Vestibular (Dizziness/Vertigo) Physiotherapy

Support for dizziness, vertigo and balance problems

Dizziness and balance problems can make everyday activities such as walking, driving, shopping, exercising or simply moving around the home more difficult.

Some people experience a spinning sensation, while others feel unsteady, light-headed or as though their surroundings are moving. Symptoms may appear suddenly, occur with certain head movements or continue after a problem affecting the inner-ear balance system.

Vestibular physiotherapy focuses on assessing how your balance system is working and using specific exercises or treatment techniques to help improve stability, movement and confidence.

What is vestibular physiotherapy?

Your balance depends on information coming from several parts of the body, including the inner ear, eyes, muscles and joints. The brain combines this information to help you understand where you are in space and remain stable while moving.

When part of this system is not working normally, you may experience dizziness, vertigo, unsteadiness or difficulty focusing your vision during movement.

Vestibular physiotherapy uses carefully selected exercises and, for some conditions, specific head-positioning techniques to help manage these symptoms.

When vestibular physiotherapy may help

An assessment may be useful if you are experiencing:

• Vertigo or a spinning sensation
• Dizziness triggered by head movement
• Dizziness when rolling over in bed
• Symptoms when getting in or out of bed
• Unsteadiness while walking
• Difficulty walking in busy environments
• Reduced balance or confidence
• Motion sensitivity
• Difficulty focusing while moving your head
• Persistent symptoms after an inner-ear problem
• Balance difficulties following vestibular neuritis
• Ongoing symptoms after labyrinthitis
• Repeated episodes of positional vertigo
• Increased risk or fear of falling
• Difficulty returning to normal activities because of dizziness

Dizziness has many possible causes, so the first step is understanding whether your symptoms appear suitable for vestibular physiotherapy.

Dizziness and vertigo are not always the same

People often use the words dizziness and vertigo to describe similar experiences, but they can feel different.

Vertigo commonly describes a sensation that you or the environment is spinning or moving when you are actually still.

Dizziness is a broader term and may include feelings of unsteadiness, floating, imbalance or light-headedness.

Understanding exactly what you are feeling, how long it lasts and what brings it on can provide useful information during your assessment.

What happens during your first appointment?

Your first appointment begins with a detailed discussion about your symptoms.

The physiotherapist may ask:

• When the dizziness started
• How you would describe the sensation
• How long each episode lasts
• Whether certain head positions trigger symptoms
• Whether rolling over in bed causes dizziness
• Whether you experience nausea
• Whether your hearing has changed
• Whether you experience ringing in the ears
• Whether you have headaches or migraines
• Whether you have fallen or nearly fallen
• What medication you currently take
• Whether you have had previous episodes
• How the symptoms affect work, driving and everyday activity

Depending on your symptoms, the physical assessment may include:

• Eye movements
• Head movements
• Balance in different positions
• Standing balance
• Walking
• Turning and changing direction
• Coordination
• Head-position tests
• Your ability to focus your vision while moving
• Movements that normally bring on your dizziness

The assessment helps determine what type of vestibular problem may be present and whether physiotherapy is an appropriate treatment.

What treatment may include

Vestibular rehabilitation is not one standard set of exercises. Treatment depends on the type of dizziness or balance problem identified during the assessment.

Balance exercises

Exercises may be used to challenge and gradually improve your balance.

These might begin with relatively simple standing activities before progressing to walking, turning, uneven surfaces or more demanding environments.

Eye and head movement exercises

Your eyes and inner-ear balance system work together to keep your vision clear while your head is moving.

Specific exercises may involve focusing on a target while moving your head. The exercises are gradually adjusted according to how well you can complete them.

Habituation exercises

Some people become dizzy during particular movements or in visually busy situations.

Carefully repeated exposure to suitable movements can sometimes help the nervous system become less sensitive to them over time.

The exercises need to be selected carefully rather than repeatedly provoking severe dizziness without a clear purpose.

Walking exercises

Walking while turning the head, changing direction or looking at different objects may be included when these activities affect your balance.

The level of difficulty can gradually increase as stability improves.

Repositioning manoeuvres

If your symptoms are caused by certain forms of positional vertigo, a specific series of head and body movements may be used to reposition particles within the inner ear.

These manoeuvres are different from general vestibular exercises and are selected after appropriate positional testing.

Home exercise programme

Vestibular rehabilitation often involves regular practice between appointments.

Your programme should be specific to your symptoms and ability. Exercises can be reviewed and progressed as your balance and tolerance improve.

BPPV and positional vertigo

Benign paroxysmal positional vertigo, usually shortened to BPPV, is a common cause of brief episodes of vertigo.

Symptoms are often triggered by particular changes in head position, such as:

• Rolling over in bed
• Lying down
• Sitting up from bed
• Looking upwards
• Bending forwards
• Turning the head quickly

BPPV occurs when tiny particles within the inner ear move into an area where they interfere with the normal balance signals sent to the brain.

The assessment may include specific positional tests designed to reproduce the symptoms and observe the response of the eyes.

If BPPV is identified, a repositioning manoeuvre such as the Epley manoeuvre may be appropriate. The exact technique depends on which part of the balance system is affected.

Recovery after vestibular neuritis or labyrinthitis

After an inner-ear condition such as vestibular neuritis or labyrinthitis, the initial severe dizziness may improve but some people continue to experience imbalance, motion sensitivity or difficulty moving their head comfortably.

You may notice symptoms when:

• Walking quickly
• Turning your head
• Moving through busy environments
• Shopping in supermarkets
• Using escalators
• Looking between different objects
• Exercising
• Walking outdoors

Vestibular rehabilitation may help the brain adapt to changes in the balance signals it receives.

