This information is intended as a general introduction to this topic. As each person is affected differently by balance and dizziness problems, speak with your health care professional for individual advice.
Most people will benefit from some type of exercise therapy for imbalance and dizziness. Vestibular rehabilitation will not, however, help those with spells of acute, active, recurrent, spontaneous vertigo (spinning sensation) – for example, acute vestibular migraine or early stages of Ménière’s disease – because the brain cannot adjust to the changing nature of these disorders.
What is vestibular rehabilitation therapy?
Vestibular rehabilitation will help strengthen the bond between the body, eyes, brain and inner ear for most patients. During vestibular rehabilitation your symptoms are intentionally provoked in a safe and controlled manner to work towards getting your brain used to what makes you uncomfortable. Its overall goal is to increase quality of life by adapting you to your disorder, decreasing your symptoms and improving your overall function. Research suggests that rehabilitation programs are most effective when they are customized. The type, frequency, and intensity of effective exercises varies from person to person.
What practitioners do vestibular rehabilitation therapy?
Vestibular therapy is not a regulated title in Canada and vestibular rehabilitation is typically a special interest area. Training differs widely between therapists, from weekend introductory courses to more intensive competency-based courses with examinations. You may want to ask if the therapist has experience with your type of vestibular disorder.
You do not need a referral to see a physiotherapist, occupational therapist, or audiologist in private practice in Canada. For many Canadians, health insurance providers cover all cost or a portion of the cost. Some extended health insurance plans may require a doctor’s referral to reimburse you for service. Contact your health insurance provider to confirm your level of coverage and whether or not you need a referral for reimbursement.
The first visit includes a full assessment that allows the therapist to set up a suitable rehabilitation program. More extensively trained vestibular therapists will use special goggles to do a more thorough assessment.
Search our Practioners List to find professional members of our Society with advanced training in vestibular rehabilitation.
Will vestibular rehabilitation therapy make me dizzy?
The exercises should cause a mild to moderate increase in dizziness for only a few seconds. This slight increase in symptoms in the short term is what helps the brain make permanent changes to decrease dizziness in the long term. Little by little, your brain will be given a chance to overcome the dizziness.
You must be careful not to overdo it. It is not helpful to push through your symptoms. Tell your therapist if you become nauseated or develop a headache during the exercises, or if your symptoms do not decrease to their earlier level within 15-20 minutes. Your therapist will change the exercises to be sure you can tolerate them better. If you do an exercise and you feel no increase in dizziness, the therapist might be able to make it a little harder or you may not need to do that exercise anymore.
How long do I need to continue with vestibular rehabilitation therapy?
Vestibular rehabilitation and balance retraining exercises do not usually need to be continued indefinitely. Patients are advised to set goals for their rehabilitation program with their vestibular therapist. Once these goals are achieved a maintenance plan can be put in place. This should include finding a level of physical activity that is suitable for you and continues to stimulate and challenge the vestibular system enough to maintain a healthy balance. Keep the exercises in mind, however, should the symptoms come back.
If you are not seeing improvement despite ongoing vestibular rehabilitation therapy and balance exercises, you may have reached some limitations in terms of function. Diagnostic testing can help work out if this is the case.
Examples of vestibular rehabilitation exercises
Vestibular rehabilitation is tailored to your particular disorder and symptoms. Some exercises are specific, such as reducing symptoms to specific movements or visual stimuli. Other exercises may be related to improving your participation in self-care, household responsibilities, leisure activities, sports, driving, or work.
A vestibular rehabilitation program may include:
- Adaptation exercises
Help coordinate the vestibular ocular reflex (VOR). A properly functioning VOR allows you to keep visual targets in focus even when your head is moving. There are several types of adaptation exercises.
- Gaze stabilization exercises
Involve moving your head while keeping your eyes focused on a target. For the exercises to work, you must move your head as quickly as you can while looking at the target. It is normal to get a little dizzy or miss the target every now and then.
- Target shooting exercises
Work on keeping your head still while moving the eyes, or vice versa.
- Habituation exercises
Designed to reset the sensitivity of the nervous system. They help your brain get used to and ignore movements or situations that make you feel dizzy. This is done through repeated, controlled exposure to signals such as complex patterns and busy environments. You may do exercises indoors and outdoors. You may go on short trips to places that trigger symptoms, such as grocery stores or shopping malls.
- Balance retraining exercises
Done by standing on different surfaces and with increasingly narrow bases of support. They are helpful for improving steadiness to perform activities of daily living as well as to lower the risk of falling.
- Balance exercises with eyes closed.
Help reduce dependence on your eyes for balance by encouraging use of the vestibular system.
