What Is Vestibular Rehab Therapy?

Vestibular rehabilitation is an exercise-based program used for dizziness, imbalance and vertigo. The exercises in it are meant to be chosen for the specific balance problem an evaluation finds. If turning your head, walking down a grocery aisle or looking up at a high shelf leaves you unsteady, you have probably been handed a sheet of exercises at some point, or found one online. Then you wondered why it helped a little, did nothing, or left the next hour worse.

I am Dr. Alireza Chizari, DC, DACNB, a Board-Certified Functional Neurologist. A question I hear often in my Calabasas practice is why the same exercise can suit one dizzy person and frustrate another. The answer lies in how the balance system compensates, and in which part of it is struggling.

If you are still trying to work out what is behind your symptoms, a dizziness evaluation in Calabasas is where that question gets answered first. The rest of this article explains why the evaluation comes before the program, and what each part of vestibular rehabilitation is designed to do.

What Is Vestibular Rehabilitation?

Vestibular rehabilitation rests on firmer evidence than many people expect. The updated clinical practice guideline on peripheral vestibular hypofunction comes from the Academy of Neurologic Physical Therapy. It recommends offering vestibular physical therapy to people with acute or subacute one-sided vestibular hypofunction, and makes the same recommendation for chronic one-sided and for two-sided hypofunction.

A Cochrane systematic review reached a similar conclusion for unilateral peripheral vestibular dysfunction. Its authors described vestibular rehabilitation as a safe, effective management, with moderate evidence that it can improve symptoms and day-to-day function in the medium term.

The word dizzy covers very different experiences: spinning, rocking, floating, a pull to one side, or a floor that feels soft. Two people who use the same word can need different exercises. In vestibular rehabilitation therapy, that is the reason the evaluation comes before the program.

How Does Vestibular Rehabilitation Work?

Vestibular rehabilitation is built on compensation, the nervous system's capacity to change how it responds to balance signals, and the clinical practice guideline describes three routes compensation may take: adaptation, habituation and substitution. These are the core vestibular rehabilitation methods, and each one is aimed at a different kind of problem.

How the Brain Adapts: Compensation as One System

Compensation is easiest to picture as one system with three tools. In the guideline's own definitions, it may involve adaptation of the vestibulo-ocular reflex, substitution of alternative strategies, and habituation of symptoms.

The vestibulo-ocular reflex is the link that keeps your eyes steady on a word or a face while your head moves. A reflex that is out of step with head movement is one kind of problem. A specific movement that provokes far more dizziness than it should is another, and a source of balance information that stays limited is a third. Each calls for a different tool, and the order of the work follows from which one the testing finds.

Adaptation: Retuning the Response to Head Movement

Adaptation exercises aim at a long-term change in how the nervous system responds to head movement. In practice, that often means keeping your eyes on a fixed target while turning your head at a controlled speed. The speed rises, the background changes, or the exercise moves from sitting to standing as accuracy holds. The aim is enough repetition for the response to change, at a level of dizziness you can work through.

Habituation: Turning Down the Reaction to a Trigger

Habituation is aimed at symptoms that a particular movement or setting reliably sets off, such as bending to load the dishwasher, rolling over in bed, a crowded store or a scrolling phone. It uses repeated, graded exposure to that trigger at a level you can recover from, so the reaction has a chance to shrink with practice.

Substitution: Leaning on the Inputs That Still Work

Substitution exercises promote alternative strategies when one source of balance information stays limited. Balance work on firm and soft surfaces, with the eyes open and closed, or in changing visual conditions, asks vision and the body's own position sense to carry more of the load.

Which input to build up is a judgment made at the evaluation, because the strategy a person already relies on is part of the picture.

Why a Generic Exercise Sheet Often Falls Short

A generic sheet of vestibular exercises cannot tell which of these routes your problem needs, or whether you have BPPV, where a repositioning maneuver usually comes first. It also cannot see whether your eyes stay on target, whether your posture shifts, or how long the symptoms take to settle afterwards. Those are the practical reasons vestibular rehabilitation starts with testing rather than with a handout.

If you have already tried home exercises and felt worse, vestibular rehabilitation may still have something to offer. The exercise may have been wrong for the cause, or the dose may have been too high to begin with.

