Advanced Vestibular

The following are advanced vestibular exercises: 

Walking with head turning:  Walk in a straight line turning your head from one side to the other every four steps.  As this gets easier, try turning every three steps, then every other step.

Hang a visually confusing piece of fabric on the wall (small checkerboard works quite well) and place a card in the middle of the fabric.  Stand about 18 inches away from the card, focus on one letter, and begin to shake your head back and forth as if saying, “no.”  This is a progression of the VOR exercises in the post entitled “Vestibular Rehab Exercises.”

To advance the exercises even more, stand on an unstable surface, such as a cushion or rocker board:

For those who struggle with ongoing positional vertigo, even after an Epley Maneuver.  The following are called Habituation Exercises.  I would like to again note that this post is to serve as a reminder of things taught in therapy.  You should not try these exercises to treat vertigo that has not been evaluated by your physical therapist:

Begin by sitting upright on the edge of the bed.  Turn your head to the right and lie down on your left side.  Wait until dizziness stops plus 30 seconds.

Return to upright, wait 30 seconds, then turn your head to the left, and lie down on your right side.  Wait until dizziness stops plus 30 seconds, and return to upright again. 

Repeat this process for 5 to 10 minutes two or three times per day.  Over time, it should make you less dizzy. 


Vestibular Rehab Exercises

Here are the most common exercises I give for

Vestibular Rehabilitation Therapy (VRT).


Visual tracking:  Hold a card 15 inches in front of you.  Hold your head still and focus on one letter on the card.  Begin to move the card back and forth while remaining focused on the same letter on the card.  After one minute, begin to move the card up and down or in diagonal patterns.  If this is easy, and does not make you dizzy, you may discontinue this one.  Some people are very visually dependent for balance.  These people may get dizzy with visual challenges, and will benefit from these exercises. 

Saccades:  Hold two cards about 18 inches apart, and 15 inches in from to of you. Look from card to card focusing briefly on the writing on each card.  Try to pick up speed as you continue to jump from card to card.  Move only your eyes. Do not move your head or the cards.  After one minute switch to vertical and diagonal placement of the cards. 


VOR (Vestibulo-Ocular Reflex): This time hold the card still, focus on one letter on the card, and begin to turn your head from side to side as if shaking your head “no.”  Try to increase speed but remain focused on your chosen letter.  Progress by shaking your head vetically, or in a diagonal direction.  Try to comtinue for one minute at a time. 

Note: It is normal to feel dizzy while doing these exercises.  Try to stick them out, as this is what allows your brain to adapt to the movement.  The intensity of your symptoms will decrease with repetition.  If you must stop, keep your eyes open and stare at a non-moving object. Try to perform these exercises several times per day.

Dizziness and Safety

Do you ever feel like you just got off a crazy ride when you are nowhere near the county fair? Dizziness becomes more common with age, but you don’t need to visit the county fair to initiate the feeling. Vestibular problems, or dizziness, grows in frequency after age 65. Balance disorders are a compelling problem because of the increased risk of falling. Falls among the elderly result in approximately 1.6 million emergency room visits yearly, and are the 6th leading cause of death in older adults. Approximately 60% of falls occur in the home.

The human body relies on the input from at lest three independent systems to interpret its position in space and regulate balance.  It then coordinates righting reactions and stabilizing movements through muscle activity. The inner ear, or Vestibular System, provides feedback to the brain about the head’s movement through space. Vision gives us a sense of where we are in relation to our surroundings, and nerves in our muscles, joints, and skin give us a sense of position or “proprioception.” Take any one of the three away, and balance is impaired.  It’s not in the literature that I can find, but I believe that our hearing plays a role in equilibrium as well.  Perhaps I should perform some research in that area!

There are ways to improve balance, and to treat vestibular disorders. A vestibular disorder called vertigo is recognized when the world appears to be spinning, when in fact you are holding still.  There are many causes for vertigo, including crystals or swelling of the fluid in the inner ear, as well as inflammation of the nerve to the inner ear.  An “Epley Maneuver” will quickly treat vertigo caused by changes in head position, while head and eye exercises can greatly improve vertigo that is due to swelling or nerve problems.  Other types of imbalance include light-headedness, instability, and loss of position sense.  The proper exercises are key for training your body to react to the inputs; balance training is essential.

For safety’s sake there are several ideas that should be considered, especially if someone in your home who is at risk to fall.  For example: rooms and hallways should be well-lit, stairs should have handrails, and vision checks should be done on a regular basis. Grab bars in the bathroom can be a big help. Throw rugs are a constant threat, as they make it easy to snag to the foot. Finally, have your family doctor perform a medication review, as there are many medications that can cause unsteadiness.

