Vestibular Therapy is Effective
For people with dizziness, vertigo, imbalance, and falls, I highly recommend Vestibular Therapy, also called VRT, Vestibular Rehab, Vestibular Rehabilitation, and Vestibular Physical Therapy.
There is a very large and growing body of research that supports Vestibular Therapy. The published research from around the world proves that this specialized type of physical therapy works!
However, I hear from people all the time who have completed 6-8 weeks of Vestibular Physical Therapy at another clinic and have not improved. One new patient I just worked with had actually completed two consecutive rounds of therapy with no improvement before I met her.
So the question becomes why doesn’t Vestibular Therapy always work?
Seven Reasons VRT Doesn’t Work
Missed the BPPV Crystals
One of the most common reasons that someone will not get better with a full 4-8 week course of Vestibular Therapy is because BPPV was missed.
BPPV crystals must be assessed and treated at the very beginning of VRT. I meet many people who have been unsuccessful with Vestibular Rehab and I find atypical BPPV when I examine them.
Atypical BPPV is an unusual type of BPPV. Treating BPPV or ruling it out is necessary for a good outcome with VRT.
The Neck is Getting Aggravated
Vestibular Physical Therapy often involves movements of the head and neck.
I have met many people who were unsuccessful in Vestibular Therapy because they had a neck problem that was not addressed. Neck problems can become aggravated with VRT exercises. This can exacerbate headaches and neck pain. Lightheadedness can be caused by neck problems being aggravated by VRT exercises. Neck problems that are not addressed may limit the results of Vestibular Therapy or make patients feel worse.
Incorrect Exercise Parameters
The research is very clear about what works for Vestibular exercise protocols. If the exercise protocols are not being followed correctly, then the exercises may not work.
Exercise parameters include a lot of details such as the angle of the head, the speed of movement, the arc of motion, the direction of movement, the duration of the exercise, any pause or hold times, etc. Precision and accuracy are keys to success with Vestibular Therapy exercise protocols.
Incorrect exercise parameters are a third reason why Vestiubular Therapy may not work.
Overlooked a Piece of the Puzzle
Most patients I meet have more than one cause of their dizziness or balance issues.
Vestibular problems are a common cause of discomfort, but sometimes other pieces of the puzzle are overlooked.
This may occur due to tunnel vision of healthcare providers focusing only on their area of specialty. For example, there may be a missing piece of puzzle, like a cardiac issue or vision problem. Blood sugar, auto-immune, and thyroid problems may be overlooked and go unaddressed.
Another puzzle piece in Vestibular Therapy that often gets missed is mental health. Sometimes anxiety, depression, or PTSD may go unaddressed. I share below more about mental health affecting VRT outcomes.
Missing puzzle pieces can limit the final level of recovery. In order to make sure that my patients consult with all the relevant professionals, I have developed my own method of evaluation for complaints of dizziness, vertigo, imbalance, and falls.
Interference affecting Brain Function
Certain things can interfere with the brain’s ability to benefit from Vestibular Therapy. The top two causes of interference are stress and medications that affect the central nervous system. Both of those things affect the function of the brain.
In order to fully benefit from Vestibular Physical Therapy, the brain function must be working well!
Medications must be reviewed by the Vestibular Physical Therapist in coordination with the prescribing physician.
Stress must be managed in order the get the best results from Vestibular Therapy.
People with unaddressed mental health fluctuations do not get the optimal outcomes from vestibular rehab.
This may be due to anxiety causing stress which interferes with the brain’s re-calibration.
Excessive worrying can definitely magnify symptoms. This can prolong the recovery process and possibly limiting the final level of recovery.
Severe anxiety or a panic attack during a treatment session may cause the treatment session to end early without accomplishing the goal of care.
Research indicates that patients with anxiety do not recover as well from vestibular problems as those without anxiety.
Depression may prevent patients from taking their medications correctly or keeping their healthcare appointments.
People with depression are less likely to complete exercises and perform self-care at home as instructed.
Lack of Sleep
I have treated many patients with infants or teenagers who keep them awake at night. Disrupted sleep can definitely interfere with the recovery process.
One of my patients with three teenage boys stayed overnight at a hotel room for the weekend so she could get a solid sleep without interruption.
