Vestibular Disorders.
What is a vestibular disorder?
The vestibular system — comprising the inner ear structures and their connections to the brain — provides the sensory information the nervous system uses to detect motion, maintain balance and stabilise gaze during head movement. When any component of this system is damaged or dysfunctional, the result is a vestibular disorder — a condition characterised by dizziness, vertigo, imbalance and the visual disturbances that accompany abnormal vestibular signalling.
Vestibular disorders are among the most common causes of dizziness in adults, accounting for approximately 40 to 50% of dizziness presentations in general practice. They are frequently underdiagnosed or misattributed to other causes — many patients spend months or years seeking a diagnosis before the vestibular origin of their symptoms is identified. Vestibular physiotherapy is one of the most effective and evidence-based treatments available and produces excellent outcomes for many presentations that patients have been told are untreatable or will simply resolve with time.
Types of vestibular disorders
Benign paroxysmal positional vertigo (BPPV) is by far the most common vestibular disorder and one of the most satisfying conditions to treat in physiotherapy — because the treatment, when correctly applied, is often immediately effective. BPPV occurs when otoconia — calcium carbonate crystals that normally reside in the utricle of the inner ear — become dislodged and migrate into one of the semicircular canals. When the head moves in the plane of the affected canal, the displaced crystals cause abnormal fluid movement, sending a false signal of rotation to the brain. The result is a brief but intense episode of rotational vertigo triggered by specific head positions — typically rolling over in bed, looking up, bending forward or lying down.
BPPV is diagnosed by the Dix-Hallpike test — a standardised positional test that reproduces the characteristic nystagmus (eye movement) and vertigo of posterior canal BPPV. The Epley manoeuvre — a sequence of head positions that guides the displaced crystals back out of the semicircular canal into the utricle — resolves posterior canal BPPV in the majority of patients within one to three treatment sessions.
Horizontal canal BPPV is treated with the Barbeque Roll or Gufoni manoeuvre. BPPV is highly responsive to physiotherapy and patients who have been living with positional vertigo for months — sometimes years — frequently achieve resolution within a single session.
Vestibular neuritis — inflammation of the vestibular nerve, most commonly following a viral infection — produces a sudden onset of severe continuous vertigo, nausea, vomiting and difficulty walking that typically peaks in the first 24 to 48 hours and then gradually subsides. The acute phase is managed medically with vestibular suppressants. After the acute phase settles — typically within one to two weeks — vestibular rehabilitation therapy is the most evidence-based intervention for accelerating recovery and reducing the persistent dizziness, imbalance and visual disturbance that can linger for months after the initial insult.
Labyrinthitis — inflammation affecting both the cochlea and vestibular nerve — produces similar symptoms to vestibular neuritis with the addition of sensorineural hearing loss. Management follows similar principles.
Menière's disease — a condition of abnormal endolymph pressure in the inner ear — produces episodic attacks of rotational vertigo lasting 20 minutes to several hours, associated with fluctuating sensorineural hearing loss, tinnitus and aural fullness. Between attacks, patients may have persistent mild imbalance and hearing disturbance. Management is primarily medical — lifestyle modifications, dietary sodium restriction, medication — with vestibular rehabilitation playing a role in managing the persistent inter-attack imbalance and the compensation for any permanent vestibular damage from repeated attacks.
Persistent postural-perceptual dizziness (PPPD) — previously called chronic subjective dizziness or phobic postural vertigo — is a chronic functional vestibular disorder characterised by persistent dizziness and unsteadiness provoked by upright posture, motion and visually complex environments. It frequently develops following an acute vestibular event and involves a maladaptive sensitisation of the postural control system. Management combines vestibular rehabilitation with cognitive-behavioural approaches and in some cases pharmacological treatment.
Cervicogenic dizziness — dizziness arising from the cervical spine rather than the inner ear — is a recognised but controversial entity where dysfunction of the upper cervical proprioceptors produces dizziness, imbalance and neck-related symptoms. It frequently coexists with cervicogenic headache and whiplash and requires cervical spine treatment alongside vestibular rehabilitation.
What are the symptoms?
Vestibular symptoms span a spectrum from brief positional vertigo (BPPV) to constant dizziness and imbalance (vestibular neuritis, PPPD). Common symptoms include rotational vertigo — a sensation that the room is spinning — dizziness or lightheadedness, imbalance and unsteadiness, oscillopsia (visual blurring or bouncing during head movement), nausea, difficulty with visually complex environments such as supermarkets or busy streets, and fatigue from the continuous effort of compensating for abnormal vestibular input.
