“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.

Many physiotherapists do offer virtual vestibular rehabilitation appointments. However, the initial assessment is often challenging to complete. If possible, it is better to do it in person. Virtual follow-up can work quite well as people are guided through different stages of exercise. The therapists will also, over time, have a better sense of what exactly is wrong with you.

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.

No, that is usually not the case. Patients are advised to set goals for their rehabilitation program with their vestibular therapists https://cz-lekarna.com/genericky-revia/. 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 to the individual and that continues to stimulate and challenge the vestibular system enough to maintain a healthy balance.

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.

There are some environmental aids that can help, for example wrist guards or hip protectors can provide some degree of protection. There are also some simple things you can do to help avoid falls in the first place. Examples include reducing clutter around the house, clearing paths for walking, using mobility aids, and installing grab bars and good lighting. Your 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.

Often vestibular therapists will retest someone’s balance or vestibular functioning with a number of objective clinical tests. Patients with BPPV may be reassessed with a Dix Hallpike or Head Roll test to determine if their BPPV has been corrected. In addition, a number of outcome measures or questionnaires may be used to get an idea of how the person is progressing over time. Vestibular therapists will also look for improvement in function with the type of treatment being done (for example, improvement in walking speed and tolerance, improved participation in daily activities, and so on).

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.

In general, it is beneficial to get a vestibular assessment to narrow down where you might be having difficulty. Is it BPPV? Is it a peripheral issue? Is it a central issue? Is it a musculoskeletal issue? That being said, there are some online resources that do kind of guide people through vestibular rehabilitation, particularly with a peripheral issue (dysfunction of the balance organs of the inner ear). The University of Southampton has a free-of-charge 6-week online Balance Retraining program to guide you through exercises on a week-by-week basis. Balance & Dizziness Canada has a Gaining Balance video featuring 35 minutes of vestibular rehabilitation exercises. It can be downloaded as an MP4 file for $10.

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.

Vision is an essential part of the balance system. If you are noticing that your vision is changing and you are finding it hard to read it seems reasonable to visit your optometrist and have your eyes checked.

In addition to that, given your history of concussion, it would probably be a good idea to see a neuro-ophthalmologist or a neuro-optometrist to assess how your eyes are working together and how you are processing visual information as these are also contributing factors to human balance. You can learn more about how these professionals can help here: https://www.balanceanddizziness.org/pdf/Health-Professionals.pdf

Also, please make sure you keep your vestibular therapist informed of your vision changes, as well as any falls you may experience. Your rehabilitation programme should continue to address these issues.

This is a bit difficult to answer. Each case is different, but usually with a central vestibular condition like that caused by a concussion, a vestibular therapist may work with the patient over a course of 3 to 6 months. The therapist will determine if improvements are seen in the person’s balance or dizziness scores over time, or if the person is noticing some subjective improvements in their daily tolerance to different activities.

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.

Yes! Although you do not want to overdo it, you must make yourself dizzy in order to get better. Little by little, you will give your brain a chance to overcome the dizziness.

Though generalized sets of movements, such as the Cawthorne-Cooksey exercises, are helpful, they do not work as well as custom-tailored exercises. Based on your written vestibular test results, a vestibular therapist should be able to give you a personalized set of exercises to best address your particular symptoms.

When should you start vestibular rehabilitation? Usually, the sooner the better is helpful. However, it is not good to start when you are in an acute phase when you are getting a few days of really intense, non-stop vertigo. Once you get through the acute phase where, for example, the peripheral vestibular injury starts to recover and you are getting back a bit more vestibular function, that is a good time to start. The more long-standing or chronic your dizziness is, the less impact vestibular rehabilitation may have on your overall recovery.

Regarding vestibular rehabilitation, the length of time since the injury can often be a barrier or a factor slowing down recovery. If it is a long-standing issue, it might not be as amenable to change. Increased age is also a factor, as is underlying fitness and any comorbidities such as diabetes, cardiac or neurological issues, history of migraines, or underlying depression or anxiety. Having had a previous vestibular problem can be an underlying risk factor for recovery.

Some of the vestibular rehabilitation activities done under supervision are taught to clients to practice at home in a safe and controlled manner. These activities include:

• motion-sensitivity exercises such as rolling in bed, sitting to standing, and walking while turning the head
• many different balance exercises
• visual or gaze exercises
• “target shooting”, that is keeping the head still while moving the eyes, or moving the head and keeping the eyes still
• the Epley maneuver to re-position ear crystals

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 suggested. 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.

Below are some optokinetic exercise videos.

This is a basic one:

• http://dizziness-and-balance.com/treatment/rehab/mdd/okn.php?arg1=50 (use the arrow keys to start the movement and control the speed)

These two are harder:

• https://www.youtube.com/watch?v=iwm4acc3wRc&t=13s
• https://www.youtube.com/watch?v=-7DqDnBNmfY

Once you are used to these, try this one:

• https://www.youtube.com/watch?v=YWaGzTFRlWg

The following playlists compile complex exercises:

• https://www.youtube.com/channel/UCwDX4UUxFH7BZhs2gFYw6oA/playlists

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. 