Some of my patients with an infant will arrange for nanny or family member to stay overnight after a treatment session to attend to the baby in the middle of the night.
People with insomnia do not usually recover as quickly as my other patients who sleep deeply after a treatment session.
Some people may take over-the-counter remedies or medications prescribed by their doctor to improve sleep.
Sleep is a key time for the brain to reset and re-calibrate after each treatment for vestibular rehabilitation.
If you are in VRT and you are not getting results, please check out my other blog on the Top Ten Barriers to Vestibular Recovery.
This blog is provided for informational purposes only. The content and any comments by Dr. Kim Bell, DPT are not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. The details of any case mentioned in this post represent a typical patient that Dr. Bell might see and do not describe the circumstances of a specific individual.
Just listening to Dr. Bell’s video on Dizziness and Vertigo is helping me to relax because now I think I have hope. Hope that I can be well again
Hi, can you direct me to Dr. Bell’s video you’re speaking about please? Thanks 😊
This is my most popular video lecture: on YouTube
I would like to watch to Dr. Bell’s video. How do I locate it?
Here are a few links that might be helpful:
My most popular video
Other educational videos
My YouTube channel
Invaluable information! Thank you, Dr Bell
l have cerebellum ataxia. does vestibular therapy help with that?
Yes, this Vestibular Researcher Dr. Courtney Hall, PT, PhD has published research that Vestibular Physical Therapy interventions can improve walking and balance in older adults even in the absence of a vestibular impairment.
With that said, you can find a Vestibular Physical Therapist using the provider directory at Vestibular.org.
If you have already tried that, you may want to also search the Provider Directory at NeuroPT.org and find someone with the credential “NCS.” That credential indicates a Neurological Clinical Specialist and they will be the most qualified provider to help you within the physical therapy profession.
I hope that helps!
Kim Bell, DPT
I think you’ve answered my conundrum, thank you so much! I had a traumatic month of alcohol withdrawal followed by an ear infection and the resulting anxiety resulted in me developing PPPD instead of compensating which my young brain should have done! Tried doing exercises last week and they made me so I’ll with migrainous symptoms so I had to stop.
Dear Dr. Bell, I treat Insomnia as a Behavioral Sleep medicine specialist and of course we tend to discourage napping, but as you pointed out in your information “Sleep is a key time for the brain to reset and re-calibrate after each treatment for vestibular rehabilitation.”, so when my patients are in vestibular therapy I actually suggest that they nap after vestibular therapy session if they are sleepy. Many will be sleepy, fatigued, and mildy nauseated. So, to me, the nap can be critical for comfort, recovery from the intense effort and stress of the therapy, and may help with the vestibular therapy being effective, but the question is raised that naps usually result in poorer nighttime sleep- so I am wondering what you think from experience and the research, if any, on this.
Hi Dr. James,
I understand the dilemma that you are discussing and agree with your points.
Based on my experience, I have decided to instruct all of my patients to sit up for 20 minutes after we finish our treatment on a couch or chair with a pillow behind their head, keeping the head level and their trunk slightly reclined back about 15-20 degrees. I also often place pillows under each elbow, so their arms are supported as they rest.
I advise against any neurological input during that 20-minute rest period, so that means no auditory input or visual input. It is a “quiet rest” period with no neurological stimulation, so their brain can settle down after the vestibular treatment session.
During that 20-minute rest break, I also apply an ice pack to the back of their neck in accordance with a tip I received from my clinical mentor, to settle down any nausea or dizziness that has been provoked during the vestibular therapy session. I will usually set them up comfortably with a sweatshirt before they sit down and a blanket after they are positioned, so they don’t get too cold from the ice.
Then I advise them to “take the day off” after each treatment. We discuss that they need to clear their schedule for the rest of the day. That specifically means no cooking, no chores, no working, no computer time, no driving, and no other appointments afterwards. That way they can take a nap after the treatment if they need to; however, I do not advise them about napping either way. I only create the space in their schedule after each treatment, that will allow them to nap if they feel their body needs it.
Some people have been holding so much tension from their vertigo that they fall asleep on the couch right after I get them set up in the upright 20-minute resting position, before I even manage to gather my equipment to get out of their home! One of my patients even started snoring as I was walking out his front door.
