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Vertigo and dizziness are common complaints, but they are not always caused by the same problem. A patient may feel that the room is spinning when turning in bed, become unsteady while walking, or experience blurred vision when moving the head. For a physiotherapist, the first challenge is to understand what is causing the symptoms before choosing an exercise or treatment technique.
Vestibular rehabilitation therapy physiotherapy is a specialised approach that uses clinical assessment, therapeutic exercises and, when appropriate, canalith repositioning techniques to manage selected vestibular disorders.
This practical guide explains the common causes of vertigo, how physiotherapists assess vestibular disorders, where the Epley manoeuvre fits into treatment, how gaze stabilisation is used, and when a patient should be referred to an ENT or other medical professional.
Quick Answer: Vestibular rehabilitation therapy (VRT) is an exercise-based physiotherapy approach used to improve dizziness, gaze stability, balance, mobility and functional performance in people with appropriate vestibular disorders.
VRT is not one fixed exercise programme. Treatment depends on the patient’s diagnosis, symptoms, functional limitations and clinical findings.
A vestibular rehabilitation programme may include:
● Gaze stabilisation exercises
● Balance and postural training
● Habituation exercises
● Walking with head movements
● Functional mobility training
● Canalith repositioning for appropriate BPPV
Clinical practice guidelines report strong evidence supporting vestibular rehabilitation for adults with unilateral and bilateral peripheral vestibular hypofunction.
Understanding the common causes helps the physiotherapist decide what to assess and whether physiotherapy is appropriate.
BPPV is one of the most common causes of positional vertigo. It occurs when displaced otoconia enter one of the semicircular canals and cause abnormal stimulation during head movement.
Patients commonly report short episodes of spinning when:
The important clinical point is that BPPV should be confirmed through appropriate positional assessment rather than assuming that every dizzy patient needs general vestibular exercises.
Vestibular neuritis can cause sudden and prolonged vertigo, nausea and significant imbalance. The patient may have difficulty standing or walking, particularly during the early stage.
However, sudden continuous dizziness can have several causes, including central neurological conditions. Therefore, appropriate screening and clinical reasoning are essential before treating the presentation as a peripheral vestibular disorder.
Ménière’s disease is associated with recurrent episodes of vertigo along with symptoms such as fluctuating hearing loss, tinnitus and ear fullness.
This presentation is different from typical BPPV and may require medical and ENT assessment. Physiotherapy may become part of rehabilitation when vestibular dysfunction, imbalance or functional limitations remain.
Quick Answer: Vestibular assessment should begin with a detailed history, followed by appropriate positional, ocular, balance and functional testing based on the patient’s presentation.
Ask about:
The timing and triggers of dizziness can provide important clues. Brief, position-triggered episodes suggest a different clinical pathway from continuous dizziness lasting hours or days.
The Dix-Hallpike test is commonly used when posterior-canal BPPV is suspected.
The patient is positioned with the head turned approximately 45 degrees and then moved into a supine position while the clinician observes for positional vertigo and characteristic nystagmus.
If the clinical history suggests BPPV but the Dix-Hallpike test does not identify posterior-canal involvement, assessment for horizontal-canal BPPV using the supine roll test may be appropriate.
The key principle is simple:
Assess the canal involved before selecting the repositioning manoeuvre.
Quick Answer: The Epley manoeuvre is a canalith repositioning procedure commonly used for appropriate posterior-canal BPPV. It is different from a general vestibular exercise programme.
A typical right-sided Epley sequence involves:
Step 1 – Starting position:
Seat the patient upright and turn the head approximately 45 degrees towards the affected side.
Step 2 – Move to supine:
Bring the patient into a supine position while maintaining the head position and using appropriate neck extension.
Step 3 – Turn the head:
Rotate the head towards the opposite side while maintaining the patient’s position.
Step 4 – Roll the patient:
Turn the patient onto the opposite side so the face moves towards the floor.
Step 5 – Return to sitting:
Bring the patient slowly back to the seated position.
The technique should be adapted according to the affected canal, clinical findings and patient limitations. Cervical restrictions and other relevant precautions should be considered before manoeuvring.
For confirmed posterior-canal BPPV, clinical guidelines recommend canalith repositioning as an appropriate treatment approach.
