Vestibular Rehabilitation: A Clinical Approach to Dizziness, BPPV & Balance

Explore key clinical considerations in the assessment and rehabilitation of dizziness, BPPV, balance dysfunction and vestibular presentations.

BREMJ Aca-Physio

8/6/20263 min read

CLINICAL RESOURCE • VESTIBULAR & NEUROLOGICAL REHABILITATION

Dizziness Is a Symptom, Not a Diagnosis

Dizziness, vertigo and imbalance can arise from a wide range of vestibular, neurological and other clinical presentations. For physiotherapists, the challenge is not simply identifying that a patient feels dizzy, but understanding the characteristics of the symptoms and how they affect movement, vision, balance and daily function.

Vestibular rehabilitation uses a clinically reasoned approach to assessment and management. The aim is to identify relevant impairments, determine which rehabilitation strategies may be appropriate and help the individual regain confidence and function.

Patients may use the word “dizziness” to describe very different experiences. Some may report spinning or vertigo, while others describe light-headedness, unsteadiness, visual disturbance, motion sensitivity or a feeling of being off balance.

A careful subjective assessment helps clarify the nature of the symptoms, how they are triggered, how long they last and what activities are affected.

This information can help guide the physical examination and determine whether the presentation is appropriate for vestibular rehabilitation or requires further medical investigation.

Understanding BPPV

Benign paroxysmal positional vertigo, commonly referred to as BPPV, is one presentation frequently encountered in vestibular practice.

Symptoms are typically associated with changes in head position, such as rolling in bed, looking upward or moving between lying and sitting.

Accurate assessment is important because different patterns of BPPV may require different positioning tests and treatment manoeuvres. The clinician therefore needs to recognise the symptom pattern, select an appropriate test and interpret the patient's response carefully.

When indicated, specific repositioning manoeuvres may form part of treatment.

Key Considerations in Vestibular Assessment

Description and behaviour of dizziness or vertigo
Duration and frequency of symptoms
Positional and movement-related triggers
Presence of nausea or motion sensitivity
Eye-movement and gaze-related symptoms
Balance and walking difficulties
Falls or fear of falling
Functional limitations
Relevant neurological or medical features
The effect of symptoms on work, exercise and everyday activities

Beyond BPPV: Vestibular Dysfunction Can Affect More Than Position

Vestibular assessment should also remain alert to symptoms or findings that may indicate a presentation outside the scope of routine vestibular rehabilitation and require further investigation or referral.

Not all vestibular presentations are positional.

Individuals with vestibular dysfunction may experience problems with gaze stability, motion sensitivity, balance or movement in visually complex environments.

For example, activities such as turning the head while walking, moving through a busy shopping centre or following a moving visual target may provoke symptoms in some patients.

Understanding which activities reproduce symptoms can help clinicians design rehabilitation that targets the individual's specific functional difficulties.

Exercise-Based Vestibular Rehabilitation

Vestibular rehabilitation may include different forms of exercise depending on the patient's presentation and assessment findings.

Programmes can involve gaze-stability activities, balance training, habituation to appropriate movements or environments, walking tasks and progressive functional challenges.

Exercise selection should be individualised. The aim is not simply to provoke dizziness, but to provide an appropriate challenge that supports adaptation, recovery and improved function.

Progression can be based on the person's response, symptom behaviour, balance ability and everyday goals.

Vision, Balance & Head Movement

Vision, vestibular input and somatosensory information work together to support orientation and balance.

This is why some patients with vestibular dysfunction may notice difficulty when turning their head, moving quickly, walking in low-light environments or functioning in visually busy surroundings.

Clinical assessment can help identify which situations are most challenging and guide rehabilitation towards activities that are meaningful to the individual.

As rehabilitation progresses, exercises can become more dynamic and better reflect the demands of everyday life.

Vestibular Rehabilitation & Persistent Post-Concussive Symptoms

Some individuals experience persistent dizziness, visual disturbance, motion sensitivity or balance problems following concussion.

In these presentations, vestibular and visual assessment may contribute useful information as part of a broader clinical evaluation.

Rehabilitation should remain individualised and may need to consider multiple contributing factors rather than treating every post-concussion presentation in the same way.

Where symptoms are complex, interdisciplinary management may also be appropriate.

What This Means in Clinical Practice

Effective vestibular rehabilitation begins with understanding what the patient means when they describe dizziness and identifying the situations that provoke their symptoms.

From there, assessment findings can help clinicians distinguish between different vestibular presentations and select appropriate treatment or rehabilitation strategies.

Good clinical reasoning is particularly important because similar-sounding symptoms can arise from different underlying problems.

Key Takeaways

Dizziness describes a symptom and can represent different clinical experiences.
BPPV is only one of several presentations encountered in vestibular rehabilitation.
Assessment should consider positional triggers, gaze stability, balance, motion sensitivity and functional limitations.
Vestibular exercise programmes should be individualised and progressively adapted.
Complex or atypical presentations may require further investigation or multidisciplinary management.