I also discuss with the patients that they will not recover as quickly from the vestibular treatment if they do not get a good night’s sleep that night. Their vestibular hangover effect will last longer if they do not have a good sleep for their brain to reset. I use the analogy of holding down the power button on your computer to make a “hard reset,” when your computer is malfunctioning, and explain that their brain needs a deep sleep for a hard reset to recover from their vertigo.
If they historically are a “good sleeper,” then I encourage them to go to bed on time, not to stay up late, and carry on as usual with their good sleeping ability.
If they do not usually sleep well, we discuss strategies to improve their sleep hygiene. We may discuss some teas or supplements they like to take to help them sleep deeply that night.
For example, a good comedy movie or sit-com, or a chat with a funny friend, and a mug of chamomile tea might be just what the doctor ordered before bed.
Also, for people who have spent a lot of time in bed during the day due to vertigo, I implement a plan to create a “cozy nest” somewhere else in their house for them to rest in during the day. Their bed is then only used for sleeping.
The long term goal of the vestibular therapy is for them to be more active during the day, not needing so much time to rest or stay sedentary as their symptoms clear up.
I have many patients who no longer need to nap in the afternoon once their vertigo is cleared up, because their extreme fatigue has cleared up also.
I hope that information is helpful!
Thank you for all the excellent work that you are doing to help your patients! Well done.
Kim Bell, DPT
Wow, these are excellent suggestions and I have no doubt they work! I will share this comment with my therapist as she is good, however I don’t think she realizes or knows the significance of the, “resting period” after our session. Today, I was a bit tired when I left therapy. And when I got home, I felt exhausted,so I lied down, but upon doing so the rush of dizziness came and I felt really sick; nauseated.
I am currently in VRT. I think it is helping because I have not had an episode since March 2021. Although I still have some pressure associated with the dizziness, I’m less fearful of it and know what to do whenever I feel the vertigo coming on.
Hi, I’m currently going to vestibular therapy twice a week, about 20 times now and still feel the same. My balance is off and my eyes often feel dizzy or unfocused. I’ve been to an eye doctor and an ent and nothing wrong was found. I’m at a loss and very depressed about it. It’s been going on since April! Any thought or information would be greatly appreciated.
Thank you, Pat
I am sorry to hear that you are still feeling so bad!
There is a large body of evidence that vestibular PT works.
Perhaps you have one of the barriers to recovery that I list in this other blog?
There may also be something that was overlooked in the initial root cause analysis.
This article may help you think about other possible root causes.
This article can help you organize your case into a helpful format for your providers to read.
You can also use this article to search for a Vestibular Physical therapist with more advanced skill level or more diverse clinical experience.
This article has home remedies that may help in the meantime.
I hope you feel better soon!
Kim Bell, DPT
Hi Dr. Bell, My wife had BPPV and following the VRT to fix the crystals she experienced severe symptoms (panic attacks/anxiety, photo-phobia that was specifically triggered by phone or computer screens or scrolling, as well as any visual movement like our child turning the pages of a book). She was doing the VRT for about a month, both in-office visits and practicing at home with a metronome. My wife’s symptoms have lasted for over two months and are pretty debilitating. At this point she’s unable to use a phone or computer and often has to spend part of the day with her eyes closed. She’s had some dizziness as well, but that’s not the primary symptom. She’s had an MRI, seen a Neurologist, neuro-opthalmologist, etc. Are these symptoms, esp. the panic attacks and the photophobia consistent with PPPD or Vestibular Migraine? Or both? Or maybe her original PT didn’t fully address the BPPV? I’m wondering if she might have better results (with VRT) with your approach…
I am so sorry to hear all this!
I have reached out to you via email to respond to this comment.
I wish you and your wife all the best.
Kim Bell, DPT
I had my first severe vertigo attack in august. A month later I had this severe attack. They thought it might be a stroke but MRI showed no evidence. I had numbness on left side of face mainly cheek and upper lip. Severe dizziness and vomiting. I was given meclizine and issues resolved. Testing ENT did showed abnormal results so he sent me for therapy. Therapy aggravated symptoms and did not resolve them. Therapist said my left eye keeps drifting off. Dr. Plans to send me to neurologist next. Opthamologist saw no issues with vision. Therapist suggested neuro-opthamologist. Meclizine is awful and puts me right to sleep. I would like to resolve this without medicine if I can but therapy didn’t help and I don’t know what to do next. It has been 5 months with no resolution.
