Vestibular Rehabilitation Therapy

February 26, 2023

The vestibular system, located in the inner ear, is responsible for controlling balance and stability, and it provides important input to the brain about head movement, spatial orientation and about the surroundings. When this system is damaged or not functioning properly, it can lead to symptoms such as dizziness, vertigo, unsteadiness, and difficulty with balance and coordination.

Vestibular rehabilitation therapy (VRT) is a form of physical therapy designed specifically to address balance issues. The goal of VRT is to retrain the brain to effectively process and interpret signals from the vestibular system, leading to improved balance, stability, and reduced dizziness and vertigo.

VRT typically involves a customized program of exercises and activities that target specific impairments and goals. These exercises may include gaze stabilization exercises, habituation exercises, balance training, and activities of daily living training. The therapy also involves canalith repositioning procedure and other techniques to treat specific vestibular conditions.

In addition to exercises, VRT may also incorporate other therapeutic interventions, such as balance aids, visual biofeedback, and psychological counseling (Cognitive behavioral therapy) to help manage anxiety and depression associated with vestibular disorders.

VRT is a highly effective form of therapy for many individuals with vestibular problems and has been shown to significantly improve symptoms and quality of life. However, it is important to work with a qualified and experienced vestibular rehabilitation therapist to ensure the best outcomes and to safely progress through the therapy program.

Concept of VRT

The vestibular recovery process involves two mechanisms:

  1. Vestibular Adaptation
  2. Vestibular Substitution.

The vestibular adaptation describes adjusts the vestibulo-ocular and vestibulospinal reflexes, while vestibular substitution involves using alternative strategies to compensate for the loss of vestibular function.

Vestibular compensation is frequently used interchangeably with vestibular substitution., but sometimes refers to the overall recovery from unilateral vestibular hypofunction. Similarly, the terms “well compensated, poorly compensated, decompensation” are also used to denote the severity of the compensation.  If a patient experiences persistent or recurring disequilibrium or vertigo, they are likely uncompensated, even if no specific abnormalities are apparent during testing.

Based on this principle of vestibular adaptation and vestibular substitution, the vestibular rehabilitation therapy is working in patients with balance issues.

1. Enhancing gaze stability

Which helps improve the coordination and control of the eyes in response to head movements. This includes exercises that target the vestibulo-ocular reflex, which is the automatic eye movement that occurs in response to head movements, and the visual-vestibular interaction, which involves the integration of visual and vestibular input.

These exercises include exercises that challenge balance and stability while looking at stationary or moving targets, and involve using visual and vestibular cues to help improve gaze stability. The goal is to improve the patient's ability to keep their eyes steady and maintain visual stability during movements, reducing the symptoms of dizziness, vertigo, and instability.

The techniques are used in enhancing gaze stability includes:

A. Vestibular Adaptation
B. Substitution by Other Eye Movement Systems
C. Enhancing Postural Stability

 D. Gaze Stability Exercises
       a) Head-Eye Exercises
       b) Eye Movement Exercises
       c) Visual Habituation Exercises by Utilizing VOR Suppression
       d) Head-Eye Exercises While Walking

2. Enhancing postural stability

The goals of vestibular rehabilitation therapy for postural stability are to help patients improve their use of stable visual references, surface somatosensory information, remaining vestibular function, and alternative postural movement strategies.

The therapist should assess the patient's vestibular deficit, remaining vestibular function, and sensory impairments before starting VRT. To assess how sensory information is used for postural stability, the Clinical Test for Sensory Interaction in Balance (CTSIB) is used. The goal of VRT for postural stability is to help patients recover normal postural strategies and improve their overall balance and stability.

Which includes:

    1. Substitution by Vision or Somatosensory Cues
   2. Adaptation: Improving the Remaining Vestibular Function
   3. Recovering Postural Strategies

• Common Mechanisms for Gaze and Postural Stability (mechanisms commonly applicable to both gaze and postural stabilities.)
   1. Decreasing head movements
   2. Spontaneous cellular recovery in ipsilesional vestibular function
   3. Substitution by unaffected vestibular function

• Postural Stability Exercises
    1. Standing Balance Exercises

    2. Postural Strategy Exercises

3. Decreasing vertigo

Decreasing the vertigo is working based on the habituation of the abnormal vestibular responses. to rapid movements. This can be achieved by identifying the typical movements that produce the most intense symptoms and providing the patient with a list of exercises that reproduce these movements. Habituation occurs through repetitive exposure to the provocative movement and leads to a decrease in response magnitude.

The habituation effect remains for a long time after therapy and most patients will notice relief within 4 to 6 weeks if they persist with their program. However, the effect is slower in the elderly and not always complete. Habituation exercises are not appropriate for patients with bilateral vestibular loss, but may have theoretical benefits for reducing oscillopsia.

• Exercises for decreasing vertigo
Stand with one arm elevated over the head, with the eyes looking at the elevated hand. Bend over and low the arm diagonally with the eyes continuously looking at the hand until the hand arrives at the opposite foot. Repeat 10 times.

4. Improving daily living activities

The last goal of vestibular recovery is to return the patient to their normal activities of daily living. Customized vestibular rehabilitation therapy (VRT) programs include gradually exposing patients to various sensory and motor environments to teach the nervous system how to accomplish functional goals.

Patients are also given suggestions for a general exercise program based on their age, health, and interests, which may include walking, jogging, aerobic exercises, or sports. Swimming should be approached with caution as it may cause disorientation for vestibular patients. Older patients should be advised not to talk while walking to prevent falling and to avoid rapid head movements if they cause imbalance. They should also not drive if rapid head movements cause imbalance.

• Exercises for improving activities of daily living
   1. Gait with sharp or wide turns to the right and left
   2. Go from a seated to a standing position, then return to sitting (one of the Cawthorne–Cooksey exercises.


   1. Herdman, S. J., & Clendaniel, R. (2014). Vestibular rehabilitation. FA Davis.
   2. Han, B. I. (2021). Simplified Vestibular Rehabilitation Therapy. Springer.

Contributing Author
Sachu SP
M.Sc. Speech & Hearing
Audio-Vestibular Specialist
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