The pattern of symptoms — whether vertigo is positional or spontaneous, brief or prolonged, associated with hearing changes, and what triggers and relieves it — is the most diagnostically useful information for identifying the type of vestibular disorder.
How is it diagnosed?
A comprehensive evaluation usually includes medical history review discussing onset, nature and associated triggers, physical and neurological examination to identify issues with balance, gait and coordination, vestibular tests measuring eye movement to provide clues about inner ear function, hearing tests as the auditory system is linked to the vestibular system, and imaging such as MRI in some cases.
The Dix-Hallpike test is the standard diagnostic test for BPPV. Video-nystagmography (VNG) provides objective assessment of vestibular function through measurement of eye movements during provocation tests. Audiometry assesses hearing function. Any vestibular presentation with neurological symptoms — sudden severe headache, diplopia, facial numbness, difficulty swallowing or dysarthria — requires urgent medical assessment to exclude central causes including stroke and cerebellar pathology.
How can physiotherapy help?
Vestibular Rehabilitation Therapy (VRT) is a form of physiotherapy specifically designed for vestibular disorders. It includes manual therapy and specific manoeuvres to restore function of the inner ear and neck movement, and habituation exercises to reduce symptoms of dizziness by repeatedly exposing the patient to specific movements.
For BPPV, canalith repositioning manoeuvres — Epley, Semont, Barbeque Roll, Gufoni — are the primary treatment and produce immediate or near-immediate resolution in the majority of cases. These are highly specialised techniques that require correct identification of the affected canal and correct execution of the repositioning sequence. A canal confusion manoeuvre incorrectly applied can worsen BPPV.
For vestibular neuritis and other peripheral vestibular hypofunction, gaze stabilisation exercises — training the vestibulo-ocular reflex to maintain clear vision during head movement — are the cornerstone of VRT. These involve progressively more challenging head movements while maintaining visual focus, systematically promoting the central compensation that allows the nervous system to adapt to the asymmetric vestibular input. Balance retraining under increasingly challenging conditions — eyes closed, unstable surfaces, dual-tasking — progressively restores postural control.
For PPPD, habituation exercises — progressive exposure to the movement and visual environments that provoke symptoms — combined with relaxation strategies and activity pacing address the central sensitisation that maintains symptoms beyond the acute vestibular event.
Cervicogenic dizziness is treated with cervical manual therapy, deep cervical flexor retraining and postural correction targeting the upper cervical proprioceptive dysfunction.
Our physiotherapists Yulia Khasyanova and Mauricio Bara both have experience in vestibular disorders and VRT and are members of the Australian Physiotherapy Association. Yulia's specialist experience in complex neurological and connective tissue conditions is particularly relevant for vestibular presentations in the context of hypermobility and cranio-cervical instability.
To book or find out more, call us on 07 3706 3407 or book online below. We see patients from across Brisbane's southside including Tarragindi, Coorparoo, Holland Park, Greenslopes and Mt Gravatt.
The vestibular system — comprising the inner ear structures and their connections to the brain — provides the sensory information the nervous system uses to detect motion, maintain balance and stabilise gaze during head movement. When any component of this system is damaged or dysfunctional, the result is a vestibular disorder — a condition characterised by dizziness, vertigo, imbalance and the visual disturbances that accompany abnormal vestibular signalling.
Vestibular disorders are among the most common causes of dizziness in adults, accounting for approximately 40 to 50% of dizziness presentations in general practice. They are frequently underdiagnosed or misattributed to other causes — many patients spend months or years seeking a diagnosis before the vestibular origin of their symptoms is identified. Vestibular physiotherapy is one of the most effective and evidence-based treatments available and produces excellent outcomes for many presentations that patients have been told are untreatable or will simply resolve with time.
Types of vestibular disorders
Benign paroxysmal positional vertigo (BPPV) is by far the most common vestibular disorder and one of the most satisfying conditions to treat in physiotherapy — because the treatment, when correctly applied, is often immediately effective. BPPV occurs when otoconia — calcium carbonate crystals that normally reside in the utricle of the inner ear — become dislodged and migrate into one of the semicircular canals. When the head moves in the plane of the affected canal, the displaced crystals cause abnormal fluid movement, sending a false signal of rotation to the brain. The result is a brief but intense episode of rotational vertigo triggered by specific head positions — typically rolling over in bed, looking up, bending forward or lying down.