I am sorry to hear this!
If just your left eye is drifting off, but not both of your eyes, then I suggest you consult a Neuro-Optometrist.
In all the specialists you listed that you have seen, you did not mention that type of specialist. That is not the same as a neuro-ophthalmologist, although that will likely be a helpful referral as well.
A Neuro-Optometrist is the provider of choice for rehabilitation of issues with one eye.
With the numbness on the left side of your face and your left eye becoming unruly shortly thereafter, you may have suffered a viral attack of some sort on the nerves on that side of your face. That is one possibility and it can affect the function of your eye.
My suggestion is that you use the Doctor Locator tool at COVD.org and consult with a local Neuro-Optometrist. The credentials of the provider I suggest for you to look for are OD, FCOVD.
Also, I encourage you to celebrate the good news that so many of your consultations are coming up empty! That is great news about the MRI being clear and no stroke, etc.
If the therapist you saw was not a vestibular physical therapist, you may want to seek a second opinion from vestibular physical therapy at some point in the future. You can use this article to look for another provider.
I hope that helps!
Kim Bell, DPT
I had a vertigo attack december 26th 2021. Ekg, bloodwork, bp was normal in the ER. ER say BPPV. Physical therapist ruled that out. Went to ENT. He says its Menieres Disease. Took 2 months to get an appointment to get balance tests and other tests done. After finally getting those done, ENT still says Menieres. Went to a neurologist while waiting for the appointment for tests. She says she thinks it’s vestibular migraine. Due to history of migraines in the past. Im going to VRT and it seems to be helping. Been going 3 weeks so far. It just seems like its at a standstill. Still feels like something is off. Been off work 3 months. What are your thoughts ??
I am sorry to hear this!
Vestibular migraine and Meniere’s are usually managed with medications and dietary changes.
I am glad that VRT seems to helping!
I suggest you pull together a solid team of specialized professionals to help you minimize your episodes and resolve your symptoms as much as possible.
Sept 5th, 2022 I had fogginess that started, it quickly progressed quickly to full blown vertigo (never had it)
I spent 4 weeks in acute phase, puking 4 to 5 times a day.
3 trips to emergency, twice for IV fluids.
I went for CT scan, it was clear.
Hearing tests were all normal.
Saw ENT almost 4 weeks ago. Diagnosed with vestibular neuritis.
Started vestibular PT 3.5 weeks ago.
Was walking better, still off balance and bobblehead.
Was able a few times to push past it and bake cookies, do a few chores.
Was doing well with the eye exercises, we added a few more, did well
Then started last thursday doing walking while turning my head side to side & up and down. Standing toe to toe.
And I seemed to go backwards over the next few days. I threw up after trying to do 🎃 with my daughter Sunday night.
I had a vestibular PT appointment today and I said I can feel my eyes not tracking my targets as well. She said she could see my eyes bobbing more.. but my sinuses felt full today and she wondered if maybe a cold was the problem.
I have been off work for 10 weeks, can’t drive, and can only do basic tasks.
I walked my dogs daily and can’t make it to the end of my street..
How can I proceed to get better. I’m frustrated. Thanks
I am sorry to hear that your recovery is taking so long!
I am sorry to hear you are frustrated by this vertigo! That is understandable.
This article has tips on recovering from vestibular neuritis.
This article discusses BPPV which can occur with a cold or just happen after vestibular neuritis.
This article discusses how an upper cervical issue can get aggravated by VPT and make you feel worse.
This article has a bit more on upper cervical dizziness, just in case that resonates with you.
I hope something in what I shared helps give you insight.
I am glad you already found a vestibular physical therapist as that sounds like the correct path through the health care system!
I hope you feel better soon!
Hi Dr. Bell,
In the Fall of 2021 I had cataract surgery on my left eye, one week later I had cataract surgery on my right eye. The day following my first cataract surgery I developed dizziness that has persisted every day since then. I would describe the dizziness more as unsteadiness. I also developed photophobia. When I am not wearing my F41 glasses I often experience debilitating fatigue, body weakness, dizziness and headaches. I have seen an ophthalmologist, neurologist, neuropathologist and cornea specialist. I had a recent MRI which showed no problems of the brain. I am not sure who to see next. After seeing all these doctors, I believe that I have a brain disorder not an eye issue brought on by the cataract surgery. I might have vestibular migraines, but I am not sure. Do you know of any neurologist that specialize in vestibular issues? Thank you
Yes, the profession called Otoneurology are Neurologists who specialize in Vestibular issues.
