This document discusses vestibular rehabilitation for patients experiencing dizziness and vertigo. It outlines the history of vestibular rehabilitation and describes common causes of dizziness such as lightheadedness, disequilibrium, and vertigo. Diagnostic techniques including head impulse tests and positional testing are used to identify vestibular disorders like benign paroxysmal positional vertigo. Physical therapy interventions for various vestibular conditions are then discussed, including repositioning maneuvers for BPPV, gaze stability and gait exercises for unilateral vestibular hypofunction, and habituation exercises. The conclusion emphasizes that movement is required for the vestibular system to recover from most lesions.

1. Vestibular Rehabilitation
HISTORY
 Cawthorne and Cooksey – First clinicians to offer exercises for
dizziness and vertigo.
 Harold Schuknecht – Cupulolithiasis theory.
 John Epley – Canalithiasis theory – Revolutionized treatment for
BPPV.
DIFFERENTIAL DIAGNOSIS FOR DIZZY PATIENT
 LIGHT HEADEDNESS – Feeling that fainting is about to occur
.(Causes – Hypotension, Hypoglycaemia, or anxiety)
 DISEQUILIBRIUM – Sensation of being off balance. (Causes –
nonvestibular problems – decreased somatosensation or weakness
in the lower extremeties)
 VERTIGO – Illusion of movement. (Causes- pathology within the
vestibular periphery or along the vestibular pathways)
 OSCILLOPSIA – Experience that objects in the visual
environment that are known to be stationary are in motion.(Cause
– Vestibular hypofunction)
DIAGNOSTIC TECHNIQUES
 Careful history
 Clinical examination – Assessment of eye movements, posture and
gait
 HEAD IMPULSE TEST – Assess semicircular canal function.

2.  HEAD SHAKING INDUCED NYSTAGMUS – Diagnosis of
people with asymmetry of peripheral vestibular input to central
vestibular regions.
 POSTIONAL TESTING – To identify whether otoconia have
been displaced into the SCC BPPV. The Dix – Hallpike test
commonly used to verify displaced otoconia.
 DYNAMIC VISUAL ACUITY – Measurement of visual acquity
during self – generated horizontal motion of the head.
 POSTURE & BALANCE TESTING – Determination of a
patient’s functional status. Testing includes static balance, weight
shifting, automatic postural responses and ambulation.
PHYSICAL THERAPY INTERVENTION
Vestibular Rehabilitation refers to interventions such as
repositioning techniques, vestibular adaptation exercises, habituation
excercices, and general exercise to improve muscle force, gait or
balance.
 BENIGN PAROXYSMAL POSITIONAL VERTIGO –
Nystagmus is generated when SCC with displaced otoconia are
placed into gravity – dependent positions, as in the Dix-Hallpike
test.
TREATMENT DIAGNOSIS
Canalith Repositioning Maneuver
(CRM)
BPPV due to Canalithiasis
Liberatory Maneuver BPPV due to Cupulolithiasis
Brandt-Daroff Exercises Persistent BPPV unresolved with
CRM/Liberatory
Residual vertigo without

3. nystagmus
Maybe useful for the patient who
cannot tolerate CRM.
 UNILATERAL VESTIBULAR HYPOFUNCTION – Recovery
time upon initiating vestibular rehabilitation averages 6 to 8 weeks.
 Primary focus – gaze and gait stability exercises.
 The two primary paradigms of vestibular adaptation are X1 (times
1) and X2 execises (times 2).
 X1 – Patient is asked to move the head horizontally (and vertically
if appropriate) as quickly as possible while maintaining focus on a
stable target.
 X2 – Patient to move the head and target in opposite directions.
 BILATERAL VESTIBULAR HYPOFUNCTION – Designed to
address the primary complaints of gaze instability during head
motion, disequilibrium, and gait ataxia.
 Other recommended activities – execises in a pool and Tai Chi.
 Habituation exercises do not work for the patient with a bilateral
vestibular loss.
 CENTRAL VESTIBULAR LESION – Time to recovery will be
6 months or more and may be incomplete.
 Though vestibular rehabilitation offers promise for treating persons
with Traumatic brain injury, it may not always be the treatment of
choice due to its irritative nature.

4.  NON VESTIBULAR DIZZINESS – Vestibular rehabilitation
techniques similar to those patients with true vestibular pathology.
 CONCLUSION – The vestibular system requires movement to
recover from most lesions.