What Is the Vestibular System?

The vestibular system is an important part of your balance system. Located within the inner ear, it detects head movement and changes in position and sends information to the brain about how you are moving in space.

Your brain combines this information with input from your eyes and muscles and joints to help you maintain balance, stabilize your vision while your head is moving, and move confidently through your environment.

When the vestibular system is not functioning normally, or when the brain has difficulty integrating this information, you may experience symptoms such as dizziness, vertigo, imbalance, visual blurring with head movement, or unsteadiness.

What Causes Dizziness and Vertigo?

Dizziness is a broad term that people use to describe many different sensations, including spinning, light-headedness, unsteadiness, floating, or feeling off-balance.

Vertigo is more specific and refers to a false sensation of movement or spinning.

There are many possible causes of dizziness and vertigo. Vestibular causes can include:

• Benign paroxysmal positional vertigo (BPPV)

• Vestibular neuritis or labyrinthitis

• Unilateral or bilateral vestibular hypofunction

• Ménière’s disease

• Vestibular migraine

• Other peripheral or central vestibular disorders

Dizziness can also arise from neurological, cardiovascular, medication-related, metabolic, visual, migraine-related, or other causes.

This is why assessment matters. The right treatment depends on identifying the likely source and pattern of your symptoms rather than treating all dizziness the same way.

What Is BPPV?

Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of positional vertigo.

Inside the inner ear are tiny calcium carbonate particles called otoconia. In BPPV, these particles become displaced from the utricle and enter one of the semicircular canals. When your head changes position, the displaced particles can stimulate the balance system inappropriately and create brief episodes of vertigo.

Common triggers include:

• Rolling over in bed

• Lying down or sitting up

• Looking upward

• Bending forward

• Turning the head into certain positions

BPPV is assessed using specific positional tests while observing for characteristic symptoms and eye movements.

When BPPV is identified, treatment typically involves a canalith repositioning manoeuvre selected according to the affected canal and presentation. These manoeuvres are designed to move the displaced particles out of the semicircular canal.

BPPV treatment is therefore different from a general vestibular exercise program—the correct treatment depends on identifying the affected side, canal, and pattern.

What Is Vestibular Hypofunction?

Vestibular hypofunction occurs when the balance organs or vestibular nerve on one side or both sides are not providing normal information to the brain.

Depending on the condition, symptoms may include:

• Dizziness or imbalance

• Unsteadiness while walking

• Difficulty walking in the dark or on uneven surfaces

• Visual blurring or bouncing with head movement

• Difficulty turning the head while walking

• Reduced confidence with movement

• Difficulty navigating visually busy environments

The nervous system can often adapt to changes in vestibular function. Vestibular rehabilitation uses targeted exercises to promote this compensation and improve gaze stability, balance, and functional movement.

What Happens During a Vestibular Physiotherapy Assessment?

A vestibular assessment begins with a detailed history. Your physiotherapist will ask about what your dizziness feels like, when it started, how long episodes last, what triggers your symptoms, associated hearing or neurological symptoms, falls or imbalance, medications, and how your symptoms affect everyday activities.

Depending on your presentation, your assessment may include:

• Eye movement and oculomotor screening

• Observation for nystagmus

• Positional testing for BPPV

• Head-movement and gaze-stability testing

• Balance assessment

• Walking and dynamic balance tasks

• Functional mobility

• Screening for central or neurological signs

• Assessment of motion or visual sensitivity when relevant

Not every patient requires every test. Your assessment is selected according to your symptoms, history, safety, and clinical presentation.

If findings suggest that your dizziness requires further medical, neurological, audiological, or ENT assessment, your physiotherapist can recommend appropriate follow-up.

How Does Vestibular Physiotherapy Work?

Vestibular physiotherapy is not one standard set of dizziness exercises.

Treatment depends on what your assessment identifies.

For example, someone with BPPV may require a repositioning manoeuvre, while someone with vestibular hypofunction may benefit from gaze-stabilization and balance exercises. A person with motion sensitivity may require carefully graded exposure to specific movements or visual environments.

Depending on your condition, vestibular rehabilitation may include:

• Canalith repositioning manoeuvres

• Gaze-stabilization exercises

• Balance and gait training

• Habituation exercises

• Gradual exposure to movement or visual environments

• Functional movement training

• Falls-risk management when appropriate

• Education and an individualized home exercise program

Exercises are progressed according to your diagnosis, symptoms, function, and response to treatment.

What Are Gaze-Stabilization Exercises?

Your vestibular system helps keep your vision stable while your head is moving through a reflex called the vestibulo-ocular reflex (VOR).

When vestibular function is reduced, some people experience blurred or unstable vision during head movement or difficulty keeping a visual target clear while walking or moving.

For appropriate vestibular conditions, gaze-stabilization exercises involve maintaining visual focus on a target while performing controlled head movements. The exercises can then be progressively modified according to speed, duration, background, position, and other factors.

These exercises are not appropriate for every cause of dizziness and should be prescribed according to assessment findings.

How Does Balance Rehabilitation Help?

Balance depends on the brain's ability to integrate information from the vestibular, visual, and somatosensory systems.

When vestibular information becomes unreliable, balance may become more difficult, particularly when walking in the dark, moving the head, standing on uneven surfaces, or navigating busy environments.

Balance rehabilitation progressively challenges these systems to improve postural stability, walking, movement confidence, and the ability to respond to everyday environments.

Exercises may involve changes in:

• Foot position or base of support

• Surface stability

• Vision

• Head movement

• Walking

• Direction changes

• Dual-task or functional activities

The difficulty is progressed according to the individual's abilities and safety.