I can highly recommend Dr. Ian Purcell, MD, PhD in San Diego.
You can also search online for one in your area by using the directory at Vestibular.org.
I hope that helps!
Kim Bell, DPT
I had a mtbi 2 years ago and which a stopped my vestibular occcular reflex from working. I’ve been getting vestibular therapy since December but I’m finding it incredibly difficult to progress the exercises and work. I spend 9 hours a day infront of a computer. Should I request time off to work through these exercises? I feel like even if I had time off work it might take a few months for the symptoms to reverse and for my brain to learn to compensate and habituate. Thanks
I suggest you find a Board-Certified Neurologic Physical Therapist, since it sounds like this started with a TBI.
You can use this article to find the link to that online directory.
This may help also: NeuroPT.org
Hi, I have had balance issues for 4 years and started VRT last fall.I am 68 now and have worked out all my adult life
I had nonhodgkins lymphoma in 2020 with chemo I was in remission after 2 months of chemo, then had a few more treatments in addition to hydration infusion. Balance issues were before chemotherapy
My ENT said it may have bee a virus and had it been treated early on, perhaps I wouldn’t have issues now.
My gait is not terrible but a bit off.
The question is, I think it helps me and do exercises at home intermittently. Had to revise my workouts to be in sync with balance.,
But, will it ever go away? I have fallen several times and walking in the darkness of my bedroom, I get a strange phenomenon. I get disoriented and proprioception is way off.
Recently a widow there is anxiety and fear living alone. I have a cane and walker but not often used. Had to move from our 2nd floor apartment as it was 13 steps up. With imbalance and getting older, I could see it would get increased difficult. I am in a ranch now.
It is so frustrating not knowing what happened here Imean you can’t link it to a structure on MRI.
Insurance will only cover for so long, then I’m on my own? Will it definitely get worse
I am sorry to hear all this!
I think this article may help answer some of your questions.
Many of my patients with foot neuropathy after chemo have benefited from this home exercise program for the feet.
You may also want to search for a vestibular PT who specializes in balance training.
This article may help you find a vestibular PT in your area.
Hello doc, my name is Ray. Here is my story in short, work as a car mechanic and I stood up and hit my head fairly hard to where I went back down conscious but in pain. Was fine for the rest of the day, about a week later maybe less I started to spin didn’t think anything of it. As I kept waiting it got worse headaches, eye pain, slight neck pain. So I started my venture with the doctors went to ENT found nothing got blood word for thyroid it came out ok but 2 tiny nodules were found but nothing to worry him very very small blood results were fine(I’d like to add i take lithium-300mg, buspar-10mg 2 times a day, clonazapan-.25mg and seroquel-50mg but split it cause the doctor said maybe that is reason why but it’s not) plus I get blood work every 2 months and I always comes out ok, went to eye doctor now I wear glasses, thought that was problem but nope Was still spinning. Then eventually my legs started to lose like balance or stability and I kept ignoring it until one day I was just basically like nope nomore and sat down on my own power but I just couldn’t get back up(it was in the middle of the car garage I work at haha) so my boss called ambulance and brought me to hospital. There they did the usual test coordination and etc plus a cat scan nothing was found. Told me to see the neurologist made a appointment next day to see one. Went in saw doctor told me to get mri and gave me a EEG or something like that which I was overthinking cause I found that machine so awesome but he said it came out ok. He also gave me a script for mri of brain and neck and lower back. Well brain mri came out as normal as anyone else’s as to what the neurologist said, as to my uncle he said that’s good eventho your brain wasn’t anything to brag about, ha. So here’s the part I expected my spine I played football since I was a little kid, my father and I loved football. I also played hockey and lacrosse all contact sports but I took football into college where I beat it up. I also was into snowboarding which I did compete in and also boxing. Both amateur status. So the lumbar and cervical spines had some issues I forgot what C section the doctor said was a bit off but found something slightly pressing on the spine which i started to go to therapy for this has all been since April 2022 when I hit my head but therapist for back only been since July 10 2022. It’s been getting better but I do have a few herniated disc’s as well. Nothing tho that I haven’t been living with since the injury’s occurred. As for concussions I have had a few none surprisingly in boxing always moved my head. But a few during football years ago I’m 36 so I’m talking 10+ years since last concussion. So I started reading your articles and I came across stress and anxiety and all these things about mental health that possibly could cause me not to heal whatever vertigo problem as to what the neurologist says to heal. I have had these issues for years and I’m trying to bring my stress and anxiety down but due to the vertigo issues they seem to hit harder which I also read about it’s normal and I hope that all this combined isn’t going to mess with me. I take my meds everyday at a set schedule and just trying to get rid of this problem cause I want to head back to school. I wanna be in the medical field like my father, mom, several of my aunts and uncles and grandfather. Eventho I do have a bachelors degree in business I didn’t like the field I did it to play football and get a “education”. Anyways lmk what you think and thank you in advance. I am going for the VGN in a week maybe less by the time you read this and then I start therapy for the vertigo once done with that. Thanks doc.
