Vestibular Physiotherapy for Vertigo

By: Paul Messner, PT
February 7, 2023
Editors: Ryan Davey, PhD and Lindsay Davey, MScPT, MSc, CDT

Vertigo is a symptom of an inner ear disorder, the most common cause of which is called Benign Paroxysmal Positional Vertigo (BPPV). Specialized Vestibular Physiotherapy can be used to treat cases of vertigo caused by BPPV.

Do I have vertigo or just ‘dizziness’?

Although it’s common to use the terms ‘dizziness’ and ‘vertigo’ interchangeably in everyday speech, these are actually distinct symptoms caused by very different underlying issues. Whereas dizziness is a feeling of light-headedness, faintness, or unsteadiness, vertigo is described as a spinning sensation when there is no motion – either the individual feels that they are spinning when they are not, or that the world around them is. Vertigo is much less common in adults than dizziness (unless of course you’ve just stepped of a ride at the local fair or just finished attempting a pirouette!).

What causes vertigo?

Vertigo is most frequently caused by an issue with the inner ear (an area known as the ‘vestibular labyrinth’).  The most common of these inner ear issues is Benign Paroxysmal Positional Vertigo (BPPV), but an infection, disease, or injury can also cause vertigo. With BPPV, tiny calcium carbonate crystals (called ‘canaliths’ or ‘otoconia’) normally found in one area of the inner ear (called the ‘utricle’), become dislodged and move into the semicircular canals elsewhere within the inner ear. The function of the semicircular canals is to help control our balance by detecting head position, specifically rotation. Not surprisingly then, when the crystals move into these sensitive ear canals it disrupts their function causing the symptom of vertigo.

BPPV symptoms typically last seconds to minutes and are not associated with hearing loss or other neurologic signs or symptoms. Sensations of vertigo when lying down or changing positions is a strong indicator of BPPV.  The condition is easily diagnosed with the Dix-Hallpike and Supine Roll maneuvers, described below.

BPPV can be caused by a multitude of conditions including Meniere’s Disease, Vestibular Neuritis, Vestibular Labryinthitis, as well as ear surgery, concussion, and migraine headaches.  BPPV can also be idiopathic, meaning, arising spontaneously or of unknown cause.

How is Benign Paroxysmal Positional Vertigo (BPPV) diagnosed?

BPPV does not show up on CT scans or MRIs, though these tests may be performed in order to rule out other conditions or get a better look at the inner ear in more detail. Instead, a diagnosis is made by a health professional who takes a detailed symptom history and performs specific tests, typically the Dix-Hallpike or Supine Head Roll maneuvers. These are physical tests where the practitioner moves the patient’s head and monitors their eye movement and reported symptoms. A positive test for BPPV would arise if upon head movement the patient’s eyes move rapidly and rhythmically in one direction for a short period of time (called ‘nystagmus’). This outcome is strongly indicative of the presence of canalith crystals in the semi-circular canals of the inner ear, and therefore used to diagnose BPPV.

The Dix-Hallpike maneuver involves assisting the patient in moving from sitting to lying down, with their head turned 45 degrees in one direction and slightly extended. The practitioner makes observations of the onset of vertigo symptoms and nystagmus (involuntary eye movement) that is indicative of BPPV.  This test is repeated on both sides, which helps determine which inner ear is the symptomatic side.

The Supine Head Roll maneuver involves a patient lying on their back and the practitioner rotating their head 90 degrees in one direction and observing the eyes for nystagmus.  Once it subsides, the head is moved to a neutral position, and then rotated 90 degrees in the other direction, again looking for signs of nystagmus. Side-lying options are also possible for performing these tests.

Vestibular Physiotherapy for Benign Paroxysmal Positional Vertigo (BPPV)

Vestibular physiotherapy is highly effective for the treatment of vertigo caused by BPPV. There are several position-based techniques that are effective at restoring the location of canalith crystals back to their proper position within the inner ear (think of rolling a ball along a curved track).  Physiotherapists trained in vestibular rehabilitation can perform these techniques with excellent results and can also direct the patient on a home program for continued care. Techniques used in Vestibular Physiotherapy include the Epley, Gans, Liberatory (Semont), Gufoni, Brandt-Daroff Maneuvers and the Lempert Roll. These techniques can be used to treat the various sub-types of BPPV including anterior, posterior or horizontal canalithiasis, and cupulolithiasis.