 I need to give some credit on this post to my colleague Tony Stump.  We published an earlier version of this article in a couple of places, and I can’t remember which part of it I wrote, and which part he wrote (old age creeping in).

Balanced Perspective

A Balanced Perspective

Did you know…

~Each year one third of adults over 65, and half of those over 85, fall?

~Falls among the elderly result in approximately 1.6 million ER visits yearly?

~Falls are the 6th leading cause of death in older adults.

~Approximately 40% of all nursing home admissions are related to falls?

Did you know…

~People who begin exercising in their 60s have positive results similar to those who have been active all their lives?  They also have better postural stability than their sedentary counterparts who were active in their 30s and 40s.

~Of numerous fall prevention interventions such as vision checks, and home environment changes, exercise is the only intervention which alone has been shown to decrease falls in the elderly.

~Strength and balance training are both important elements of an exercise program for fall prevention.

~I believe in setting up an individualized program of strength and balance training for each client in need, taking the time to understand each patient’s problem areas and goals, and working with the client and family to find the best possible outcome.


Patnode-Krause,J, Wilmarth, M., Exercise and Fall prevention in Seniors, Today in PT., July 20, 2009, 33-37

Gardner, M Robertson C, Campbell, J. Exercise in Preventing Falls and Fall-Related injuries in older people: a review of randomized controlled Trials. Br J Sports Med. 200;34:7-17

Skelton DA, Effects of physical activity on postural stability.  Age and Aging. 2001;30-s4:33-39

Home Epley

For those who have previously been diagnosed, yet have recurrent Benign Paroxysmal Positional Vertigo, BPPV, The Epley Maneuver can be performed at home.  Following are instructions to help you.  This is the procedure for the right ear:

Begin by sitting on your bed and turning your head to the right 45 degrees and lying down with your  head over the edge of a pillow.  Your head should lie all the way back to the table, or about 30 degrees extension.  Hold this position about one minute, or until spinning has stopped + 20 seconds.


Next: do not lift your head, but turn it to 45 degrees to the left.  Again, hold about a minute or until spinning has stopped + 20 seconds.





Third, roll onto your left shoulder, but keep your head turned 45 degrees compared to your body.  You will end up staring at the floor in front of you.  Once again, hold 30 seconds, or until spinning stops +20 seconds. 





Finally, slide your feet over the edge of the bed, and move up sideways into a sitting position.  Keep your chin down as you arise, and sit for a few minutes to regain your equilibrium. 

Positional Vertigo

Benign Paroxysmal positional Vertigo, BPPV, is the most common form of vertigo.  Up to 20% of people over 65 may have this condition at any given time.  It is characterized by feelings of dizziness or spinning with changes in head position.  BPPV causes brief bouts of vertigo that usually last less than a minute, but can cause falls, nausea, and can be very disconcerting.  Over time the human brain adapts to this dizziness until the person may feel unsteady most of the time, or may begin to experience neck pain or headaches from “bracing against” that dizzy feeling.

The problem originates in the inner ear in the semicircular canals (shown aqua blue).

Crystals normally found in one part of the inner ear, make their way to the semicircular canals, and lie against nerves, telling the brain that movement has continued long after the head has actually stopped.  This causes confusion in the brain, and>>vertigo!

Once diagnosis of BPPV has been made, a simple series of  head movements can be completed to move the offending crystals out of the way, where they won’t cause vertigo.  Following are photos of the treatment for left-sided BPPV.  This is called an Epley Maneuver, after the doctor who first practiced it:


VERTIGO:  A whirling senstion in the head with a tendancy to fall

One of the things that has become a specialty for me in physical therapy has been treatment of dizziness and vertigo.  Vertigo refers to a sense of spinning of self or environment.  Dizziness is a wastebasket term that may mean being light-headed, woozy, or possibly spinning.  A physical therapist’s job is to assess the symptoms, and determine the underlying cause of the problem.

When I meet a person with dizziness for the first time, I observe his or her movement and gait.  Then I ask questions about the nature and history of the problem.  Symptoms can arise from the inner ear, the brain, the nerves in between, or they can be a side effect of medication, blood pressure changes, or other diseases.  A complete evaluation is necessary to determine the causes.

With that said, I plan to post some of the exercise programs I prescribe for my clients with dizziness.  Not every treatment posted here is good for every person with dizziness.  This is not meant to diagnose, or be a substitution for evaluation and treatment by a qualified professional.  The posts will be to assist my patients in remembering what they have learned in the office.  I will post these under HOME PROGRAMS.