- Strengthening exercises
Improve muscle support of your body.
- Gait training
For example treadmill training and relearning to walk over unstable surfaces.
- Range of motion exercises
Help if you have been limiting movement of your head of body to minimize dizziness.
- Learning and practicing strategies
These help deal with or prevent your symptoms.
- Breathing and relaxation exercises
Help regulate the autonomic nervous system (the part of the nervous system that regulates key involuntary functions).
- Walking and other aerobic activities.
I’m unable to access a therapist – what can I do at home?
Vestibular rehabilitation and balance retraining is most effective when you follow a set of exercises tailored by a therapist to your specific needs. Some vestibular therapists offer video appointments. If you are unable to access a therapist, however, there are a number of exercises that can be done at home:
- Cawthorne-Cooksey habituation exercises
A graduated set of exercises that help relax the neck and shoulder muscles, train the eyes to move independently of the head, practice good balance in everyday situations, practice the head movements that cause dizziness , improve general co-ordination, and encourage natural unprompted movement.
- Gaining Balance video
Follow the graduated vestibular rehabilitation exercises presented on Balance & Dizziness Canada’s 35-minute video.
- Balance Retraining
An internet-based intervention developed by the University of Southampton. The exercises are similar to Cawthorne-Cooksey.
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Click on Vestibular Rehabilitation to see FAQ.
“I’ve started to feel more unbalanced lately, even having a fall. I don’t have any dizziness I’m over 90 years of age. I do the Epley manoeuvre daily, but it doesn’t help. What might be my problem?”
There are many reasons for increasing imbalance without dizziness as we age. Often, there are overlapping reasons. As a starting point, we suggest reading our Age-Related Dizziness and Imbalance page as well as visiting a general practitioner or geriatrician for a thorough physical checkup as well as a referral for testing of your vestibular system.
In addition, a physiotherapist will be able to assess your gait and muscle strength. It is likely that you can make progress towards greater stability be getting and practicing a set of exercises tailored for your needs by a physiotherapist.
The last thing you want is a serious fall. Ask about falls prevention workshops or classes in your area. A family doctor or physiotherapist should be able to help you with tracking down something suitable in your area.
In the meantime, be particularly mindful of your risk of falling, particularly on uneven ground, on stairs, and in the dark. Wear supportive shoes even inside. Our Falls Prevention page has many more tips. A physiotherapist will be able to give you more advice specific to your needs.
The Epley manoeuvre is helpful only for people with one specific condition, BPPV. The hallmark symptom of this condition is brief, spinning dizziness (vertigo) that lasts less than a minute. As you report not being dizzy, it is unlikely you have BPPV. While there is no harm in doing the Epley, it won’t help unless you have BPPV. As a retired engineer, you may find it interesting to read about the physics of displaced crystals in the inner ear on our BPPV page. It is an interesting topic.
With neck pain, a vestibular therapist tries to narrow down if there is an underlying association between the pain and the dizziness. The therapist often does an assessment of the neck, looking at joint stiffness, stability, and so on. They will put together a lot of different information to try and come to an understanding of the cause. The therapist should be able to identify whether it is a cervicogenic type of dizziness (related to neck movement – think turning your head) or something wrong with the vestibular system (related to head movement – think “lying down in bed”).
The half-somersault manoeuvre is meant to be self-taught and performed, but, depending on how dizzy, fit and healthy you are, it may be difficult to do. It is an alternative to the Epley manoeuvre, which can also be self-administered. You can read more about the half-somersault maoneuvre here.
Alternatively, you can see a vestibular physiotherapist who can help you with the manoeuvres, both teaching you how to do them and performing them for you. You can find a Vestibular Physiotherapist in your area here. Choose “Find a Physio” or “Find a Clinic” and select the “Advanced Search” option. Enter your criteria, including your city.
I couldn’t help but notice that you mentioned in your email that you suffer from Ménière’s Disease. Note that these manoeuvres are aimed at positional vertigo, which may occur in Ménière’s disease. Positional vertigo presents as short-lived episodes of spinning dizziness that occur only when you move your head in certain ways. On the other hand, Ménière’s Disease presents with intense spinning (dizziness) episodes, that come on suddenly, often for no apparent reason. These are often accompanied by vomiting and last for hours. The manoeuvres for positional vertigo are not recommended when these longer and more severe episodes occur.
Yes, some types of vestibular disorders are less responsive to vestibular rehabilitation than others.
The principle of vestibular rehabilitation is to decrease symptoms by training the brain to optimize the use of the inner-ear input and to integrate that input effectively with the visual and proprioceptive information. Sudden changes in inner ear function can produce severe symptoms of vertigo and vomiting but once the inner ear function stabilizes, the brain can be trained to readjust to it.
