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.
- 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
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)
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:
- 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?
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:
Page updated May, 2021.