What Is Motion Sensitivity?

Some people feel dizzy or disoriented during movements or in visually complex environments such as grocery stores, crowds, scrolling screens, traffic, escalators, or busy patterns.

When appropriate, vestibular rehabilitation may use habituation or graded exposure to repeatedly introduce specific movements or visual stimuli in a controlled way.

The purpose is not simply to make you dizzy. The exposure is carefully selected and progressed so that the nervous system can gradually become less sensitive to movements or environments that provoke symptoms.

Because visual-motion sensitivity can occur with several different conditions, assessment is important before determining whether habituation is appropriate.

When Does Dizziness Need Medical Attention?

Most dizziness is not caused by a medical emergency, but new or unusual dizziness can occasionally be a sign of a serious neurological or cardiovascular condition.

Call 911 or seek emergency medical attention if sudden dizziness or vertigo occurs with symptoms such as:

• New weakness or numbness of the face, arm, or leg

• New difficulty speaking or understanding speech

• New severe difficulty walking or inability to stand

• New double vision or significant vision changes

• New severe coordination problems

• Sudden severe headache or neck pain

• New confusion or altered consciousness

• Sudden severe unexplained vomiting with neurological symptoms

New, severe, continuous dizziness, particularly when accompanied by significant difficulty walking, neurological symptoms, or other concerning changes, should receive urgent medical assessment.

Sudden hearing loss associated with dizziness also requires prompt medical assessment.

Physiotherapy assessment is appropriate when vestibular rehabilitation is indicated, but it does not replace emergency or medical evaluation when symptoms suggest a potentially serious condition.

Why Choose Strathcona Physical Therapy for Vestibular Physiotherapy?

Vestibular rehabilitation is a specialized area of physiotherapy that requires detailed assessment and clinical decision-making.

At Strathcona Physical Therapy, our physiotherapists have completed advanced competency-based training in vestibular rehabilitation through a Duke University–sponsored program in Atlanta.

This intensive advanced training includes assessment and clinical decision-making for BPPV, peripheral and central vestibular disorders, eye movements and nystagmus, balance and gait dysfunction, vestibular hypofunction, and other complex dizziness presentations.

Our approach includes:

• Advanced training in vestibular assessment and rehabilitation

• Detailed assessment of dizziness, vertigo, and balance disorders

• Positional testing and treatment for BPPV

• Individualized vestibular exercise programs

• Gaze-stability and balance rehabilitation when indicated

• Recognition of findings that may require further medical investigation

• Collaboration with physicians and other healthcare professionals when appropriate

• Access to concussion rehabilitation when dizziness occurs as part of a broader post-concussion presentation

Rather than assuming every person with dizziness needs the same exercises, we focus on understanding the pattern of your symptoms, identifying the systems that may be involved, and selecting treatment based on your individual findings.

Vestibular Physiotherapy FAQs

Is dizziness the same as vertigo?

No. Dizziness is a broad term that can describe light-headedness, imbalance, disorientation, or other sensations. Vertigo refers specifically to a false sensation of movement or spinning. Understanding exactly what you feel and when it occurs can help guide the assessment.

Is all dizziness caused by the inner ear?

No. Dizziness has many possible causes, including vestibular, neurological, cardiovascular, medication-related, migraine-related, and other conditions. This is one reason a detailed history and appropriate screening are important.

How do I know if I have BPPV?

BPPV typically causes brief episodes of vertigo triggered by specific changes in head position, but symptoms alone cannot reliably identify the affected canal or side. Positional testing can help confirm the characteristic pattern and guide the appropriate repositioning manoeuvre.

Can BPPV be treated in one appointment?

Some people improve substantially after one repositioning treatment, while others require additional treatment. Response can depend on the canal involved, the BPPV variant, recurrence, and other individual factors.

Are vestibular exercises supposed to make me dizzy?

Some exercises intentionally create a mild, controlled level of symptoms as part of adaptation or habituation, but making symptoms worse is not the goal.

Exercises should be selected and dosed according to your condition and response. Significant or prolonged worsening should be discussed with your physiotherapist.

Can vestibular physiotherapy help with balance problems even if I am not experiencing spinning?

Yes. Vestibular disorders do not always cause spinning vertigo. Some people primarily experience imbalance, unsteadiness, visual instability, or difficulty walking with head movement.

What is the difference between vestibular physiotherapy and regular physiotherapy?

Vestibular physiotherapy involves specialized assessment and treatment of the systems involved in dizziness, vertigo, gaze stability, and balance. This can include examination of eye movements and nystagmus, positional testing, vestibular function, balance, and gait in addition to a broader physiotherapy assessment.

Can concussion cause vestibular symptoms?

Yes. Dizziness, imbalance, and visual-motion sensitivity can occur following concussion. If vestibular dysfunction is suspected, a specialized vestibular assessment may be appropriate. Patients with a broader post-concussion presentation may also benefit from our dedicated Concussion Management service.

Do I need a doctor's referral for vestibular physiotherapy?

You can generally book a physiotherapy assessment without a physician referral. However, your extended health benefit plan may require a referral for reimbursement, and certain symptoms or assessment findings may require further medical investigation.

How many vestibular physiotherapy sessions will I need?

There is no standard number. Treatment duration depends on the underlying condition, severity of impairment, individual goals, other health factors, and response to rehabilitation. BPPV may require relatively few visits, while vestibular hypofunction or complex balance disorders may require a longer progressive rehabilitation program.