However, if the nature of the vestibular disorder is to fluctuate or to deteriorate progressively, it can be extremely challenging for the brain to adjust to these repetitive changes. Individuals suffering from Ménière’s disease, for example, are not good candidates for vestibular rehabilitation when they are going through active stages of the disorder in which spells are happening often. Patients with recurrent types of vestibular disorders often benefit more from medical management of the attacks than from vestibular rehabilitation.
One vestibular disorder that does not classically fluctuate but also does not respond well to vestibular rehabilitation is semicircular canal dehiscence (SCD). In cases not treated surgically, avoidance of triggers remains the best management strategy; for example, patients should avoid exposure to loud sounds that can trigger dizziness or imbalance.
Even if vestibular rehabilitation exercises don’t help you, vestibular therapists may be able to educate you on ways to manage your condition or symptoms. Examples include learning how to pace activity, using mobility aids such as a walker or cane, or even just moving more slowly and not doing quick movements that might make you feel dizzy or off balance. A therapist may also work with your on improving your strength and balance to either avoid losing your balance or, if possible, better controlling the force of a fall to minimize injury.
Vestibular therapy can help with the ongoing motion sensitivity of PPPD. Therapy is used to try and dampen down a person’s sensitivity to movement and their sensitivity to visual stimuli, with the goal of trying to get them used to movement. If someone has been living in fear of movement and is quite anxious, vestibular therapy tries to bring down some of those underlying factors. By gradually practicing movements and activities over time, people with PPPD get more comfortable with day-to-day movement.
If vestibular rehabilitation can help you with a balance problem related to medication, it will depend on how the medication has affected your vestibular system, and if you have the ability to activate that part of the vestibular system. For example, there are certain antibiotics, such as gentamicin, that are highly toxic to the vestibular system. People who have taken these antibiotics may have difficulty training their vestibular system because the input from their inner ears may have been affected. If you have imbalance related to less toxic medication, balance training can often help to improve your functioning. If, however, medication has affected your vestibular system, the visual system and peripheral system (dysfunction of the balance organs of the inner ear), the treatment effect might be limited.
In general, there is nothing in particular that links vestibular exercises to making the crystals dislodge from where they belong, and thereby causing BPPV. Vestibular therapists have people doing a lot of different activities – in general, these are exercises done in an upright position, whereas BPPV is typically brought on by laying the head back. Vestibular exercises done for vestibulo-ocular reflex (VOR) or for balance do not tend to provoke BPPV. If BPPV is going to happen, it is going to happen – there is really no rhyme nor reason why the crystals tend to slide into a semicircular canal. And if they do, it is fairly easy for a vestibular therapist to correct.
You might feel a bit off balance, dizzy and/or nauseous for a day or two after an Epley manoeuvre, but these symptoms should settle down over time. For the most part, people tolerate the Epley manoeuvre quite well. If the therapist does repeated Epley or other manoeuvres – one, after the other, after the other – and your situation does not improve, it may be that something other than BPPV is causing your dizziness. In that case, following up with your vestibular professional and getting reassessed may help narrow down the cause.
If there are signs of vestibular dysfunction, vestibular rehabilitation may help because the migraine has affected the functioning of the vestibular system. However, if there is more permanent damage or it is a chronic long-term condition that happens over years and years, vestibular rehabilitation might get people used to (habituated) to some of the symptoms. Vestibular therapists can also educate people on how to avoid possible triggers that could worsen their migraines. For example, avoiding processed foods, stress or certain modifiable factors.
Motion sickness and an overall reduced tolerance to movement is often reported in patients who suffer from migraine. The recommendation is to treat the migraine first. When migrainous episodes are under control, patients benefit greatly from vestibular rehabilitation aimed at increasing motion tolerance. Identifying and avoiding triggers is one way to keep migraines under control as well reduce the number of episodes. Triggers include stress, foods (e.g., cheese), alcohol (e.g., red wine), smells. Preventative medications can also be used to avoid migraine episodes from happening.
I have been diagnosed with BPPV. My community has no support group for dizziness. I don’t know where to turn. Can you give me a plan of action?
You have expressed the feelings of many people affected by dizziness! It is not always easy to find support in your community; you end up seeing quite a few professionals and they are not always on the same page as to your diagnosis and treatment plan. You may be left with uncertainty about what you can expect in the future. Without getting into too much detail about your diagnosis and treatment (you can read more about BPPV here) you are encouraged to do the following:
1) Get informed (learning more about BPPV is a start) and then clarify with your healthcare professionals what their treatment plan is. Ask as many questions as you need. Read some more if you need to. Here is a list of recommended books.