In addition to relocating misplaced canalith crystals, Vestibular Physiotherapists may employ traditional musculoskeletal physiotherapy techniques particularly at the neck and shoulders, in order to optimally manage a patient’s BPPV symptoms. Interestingly, in patients with vertigo the central nervous system will act automatically to restrict neck movement. This self-defence mechanism is an attempt by the body to avoid positions that provoke symptoms and to create more ‘stability’. However, it can also unintentionally initiate significant muscle tension, joint stiffness, pain, headaches, and dizziness (‘cervicogenic dizziness’). This same self-defence mechanism (and its unintended side effects) is often observed in individuals who have sustained a whiplash or concussion injury.  Manual therapy, acupuncture, massage, and dry needling can be used to treat the neck symptoms that often occur alongside the vertigo symptoms in patients with BPPV.

Vestibular Physiotherapists may provide vertigo-specific home exercises, as well as other exercises to address any neck-specific issues. Home exercises for vertigo are designed to decrease involuntary eye movement (‘gaze stabilization’), to prevent a condition that affects near vision and eye muscle coordination called ‘convergence insufficiency’, and to encourage good postural stability (how you support your head) when at rest and in motion.  All of these approaches can further help reduce the symptoms of vertigo. Symptoms can also be diminished through ‘habituation’ techniques that can help a patient learn to cope with and be less sensitive to persisting feelings of vertigo, so that they can carry on with their daily life.

The goal of Vestibular Physiotherapy is to resolve the underlying cause of BPPV by relocating canalith crystals and thus to resolve the sensation of disequilibrium and oscillopsia (the illusion of an unstable environment). Vestibular Physiotherapy reduces fall risk and improves balance while walking, and helps patients maintain clear vision during head movement.

Does clinical evidence support Vestibular Physiotherapy for vertigo?

There is much evidence to support Vestibular Physiotherapy as the first-line approach to the treatment of vertigo and balance disorders stemming from an inner ear dysfunction such as BPPV. Evidence Based Clinical Practice Guidelines from The American Physical Therapy Association indicates that vestibular rehabilitation provides substantial benefit to patients with acute or subacute unilateral (one-sided) vestibular dysfunction, and should be considered for any patients experiencing dizziness, disequilibrium, motion sensitivity, oscillopsia or balance disorders (ref 1). With acute-onset vertigo, vestibular physiotherapy is widely considered to be the best first-line approach to resolve symptoms, often in a single or very few sessions, in many cases.

A study by Horak et al. evaluated the effectiveness of vestibular rehabilitation compared to the use of specific vestibular medications, on vertigo and imbalance. The vestibular rehabilitation group had a significant improvement in postural stability and vertigo. The group receiving vestibular medications did not demonstrate improvement (ref 2).  Along these same lines, a prospective observational study by Shepard et al. showed certain medications actually suppressed the vestibular system and have been shown to prolong recovery time (ref 3).

In summary, Vestibular Physiotherapy is a highly effective and evidence-based approach for the treatment of BPPV that can meaningfully improve the quality of life in individuals with vertigo.

About the Author

Paul Messner is an orthopaedic and vestibular physiotherapist at Toronto Physiotherapy. He has formal training in Advanced Vestibular Rehabilitation and regularly treats acute BPPV and vertigo in his practice.  He has also worked with patients burdened by complex diagnoses such as Ménière’s disease and Mal de Debarquement Syndrome who have achieved positive results under his care.


  1. Hall C., Herdman, S., et al. Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Updated Clinical Practice Guideline from the Academy of Neurologic Physical Therapy of the American Physical Therapy Association. J Neuro Phys Ther. 2022, 46(2), 118;
  2. Horak, F., Jones-Rycewicz, C, et al. Effects of vestibular rehabilitation on dizziness and imbalance. Otolaryngol Head Neck Surg. 1992, 106(2), 175;
  3. Shepard N., et al. Vestibular and balance rehabilitation therapy. Ann Otol Rhino. 1993, 103(3 Pt 1), 198;

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