I am sorry to hear what you are going through!
I am amused that you started off this comment saying it was the “short” version of your story.
I have a few articles on mental health and dizziness:
I am pleased to hear that you have sought out professional care for your mental health issues, since they can be exacerbated by vertigo.
Your description of your symptoms is not completely clear to me, so I suggest that you create a case summary for your situation by answering the questions that I ask in this article.
Then share that organized set of information with your healthcare providers, so they are not overwhelmed with extraneous details.
If the doctors determine you have a vestibular problem, you can use this article to search for a vestibular physical therapist near you.
If you want a second opinion about your vision, you can seek a consult with a Neuro-Optometrist using the Doctor Locator tool at COVD.org.
If you think the issue is related to your spine, I suggest you search for an orthopedic manual physical therapist using this directory.
You may need a “team approach” with multiple providers to attack this problem from multiple angles.
You can have more than one cause of your symptoms!
Hi. Here is my story.. 🙂
I am 27 years old and since i was 14 i have constant diziness by constant i mean it never stopped.
I was just laying down on the couch watching tv and i felr like something hit me on the head and everythung became dizzy
Diziness feels like i am on a boat. its not going to one or another side but more like slightly rotating but always around the dot.. Ive been to countless doctors from eye,to neurologists to shrinks,mri,did many rests like for neck blood vesels and .any many others. I am on medications and threated for pannic attacks but pannic attacks comes and goes but the diziness is not changing. i think its something wrong with my inner ear.
Here comes the frightening part.
I tried doing caloric test many years ago but as soon as they inserted water in .my ear i started seeing even more severe diziness and i just started pannicking and i couldnt continue the test. i know that this is the most accured testing but i feel like i will never be able or brave enougg to do it.
But, my question is: Is it safe to try vrt excersises that i found online on my own? is it bad if i do them without being diagnozed with any specific diagnosis related to vertigo ? can i .make my symptoms even worst? Thank you for your answers and wish you a nice day 🙂
I am so sorry to hear all this!
I do not recommend trying exercises that you found online.
My suggestion is that you try to find a vestibular physical therapist.
That way you can have a proper evaluation and individually prescribed exercises if needed.
You can use this article to search online for that type of provider.
Thank you for all the information!
I experienced my first bout of vertigo BPPV 7 years ago.
The ENT told me I had vestibular weakness on the left (36%).
A few weeks ago I experienced vertigo. We got the crystals out with a virtual vertigo PT and I’m on week 3 of doing some vestibular exercises.
I notice not that both my bouts of vertigo now have this lighheadedness and nausea feeling and it takes a long times for it to settle.
I also notice when I wake up, I get lightheaded and nausea. Sometimes continues through the day.
Can this happen with people vertigo? Like a side effect of vertigo??
I am glad that the “virtual vertigo PT” was able to help you with the crystals.
You can certainly report your current symptoms to that provider who is supervising your exercise program, and ask him or her the same questions you are asking here. Those are great questions!
I suggest an in-person evaluation with a vestibular physical therapist because there are a number of root causes that can cause the symptoms you describe.
You can use this article to search for a vestibular PT provider in your area, hopefully who can see you in person for further assessment of your lingering symptoms.