The BPPV Exception: When a Maneuver Comes First

Benign paroxysmal positional vertigo (BPPV), in which spinning is triggered by changes in head position, is the main exception to an exercise-first approach. In the Cochrane review, repositioning maneuvers worked better in the short term than exercise-based vestibular rehabilitation for BPPV, while combining the two was effective for longer-term functional recovery, as the review abstract summarises.

When positional testing confirms BPPV, a canalith repositioning maneuver is usually the first step, and exercises may help afterwards. Testing first keeps someone with BPPV from spending weeks on habituation drills that were never aimed at the cause.

Can Vestibular Rehabilitation Make Dizziness Worse at First?

Vestibular rehabilitation can make dizziness feel somewhat worse when a program first starts, and with continued practice those symptoms usually lessen, according to an NHS hospital trust's patient leaflet on vestibular physiotherapy.

The same leaflet describes the exercises as helping the brain adapt to changed signals from the balance system. A brief, manageable rise in symptoms during an exercise may be part of what prompts that adaptation.

Dose is where the skill lies. Too little challenge may not prompt any change. Too much can leave you wiped out for the rest of the day, more guarded about moving and less able to practice the next morning, so pushing harder does not necessarily mean faster progress.

How to Tell a Productive Reaction From Overload

A reaction that is mild and settles soon after the set is the kind a vestibular program plans for. Symptoms that build through the session, last for hours, or spill into the next day are worth reporting to whoever is guiding your program, because the dose, the target or the diagnosis itself may need another look. Progress is judged by the trend over several weeks and by what you can do day to day, more than by how a single session felt.

Which Vestibular Rehabilitation Techniques Fit Which Problem?

Vestibular rehabilitation techniques differ by the problem they target. The table matches each method to what it is designed to change, using the clinical practice guideline's definitions and the Cochrane findings on BPPV.

Many programs combine more than one technique, and the mix is adjusted as retesting shows which systems are responding.

Who May Benefit From Vestibular Rehabilitation Therapy?

Vestibular rehabilitation therapy may help people whose evaluation shows a balance problem that exercise can train. The guideline evidence is most established for peripheral vestibular hypofunction, whether one-sided or two-sided.

It is used for dizziness, imbalance and vertigo, and Cleveland Clinic's overview of vestibular rehabilitation notes that people who have had a stroke or brain injury, or who fall often, may also benefit.

Dizziness on its own does not show that an exercise program is the right next step. The patterns people describe are clues: spinning when rolling over, rocking or floating after a car ride, unsteadiness in the dark, or discomfort in a store or in traffic. The evaluation sorts out which of them a program can address.

Older Adults and Fall Risk

Balance problems in older adults are a fall-risk question as much as a dizziness question. A large population study of US adults, published in Archives of Internal Medicine, found that people with vestibular dysfunction who also had symptoms of imbalance had a markedly higher risk of falling.

An older adult who has started holding the rail, avoiding curbs or slowing down on uneven ground is worth evaluating for the balance system itself, alongside the checks on vision, medication and home safety that their primary care physician already does. When a program is part of the plan, it is paced around what can be practised safely at home and progressed as balance testing changes.

Vestibular Rehabilitation After a Concussion

After a concussion, vestibular rehabilitation may be part of care when dizziness, neck pain or balance problems persist. The international consensus statement on concussion in sport includes cervicovestibular rehabilitation, which pairs neck and vestibular work, in a targeted approach for athletes with those symptoms.

The signs that point toward this kind of care have their own article: when to consider vestibular rehab after a concussion.

Can You Do Vestibular Rehabilitation at Home?

Yes, vestibular rehabilitation can include home exercises, as part of a guided plan. The clinical practice guideline recommends supervised vestibular physical therapy, taking your preference into account, and continuing a prescribed exercise plan at home can help prevent or treat dizziness and imbalance. For exercises you can start with, see vestibular exercises for balance and vertigo, chosen with your clinician.

How Long Does Vestibular Rehabilitation Take?

How long vestibular rehabilitation takes depends on the cause and on how the nervous system responds, so there is no fixed number of visits to promise. Confirmed BPPV, where a repositioning maneuver comes first, is a different course of care from chronic dizziness that involves a concussion, migraine or the neck. Retesting against the first evaluation sets the pace, and how long vestibular rehab takes walks through what shapes that course.