Some physiotherapists, occupational therapists and audiologists have completed post-graduate training in vestibular rehabilitation therapy. Start by searching the Practitioners List on our website. As well, some provincial professional organizations and associations have some listings as well. Just be mindful to educate yourself on the level of training for those listed – those who have taken competency-based courses are the most highly qualified.

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.

In a nutshell, vestibular rehabilitation gets our brains used to what makes us uncomfortable. The overall goal of vestibular rehabilitation is to increase quality of life by acclimatizing the body to the disorder. Vestibular rehabilitation is:

• symptom-based
• matched to the individual’s particular needs
• appropriate for people with a vestibular disorder or a secondary complication

During vestibular rehabilitation, the vestibular symptoms are intentionally provoked in a safe and controlled manner to desensitize the brain. Clients are taught how to move their heads, for example, so their brains gradually become habituated to the movement and recognize that it isn’t a scary thing to be avoided.

The initial visit to a vestibular physiotherapist includes a full assessment that allows the physiotherapist to set up a rehabilitation program that allows the client to progress safely through sets of exercises.

Physiotherapists take a big picture approach, promoting overall health and exercise to prevent secondary complications as well as increased activity levels to guide clients towards full recovery. They emphasize the importance of stress and sleep management: anxiety and fatigue result in exaggerated symptoms. Keeping a log and rating your symptoms on a one (best) and ten (worst) scale is recommended. If your dizziness it ten out of ten on a really bad day, look back and see what happened – how was your sleep, did something stressful happen?

The outcome for vestibular rehabilitation varies, depending on the patient and the condition. In general, BPPV patients do really well. A full resolution of their vertigo can be expected in 1 to 2 sessions.

People with a single-sided vestibular peripheral injury (dysfunction of the balance organs of one inner ear) often see improvement over the course of 4 to 6 weeks. If it is a bilateral (both ears) issue, it could be up to 2 or 3 months. For central issues, such as a chronic, concussion-related condition, it could take a number of months to treat.

If you feel more anxious when on these surfaces, here are some suggestions you could explore.

You may try to first just stand on the edge of that surface. While standing there, just notice your body. “Scan” it with your attention, all the way from the soles of your feet to your head. Notice any areas of tension and soften them if you can. Notice whether your heart is beating fast, your breathing is shallow or you are sweating. If that is happening, take some deep breaths, with a longer out-breath, like a sigh of relief. Intentionally relax and slow down. Take as much time as you need to feel calm, relaxed and safe just standing there.

Then you may also want to work on some sort of habituation to these surfaces. I’d try starting with some walking poles and see if you feel more stable and less like falling when on these types of surfaces. You’d want to try perhaps just a few steps at a time, for just as long as you feel safe. You would want to repeat this several times a week for some practice and exposure. If the process works, you should start to feel that you don’t tense up as much and feel more relaxed. Then you could try using only one pole and repeat until you feel stable. You could then try using no poles and see how you are.

These are the poles we normally recommend, but you may be able to find a cheaper alternative:

https://www.amazon.ca/URBAN-POLING-ACTIVATOR-Balance-Stability/dp/B08M6H7X37/ref=sr_1_4_sspa?keywords=Walking+Poles&qid=1671412097&sr=8-4-spons&psc=1&spLa=ZW5jcnlwdGVkUXVhbGlmaWVyPUExWFE2TlVRQkZKVlBPJmVuY3J5cHRlZElkPUEwMTYyMjQ4MU81TU1JWDgzMUhTMyZlbmNyeXB0ZWRBZElkPUEwMDk2NDU3MlhYUllDR0UxUExFWCZ3aWRnZXROYW1lPXNwX2F0ZiZhY3Rpb249Y2xpY2tSZWRpcmVjdCZkb05vdExvZ0NsaWNrPXRydWU=

Vestibular rehabilitation is not appropriate during the acute stage of a vestibular disorder. The best time to start is after the acute stage has passed or, for recurrent conditions such as Ménière’s disease, between bouts https://mannligapotek.com/generisk-cialis/. Although it is not necessary to have a doctor’s referral to start vestibular rehabilitation, it is a good idea to see your doctor about dizziness problems and be cleared from any medical “red flags.” It is also important to get other medical tests done to rule out other reasons why you are feeling dizzy or light-headed. In addition to the vestibular system, problems with major body systems can cause dizziness.

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.

• https://www.youtube.com/watch?v=iwm4acc3wRc&t=13s
• https://www.youtube.com/watch?v=-7DqDnBNmfY

Once you are used to these, try this one:

• https://www.youtube.com/watch?v=YWaGzTFRlWg

The following playlists compile complex exercises:

• https://www.youtube.com/channel/UCwDX4UUxFH7BZhs2gFYw6oA/playlists

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.