright (vertical)
4. Do not go to the hairdresser or dentist
5. No exercise which requires head movement
6. For at least a week, avoid provoking head posting that brings BPPV on again.
7. Avoid sleeping on the “bad” side (symptomatic side)
8. Do not turn your head far up or far down.

Brandt-Daroff Exercise:

Treatment may also include individualized vestibular physical exercises designed to help retrain the brain. Adaptation exercises can be performed at home. The goal of this exercise is to loosen and disperse particles from the cupula of the posterior semicircular canal. These exercises should be performed for two weeks, three times a day for three weeks, twice per day. This adds up to 42 sets in total. Symptoms sometimes suddenly go away during an exercise period. A trained professional should be involved in determining whether this is an appropriate exercise for each individual and to help ensure that the exercise is being performed correctly, safely, and effectively.

Brandt- Daroff Exercise:


1. Begin by sitting on your bed in an upright position.
2. Move into a side-lying position until the vertigo ends
3. Return to upright, sitting position for a fixed interval.
4. Move into a side-lying position on the opposite side.
5. Return to the sitting position for a fixed interval and so on.

Eye-Head Coordination

Vestibulo-Ocular Reflex (VOR)

The VOR acts to maintain stable vision during head movement. Assessment of the patient’s ability to keep eyes fixed during horizontal and vertical head to keep eye motions of varying speed is typically examined. The patient’s ability to keep eyes fixed on an object while the head is moving is also accessed. Complaints of dizziness, blurred vision of illusionary movements are noted.

Treatment exercises are used to improve eye coordination when the head is still and in motion. Tracking exercises are performed initially if the patient has dizziness during these eye movements. Next, the patient is asked to keep their eyes fixed on a central target while moving the head either horizontally or vertically for a longer period of time. The patients repeat these exercises first in a supported sitting position, and progress to standing and walking.