Treatment may include eye and head exercises, walking practice, balance work and gradual exposure to movements that have become difficult.

Difficulty focusing during movement

One role of the vestibular system is to help keep your vision stable when your head moves.

If this system is affected, you may feel that your surroundings bounce, blur or become difficult to focus on while walking or turning your head.

Exercises may involve keeping your eyes focused on a target while completing controlled head movements.

The speed and difficulty of these exercises are progressed gradually according to your response.

Balance and walking

Vestibular problems can make walking feel less automatic.

You may feel particularly unsteady:

• In the dark
• On uneven ground
• When turning
• In crowded places
• While moving your head
• When walking quickly
• On stairs
• In unfamiliar environments

Treatment may begin with basic balance exercises before progressing towards situations that are more similar to everyday life.

The aim is to improve both physical balance and confidence when moving around independently.

Dizziness in busy environments

Supermarkets, shopping centres, traffic and other visually busy environments can sometimes increase vestibular symptoms.

You may feel uncomfortable when there is a lot of movement around you or when your eyes need to process large amounts of visual information.

Rehabilitation may gradually introduce visual and movement challenges so that these situations become easier to tolerate.

Progression needs to be gradual, particularly if symptoms are easily triggered.

Motion sensitivity

Some people become dizzy during movements that did not previously cause a problem.

Examples may include:

• Turning quickly
• Looking upwards
• Bending down
• Moving between sitting and standing
• Watching fast-moving objects
• Travelling in a vehicle
• Exercising

Avoiding every movement that causes dizziness can sometimes make returning to normal activity more difficult.

Where appropriate, rehabilitation may involve gradually practising selected movements so that the balance system becomes better able to tolerate them.

Falls and confidence

Dizziness and poor balance can increase concern about falling.

After a fall or a period of significant dizziness, some people begin limiting their activity because they no longer feel confident walking independently.

The assessment may look at:

• Standing balance
• Leg strength
• Walking
• Turning
• Stepping
• Reactions to changes in balance
• Confidence on different surfaces

Treatment may then combine vestibular exercises with general balance and strengthening work where appropriate.

Returning to everyday activities

Vestibular symptoms can affect more than physical balance.

You may begin avoiding:

• Shopping
• Driving
• Exercise
• Social activities
• Public transport
• Busy environments
• Longer walks
• Work-related movement

Rehabilitation can gradually work towards these situations rather than focusing only on exercises completed inside the clinic.

The aim is to help you manage the environments and activities that are relevant to your normal life.

Returning to exercise

Dizziness can make people cautious about exercising, particularly if faster movement or changes in head position trigger symptoms.

Returning to exercise can usually be gradual.

Depending on your symptoms and goals, rehabilitation may progress towards:

• Walking
• Gym exercises
• Cycling
• Running
• Yoga or Pilates
• Recreational sport
• More demanding balance activities

Exercises can be modified initially and progressed as your balance and tolerance improve.

Dizziness and neck movement

Some people with dizziness also experience neck pain or stiffness.

This does not automatically mean that the neck is causing the dizziness. Because dizziness has many possible causes, vestibular symptoms should be assessed carefully before drawing that conclusion.

Where a relevant neck problem is also identified, treatment may include appropriate neck movement or strengthening alongside vestibular rehabilitation.

How quickly does vestibular rehabilitation work?

Recovery varies considerably depending on the cause of the symptoms.

Some positional vertigo problems may respond relatively quickly to an appropriate repositioning manoeuvre.

Other vestibular conditions may require regular exercises over a longer period while the brain and balance system gradually adapt.

Progress may also depend on:

• How long symptoms have been present
• The underlying cause
• General health
• Balance and strength
• How often exercises are completed
• Whether other medical conditions affect mobility
• How sensitive you are to movement

Your programme can be reviewed and adjusted as symptoms change.

A small increase in dizziness during exercises

Some vestibular exercises are designed to challenge the balance system, so a mild and temporary increase in symptoms can sometimes occur.

This does not mean that exercises should cause severe or prolonged dizziness.

Your physiotherapist will explain what level of symptoms is expected and how long they should take to settle.

If exercises consistently make you significantly worse, the programme may need to be adjusted.

When dizziness may need medical assessment

Dizziness is not always caused by the inner-ear balance system.

It can also occur with other medical conditions, medication changes and problems affecting other parts of the body.

Further medical assessment may be needed if the history or examination suggests that vestibular physiotherapy is not appropriate.

Seek urgent medical assessment if sudden dizziness or vertigo occurs alongside symptoms such as:

• New weakness or numbness in the face, arm or leg
• Difficulty speaking or understanding speech
• New double vision or significant visual changes
• A sudden severe headache
• Fainting or loss of consciousness
• New severe difficulty walking
• Sudden major loss of coordination
• New hearing loss
• Significant chest pain
• Severe or rapidly worsening symptoms

New neurological symptoms should not simply be treated as routine vertigo.

Treatment based on your symptoms and goals

Vestibular rehabilitation should reflect what dizziness or imbalance is preventing you from doing.

Your goal may be to:

• Turn over in bed without vertigo
• Walk more confidently
• Return to work
• Move your head without feeling dizzy
• Go shopping comfortably
• Drive again when medically appropriate
• Exercise
• Use stairs confidently
• Walk outdoors
• Reduce your risk of falling
• Manage busy environments more comfortably

Your rehabilitation programme can be developed around these practical goals and progressed as your balance and confidence improve.