Vestibular rehabilitation (VR) is a programme of rehabilitation which includes administration of a set of graduated and customised exercises (gaze stability, habituation and dynamic balance) and/or physical manoeuvres (e.g. Epley, Lempert) in patients with stable peripheral vestibular deficit.  

One of the most common forms is benign paroxysmal positional vertigo (BPPV), due to movement of calcium carbonate crystals in the semi-circular canals. Patients usually describe vertigo symptoms (illusion of movement) or general dizziness with head/ neck movements, or turning in bed. Sensation of vertigo lasts seconds or up to a minute but general light dizziness and/or unsteadiness might last longer.  

Patients with peripheral vestibular disorders such as labyrinthitis or vestibular neuritis typically experience an acute episode of dizziness for 24-72hrs, accompanied by nausea and vomiting. True vertigo (usually rotatory) lasts seconds or minutes with head movement. Symptomatology reduces with central compensation over a period of days and weeks, though this might be incomplete (persistence of symptoms from months to years has been reported in 30-50% of cases). Following the acute phase, if the symptoms do not settle naturally, treatment with gaze and balance exercises can be very successful in improving central compensation. 

Who to refer

  • BPPV patients with vertigo/dizziness on body movements such as turning over, lying down, bending, looking up where: 
    • canalith repositioning manoeuvre (CRM) performed at the first presentation in primary care was unsuccessful and BPPV diagnosis is not in doubt
    • ongoing symptoms after 2 weeks of Brandt-Daroff exercises where CRM not available or is inappropriate  
  • vertigo or dizziness initiated by head/neck movement caused by vestibular neuritis/ labyrinthitis where symptoms of positional dizziness persist >6 weeks from the initial onset 
  • imbalance due to suspected bilateral vestibular hypofunction (often following treatments with ototoxic agents) with reports of oscillopsia (an illusion that  the world moves as the patient moves, e.g. bobs up and down as the patient walks)  
  • symptomatic patients with confirmed diagnosis of persistent postural-perceptual dizziness (PPPD) who did not have previous vestibular rehabilitation input 
  • patients with other conditions e.g. Meniere’s disease, vestibular migraine, only if indicated by secondary care consultant  

Gradual withdrawal from vestibular suppressants is recommended wherever possible, as these prevent central compensation and prolong symptomatology. Symptomatic drug treatment is not usually helpful for people with BPPV.  

Referral is via SCI-gateway to Mountainhall...Regional rehab service...Physio comm rehab.

Who not to refer

  • Patients with neurological or cardiovascular signs or symptoms - consider referral to neurology or cardiology

 

For any of the following, consider referral to ENT for initial assessment.

  • There is hearing loss which is unilateral/asymmetrical or of sudden onset 
  • There is tinnitus associated with spells of vertigo 
  • There is ear pain/infection/discharge.

Editorial Information

Last reviewed: 27/12/2023

Next review date: 27/12/2025

Author(s): Marcin Strak.

Version: 1.0

Reviewer name(s): Marcin Strak.