What Happens at a Vestibular Rehabilitation Evaluation in Calabasas?

A vestibular rehabilitation evaluation at California Brain & Spine Center in Calabasas begins with a 120-minute neurodiagnostic assessment, so that every exercise in the program is chosen from findings rather than from a template.

Dr. Alireza Chizari, DC, DACNB, carries out the assessment, and the history comes first: what the dizziness feels like, when it started, whether it is constant or comes in spells, which movements set it off, how long a flare lasts, and whether there was a concussion or whiplash. Driving, stores, stairs, screens and walking in the dark all give clues.

Eye Movement Testing

Eye movement testing looks at fixation, smooth tracking, quick eye jumps called saccades, and gaze stability during head movement, along with whether moving the eyes or head brings on symptoms. Someone who gets dizzy reading signs while walking may have a different problem from someone who gets dizzy only when rolling over in bed.

Balance and Gait Under Changing Sensory Conditions

Standing balance is tested with the eyes open and closed and on firm and soft surfaces, which shows how much a person is relying on vision, on the body's position sense or on the inner ear. Walking may be observed with head turns or changes in speed when it is safe to do so. The aim is to find the situations where the system loses efficiency.

Neck and Position Sense

When dizziness began after whiplash or a head injury, or comes on with neck movement, the assessment also checks neck motion and position sense, so that a neck contribution is neither assumed nor overlooked.

Upright and Autonomic Tolerance

Lightheadedness on standing, a racing heart, or poor tolerance of heat or exercise can change where a program should start, so the assessment also looks at how the body handles being upright. Someone who struggles to stay on their feet for long may need a gentler starting dose than someone whose only problem is brief positional vertigo.

Once the findings are mapped, a plan may include vestibular rehabilitation, canalith repositioning when BPPV is confirmed, or balance disorder therapy, when clinically appropriate after evaluation. The same gaze and balance measures are repeated later to show whether a specific system is changing. If nothing changes despite steady practice, the plan is reconsidered rather than repeated.

Dr. Chizari works alongside primary care physicians, ENTs, physical therapists and medical neurology when a case needs broader medical input.

What Do Patients Often Ask Me About Vestibular Rehab?

One question patients often ask me is whether vestibular rehab is just a set of balance exercises they could find online. The exercises themselves are often simple. What takes the time is choosing the right ones for the problem the testing found, setting a dose the person can recover from, and changing both as the retests come in.

Another question I hear is whether feeling a little worse after a session means it is not working. Feeling somewhat worse at first is common, so I ask people to tell me how they felt that evening and the next morning, as well as during the exercise. A reaction that settles is useful information, and one that lingers for hours tells me the dose needs to change.

People also ask what the first visit involves. It is the 120-minute neurodiagnostic assessment described above, and the results are explained in plain terms before any program is suggested.

"Then we did the full examinations like eye tracking and balance test and he explained my results and what they mean for my symptoms."

From a Google review

California Brain & Spine Center in Calabasas is where Dr. Alireza Chizari, DC, DACNB, provides functional neurology evaluations and neurological rehabilitation for dizziness and balance problems. Patients come from across the West Valley and Los Angeles, including Agoura Hills just along the 101, and the assessment is the same wherever someone starts.

What Else Do People Ask About Vestibular Rehabilitation?

These are questions about vestibular rehabilitation that come up at a first visit and are not answered above.

Where Does Vestibular Rehabilitation Start?

Vestibular rehabilitation starts with knowing which part of the balance system needs the work, and that is what I want you to understand by the end of a first visit.

Adaptation suits a reflex that is out of step with head movement, habituation a trigger that sets off too much, and substitution an input that stays limited, with a maneuver first when the cause is BPPV. If dizziness is shaping how you drive, work or move through a store, it is worth finding out which of those applies to you.

California Brain & Spine Center | (818) 649-5300 | Calabasas, CA 91302. You can book a complimentary consultation online at californiabrainspine.janeapp.com.

This content is for educational purposes only and is not medical advice. Consult a qualified healthcare provider about your specific situation.