What is Vestibular Rehabilitation Therapy

Vestibular rehabilitation therapy (VRT) is a specialized form of therapy intended to alleviate symptoms caused by vestibular disorders. It is an exercise-based program primarily designed to reduce vertigo and dizziness, visual disturbance, and/or imbalance and falls. After injury to the vestibular system occurs, the central nervous system can compensate for reduced function of the inner ears. Essentially, the brain copes with the disorientating signals coming from the vestibular system by learning to rely more on alternative signals coming from other systems in the body to maintain balance. This is achieved through various exercise strategies outlined below. With compensation, the patient’s symptoms can be alleviated which allows them to return to normal function.

What Types of Problems Benefit From VRT?

Patients typically referred for Vestibular Rehabilitation have been diagnosed with a vestibular condition including:

  • Benign Paroxysmal Positional Vertigo (BPPV)
  • Vestibular Neuritis/Labyrinthitis
  • Unilateral Vestibular Hypofunction (UVH)
  • Vestibular Migraine
  • Persistent Postural Perceptual Dizziness (PPPD)
  • Mal de Debarquement (MDD)
  • Cervicogenic Dizziness
  • Post Concussion Syndrome (PCS)
  • Neurological conditions (i.e. stroke, traumatic brain injury)
  • Recurrent Vestibulopathy

Dizziness can be caused by many other different reasons. 

If you have not yet been assessed or diagnosed with a vestibular condition, common symptoms that can be helped with vestibular rehabilitation include:

  • Vertigo (sense of spinning)
  • Dizziness at rest
  • Dizziness or altered vision with head movements
  • Neck tightness, stiffness and/or pain
  • Imbalance (difficulty getting up or walking without holding onto something)
  • Headaches
  • Frequent falls

Is Vestibular Rehabilitation Therapy Right for Me?

In order to determine if VRT is appropriate for you, we recommend scheduling an assessment with one of our Vestibular Physiotherapists.

In your initial appointment, your physiotherapist will take a detailed history of your symptoms and review any relevant medical history. Your assessment may also include other objective evaluations including:

  • Visual stability 
  • Oculomotor function
  • Standing balance
  • Stability with walking
  • Neck mobility and tenderness on palpation to various structures in your neck
  • Inner ear positional testing, including infra-red goggle testing

Based on the findings of your assessment, your physiotherapist will determine if you are an appropriate candidate for VRT. The goal of your treatment plan will be to improve any deficits that were identified in the assessment. This, in turn, will help to improve your daily symptoms and your ability to function in activities of daily living.

How Do You Do Vestibular Rehabilitation Therapy?

VRT exercises are not difficult to learn but require consistency by the patient to achieve success.  We often recommend the exercises be performed 2-3 times in a  day, which can be tedious or difficult to incorporate into a busy schedule. We often suggest that our patients set up a regular schedule so that the exercises can easily be incorporated into daily life. The exercises may, at first, make symptoms seem worse. But with time and consistent work, symptoms should steadily decrease until they are completely relieved. I often use a weight lifting analogy: when you first start lifting a certain amount of weight, it is difficult and your muscles are sore after your workout. But, over time, the weights become easier to lift and your muscles hurt less over all. It is then that you are ready to progress to lifting heavier weights, or — in the case of VRT — performing more complex vestibular exercises.

What are the types of exercises I will learn in a vestibular rehabilitation program?

Vestibular rehabilitation exercises can typically be divided into three categories

  1. Habituation
  2. Gaze Stabilization
  3. Balance Training

Habituation Exercises

Habituation exercises are used to treat symptoms of dizziness that are produced because of head motion or visual stimuli. These patients typically report increased dizziness when they turn their heads quickly or with position changes like bending forwards to tie their shoes or looking upwards. Habituation exercises are also appropriate for patients who have difficulty in highly visually stimulating environments like grocery stores and busy gyms, as well as when looking at screens. The primary purpose of habituation exercise is to reduce symptoms through repeated exposure to specific movements or visual stimuli that provoke dizziness. These exercises are designed to provoke a mild level of symptoms to allow the central nervous system to habituate to the stimuli. The increase in symptoms should only be temporary and should return to baseline after 15-20 minutes. Over time and with excellent compliance to the program, the intensity of dizziness with these exercises should decrease as the brain learns to ignore the abnormal signals it is receiving from the inner ear system.

Gaze Stabilization Exercises

Gaze stabilization exercises are used to improve visual acuity during head movements. These exercises are recommended for patients who report that their visual world appears to wiggle or move when reading or when trying to identify objects in the environment. A very common exercise to promote gaze stability involves fixating on an object while the patient repeatedly moves their head back-and-forth or up-and-down for several minutes.

Balance Training Exercises

Balance training exercises are used to improve steadiness so patients can more successfully participate in activities of daily living, work and leisure or physical activities. After assessing several measures of your balance, your physiotherapist will provide you with exercises that are moderately challenging but safe enough so you do not fall while performing them. Ultimately, these balance exercises should help improve your ability to walk outside on uneven ground or navigate your environment in the dark. A comprehensive balance training program should help improve your ability to sit, stand, walk, turn, bend over, and reach while maintaining your balance. It is our goal to help you get back to as many of your desired activities as possible, including running or sports. 

Your physiotherapist may recommend additional exercises outside of these three categories including neck stretching, dual tasking, cognitive exercises, postural training and/or education on ergonomics.

It is important to understand that no two exercise programs are exactly alike. Your exercise program should be developed by a physiotherapist who has identified your specific needs. If you have tried some exercises you found online and didn’t notice any change, the exercises may not have been appropriate for you specifically!

I think I may have BPPV? Should I try vestibular rehabilitation?

Benign Paroxysmal Positional Vertigo (BPPV) is a common cause of vertigo. It is important that you are appropriately assessed in order to be diagnosed with this condition. Your vestibular physiotherapist is trained to assess your inner ears with positional testing which puts your head in different positions to try and elicit the sensation of vertigo. Repositioning maneuvers are then used to treat the specific type of BPPV that has been identified. For more information on this, click on the link above.  

After BPPV has been successfully treated with repositioning maneuvers, some individuals will continue to report more generalized dizziness or imbalance that persists over time. In these cases, the prescription of habituation exercise and/or balance training may be appropriate.

How long is a typical vestibular rehabilitation program?

We typically see patients 1-2 times per week for an average of 6-8 weeks, but this varies based on the patient’s diagnosis, severity of symptoms, and their response to therapy. The effectiveness of the exercise program depends not only on the exercises chosen by the physiotherapist but also on the patient’s adherence to the program. Some patients may be seen for only 2-3 sessions and others may need consistent treatment for several months.

What type of recovery or outcome can I expect from vestibular rehabilitation?

Expected vestibular rehabilitation outcomes include:

  • Decreased dizziness symptoms 
  • Decreased nausea
  • Improve focus or concentration
  • Improved balance in standing or sitting
  • Decreased risk of falling 
  • Improved ability to stabilize gaze
  • Improved ability to track or focus on objects near and far
  • Improved neck mobility, stiffness and/or pain
  • Increased confidence to return to desired activities and hobbies