2) Once you feel you have a direction to follow for treatment, stick with it for a set amount of time. Six weeks is a reasonable time frame. During this time, try your very best to stick with the treatment plan and to stay positive.
3) Use the online resources of our Society and your local sources of support. Since you mentioned that there are no specific dizziness support groups, how about you try your community for balance exercises, for example? You can also look for tai chi classes and classes designed for falls prevention. You will most likely find others dealing with similar issues.
4) At the end of your “trial” with this plan, reassess your symptoms and your goals. You may find that you were on the right track, or you may need to start on number one all over again and try a different treatment plan.
Keep in mind that, even if you need to go back and follow a different course of action, that is okay. It will not be forever. Give yourself again about six weeks time and reassess. Stay in the present moment as much as you can, focusing on what you can effectively do right then and there.
If your problem is “central positional nystagmus,” the treatment approach is through habituation. Instead of having Epley or other manoeuvres performed, you can try Brandt-Daroff or other vestibular rehabilitation exercises. These habituation exercises retrain the brain and are beneficial for most patients. They are helpful for both peripheral and central types of dizziness.
If you are motion sensitive, you can start by doing tiny doses of movements that make you feel nauseated. For example, move your head back and forth for just 30 seconds. Then push yourself for one or two seconds longer and give your brain a chance to overcome the feeling of nausea. Gradually, your brain will get habituated to more motion.
If done properly and routinely, those with motion sensitivity, BPPV or central positional nystagmus should start to feel some benefit from habituation exercises in three to four weeks and feel a lot better in about five to six weeks. If you are unsure how to do these exercises, have back or neck problems, or can’t do them quickly enough on your own, have a physiotherapist, audiologist or ENT (otolaryngologist) do them.
The balance system is complex and involves the brain analyzing and interpreting information from three major systems: the inner ear sensors for balance (vestibular system), the visual system, and the sensation that goes from the skin, muscles and joints (proprioceptive system).
Any sensation of dizziness and imbalance may result when one or more of these four parts are not functioning well. Therefore, the perceived asymmetries you experience may stem from the vestibular organs, from the proprioceptive system and/or from the brain’s processing of the their information. You did not mention visual issues, but treating these symptoms often involve also addressing the processing of visual information, with and without head movements.
You may wish to pursue assessments to clarify whether you do have asymmetries in your balance system, namely a vestibular assessment (for the inner ear sensors and their connections with eyes and brain) and a physiotherapy assessment, for the proprioceptive and musculo-skeletal systems. Proper treatment/rehabilitation can then be tailored to your needs.
You might have an underlying condition that behaves like BPPV. A second possibility is recurrent BPPV; it can be fixed by a manoeuvre but then comes back. It is also possible that the source of your problem is not in the inner ear, but higher up in your brain. If the sensors in your brain that interpret the information sent by the ear are not working properly, these manoeuvres will be of no use.
It is very common to have dizziness triggered by watching things move, as opposed to moving oneself. Many people feel dizzy in busy visual environments, such as browsing in a crowded grocery store, at busy intersections, or even seeing someone carrying a boldly striped bag. This problem is caused by your brain not being able to match up the information coming from your eyes, your inner ear and the proprioception sensors on your joints. When you watch a 3-D movie, your eyes follow things around as if you were actually moving. If your brain is hard-wired to believe your eyes more than your inner ear or body, the message from your eyes will dominate and you’ll feel dizzy.
A treatment for visually-stimulated vertigo consists of watching things in motion. Repeatedly watching full-screen versions of the NED Leader (right and left) video clips on YouTube is recommended. When you get the feeling that you want to look away, watch for three to five seconds longer. Becoming accustomed to doing the tai chi “cloud hands” movement follows the same principle; it habituates your brain to the movement of your hands. Read more about motion and cyber sickness.
Below are some optokinetic videos.
Once you are used to these, try this one:
The following playlists compile complex exercises:
Vestibular rehabilitation usually does not help in the early stages of Ménière’s disease. Patients will have attacks that can neither be predicted nor be kept under control with exercises. Vestibular rehabilitation does not work well when a patient’s condition fluctuates – that is, good hearing and balance between attacks and poor during attacks.
With continued attacks, patients lose much of their hearing and balance. Once the balance function is greatly diminished and does not change a lot when in or between attacks, the patient is a candidate for vestibular rehabilitation. If a patient has lost balance function on one side, the brain can be trained to compensate for the loss; however, it takes practice.
Page updated May, 2021.