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Exercises and Benign Paroxysmal Positional Vertigo (or BPPV)

Vestibular rehabilitation has developed through recent years and now tends to be grouped into three main approaches of habituation, substitution and adaptation:


1. Habituation

This approach encompasses repeated exposure to a movement that is symptomatic, with a reduction in symptoms over time.  Your physiotherapist will identify eye, head or body movements to practice and gradually increase our tolerance over time.  The oldest approach of exercises, the Cawthorne-Cooksey Exercises are a form of habituation approach, however, should not be the only approach included in a rehabilitation program for a vestibular condition.


2. Substitution

This approach is aimed at using alternative strategies to maintain visual stability when vestibular function is lost or compromised.  Implementing a substitution for visual stability, is not as efficient as the primary method using the vestibulo-ocular reflex.  However, it can be useful starting point in rehabilitation programs and is important when bilateral peripheral problems are evident. 

 3. Adaptation

This is linked to the plasticity and adaptability of the vestibular system.  Specific exercises that target visual stability are the basis of the adaptation approach, with variations on distance, text size, standing surface, background and speed used to progress the difficulty.  This is the main focus of evidence-based vestibular rehabilitation.


Following a thorough assessment, other treatments can be included, such as:

  • gait re-education

  • general balance

  • relaxation

  • muscle strengthening

  • education and discussion of strategies i.e. safety issues

  • a goal-based approach


If visually induced dizziness is present, then adding sensory re-weighting and exposure to visual motion exercises should be included later. 


Treatment plans are customised and individualised based on the assessment findings.  Research has shown that supervision is required for vestibular rehabilitation to be effective.  Therefore, whilst a home exercise program will be provided for practice independently every day, follow up should be arranged with the physiotherapist to review and progress rehabilitation. 


In the presence of benign paroxysmal positional vertigo (BPPV) then positional tests such as the Dix-Hallpike and roll tests, and treatment manoeuvres such as the Epley manoeuvre can be completed.

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