Gaze stabilisation becomes particularly important when a patient has vestibular hypofunction and difficulty keeping vision clear during head movement.
A basic gaze stabilisation exercise involves focusing on a stationary target while moving the head horizontally or vertically. As the patient improves, the physiotherapist can progress the exercise by changing speed, body position, visual background and functional demands.
The programme should be individualised. Current clinical practice guidance supports gaze stabilisation and balance exercises for appropriate peripheral vestibular hypofunction and recommends supervised rehabilitation with a suitable home programme.
The goal is not simply to give the patient more exercises. The physiotherapist should identify the specific limitation and progressively challenge the patient’s vestibular, visual and balance systems.
A trained physiotherapist may manage a patient independently when the presentation is consistent with a peripheral vestibular disorder, the diagnosis is sufficiently clear, and the treatment is within the clinician’s professional competence.
Examples may include:
However, referral should be considered when the presentation is unusual, or the diagnosis is uncertain.
Referral or multidisciplinary management is appropriate when:
A physiotherapist should not try to force every dizziness presentation into a BPPV diagnosis. Recognising when a patient needs further investigation is an important part of vestibular clinical reasoning.
The biggest mistake in vestibular physiotherapy is treating dizziness as a generic balance problem.
Common errors include:
Good vestibular rehabilitation is diagnosis-based and patient-specific.
Vestibular rehabilitation requires more than learning one repositioning manoeuvre. A clinician should understand vestibular anatomy, nystagmus, positional testing, BPPV, gaze stabilisation, habituation, balance assessment and clinical decision-making.
A structured vestibular rehabilitation course can help physiotherapists build these skills through theoretical learning, case-based clinical reasoning and practical training.
Training programmes available in India include certificate pathways covering vestibular assessment, BPPV, canalith repositioning, VRT protocols and patient-centred rehabilitation. For example, AIB India currently offers International Vestibular Rehabilitation Certificate programmes for eligible healthcare professionals, including physiotherapists.
Advanced training can also cover diagnosis-based VRT strategies, adaptation, habituation, substitution, outcome measures and complex vestibular cases.
For a physiotherapist choosing a course, the priority should be practical clinical competence—not simply obtaining another certificate.
Vestibular rehabilitation therapy physiotherapy is a specialised approach using assessment, therapeutic exercises and appropriate repositioning techniques to manage selected vestibular disorders, dizziness, imbalance and related functional limitations.
Yes. Physiotherapy can play an important role in managing conditions such as BPPV and peripheral vestibular hypofunction when the patient is appropriately assessed and the treatment matches the underlying disorder.
The Dix-Hallpike test is primarily used to assess suspected posterior-canal BPPV by observing positional vertigo and characteristic nystagmus.
No. Epley is a specific canalith repositioning manoeuvre mainly used for appropriate posterior-canal BPPV. Vestibular rehabilitation is a broader treatment approach that may include gaze stabilisation, balance, habituation and functional exercises.
There is no single treatment duration for every patient. Recovery depends on the underlying vestibular disorder, symptom severity, functional limitations, comorbidities and response to treatment. Clinical guidelines recommend progressing and discontinuing rehabilitation according to individual goals, symptoms and functional recovery rather than following one fixed timeline.
Yes. Physiotherapists can develop vestibular expertise through specialised education, clinical experience and vestibular rehabilitation CPD or certification programmes. Training should include assessment, BPPV management, vestibular exercises, clinical reasoning and referral decisions.
Vestibular rehabilitation is not simply about giving a patient balance exercises. The most important step is identifying the reason for the dizziness and matching treatment to the clinical presentation.
For BPPV, appropriate positional assessment and canalith repositioning are central. For vestibular hypofunction, progressive gaze stabilisation, balance and functional exercises can help improve stability and daily function. When symptoms are atypical or red flags are present, referral to ENT, neurology or another appropriate specialist is part of safe clinical practice.
For physiotherapists, developing vestibular skills can open an important area of clinical practice. Learning how to assess dizziness, recognise BPPV, perform appropriate repositioning techniques and design evidence-based vestibular rehabilitation programmes can make treatment more precise and patient-centred.
If you want to develop practical skills in vestibular assessment, BPPV management and vestibular rehabilitation, explore our Vestibular Rehabilitation / CPD Course and build the clinical confidence needed to manage dizziness and balance disorders more effectively.