BPPV is diagnosed by the Dix-Hallpike test — a standardised positional test that reproduces the characteristic nystagmus (eye movement) and vertigo of posterior canal BPPV. The Epley manoeuvre — a sequence of head positions that guides the displaced crystals back out of the semicircular canal into the utricle — resolves posterior canal BPPV in the majority of patients within one to three treatment sessions.
Horizontal canal BPPV is treated with the Barbeque Roll or Gufoni manoeuvre. BPPV is highly responsive to physiotherapy and patients who have been living with positional vertigo for months — sometimes years — frequently achieve resolution within a single session.
Vestibular neuritis — inflammation of the vestibular nerve, most commonly following a viral infection — produces a sudden onset of severe continuous vertigo, nausea, vomiting and difficulty walking that typically peaks in the first 24 to 48 hours and then gradually subsides. The acute phase is managed medically with vestibular suppressants. After the acute phase settles — typically within one to two weeks — vestibular rehabilitation therapy is the most evidence-based intervention for accelerating recovery and reducing the persistent dizziness, imbalance and visual disturbance that can linger for months after the initial insult.
Labyrinthitis — inflammation affecting both the cochlea and vestibular nerve — produces similar symptoms to vestibular neuritis with the addition of sensorineural hearing loss. Management follows similar principles.
Menière's disease — a condition of abnormal endolymph pressure in the inner ear — produces episodic attacks of rotational vertigo lasting 20 minutes to several hours, associated with fluctuating sensorineural hearing loss, tinnitus and aural fullness. Between attacks, patients may have persistent mild imbalance and hearing disturbance. Management is primarily medical — lifestyle modifications, dietary sodium restriction, medication — with vestibular rehabilitation playing a role in managing the persistent inter-attack imbalance and the compensation for any permanent vestibular damage from repeated attacks.
Persistent postural-perceptual dizziness (PPPD) — previously called chronic subjective dizziness or phobic postural vertigo — is a chronic functional vestibular disorder characterised by persistent dizziness and unsteadiness provoked by upright posture, motion and visually complex environments. It frequently develops following an acute vestibular event and involves a maladaptive sensitisation of the postural control system. Management combines vestibular rehabilitation with cognitive-behavioural approaches and in some cases pharmacological treatment.
Cervicogenic dizziness — dizziness arising from the cervical spine rather than the inner ear — is a recognised but controversial entity where dysfunction of the upper cervical proprioceptors produces dizziness, imbalance and neck-related symptoms. It frequently coexists with cervicogenic headache and whiplash and requires cervical spine treatment alongside vestibular rehabilitation.
What are the symptoms?
Vestibular symptoms span a spectrum from brief positional vertigo (BPPV) to constant dizziness and imbalance (vestibular neuritis, PPPD). Common symptoms include rotational vertigo — a sensation that the room is spinning — dizziness or lightheadedness, imbalance and unsteadiness, oscillopsia (visual blurring or bouncing during head movement), nausea, difficulty with visually complex environments such as supermarkets or busy streets, and fatigue from the continuous effort of compensating for abnormal vestibular input.
The pattern of symptoms — whether vertigo is positional or spontaneous, brief or prolonged, associated with hearing changes, and what triggers and relieves it — is the most diagnostically useful information for identifying the type of vestibular disorder.
How is it diagnosed?
A comprehensive evaluation usually includes medical history review discussing onset, nature and associated triggers, physical and neurological examination to identify issues with balance, gait and coordination, vestibular tests measuring eye movement to provide clues about inner ear function, hearing tests as the auditory system is linked to the vestibular system, and imaging such as MRI in some cases.
The Dix-Hallpike test is the standard diagnostic test for BPPV. Video-nystagmography (VNG) provides objective assessment of vestibular function through measurement of eye movements during provocation tests. Audiometry assesses hearing function. Any vestibular presentation with neurological symptoms — sudden severe headache, diplopia, facial numbness, difficulty swallowing or dysarthria — requires urgent medical assessment to exclude central causes including stroke and cerebellar pathology.
How can physiotherapy help?
Vestibular Rehabilitation Therapy (VRT) is a form of physiotherapy specifically designed for vestibular disorders. It includes manual therapy and specific manoeuvres to restore function of the inner ear and neck movement, and habituation exercises to reduce symptoms of dizziness by repeatedly exposing the patient to specific movements.
For BPPV, canalith repositioning manoeuvres — Epley, Semont, Barbeque Roll, Gufoni — are the primary treatment and produce immediate or near-immediate resolution in the majority of cases. These are highly specialised techniques that require correct identification of the affected canal and correct execution of the repositioning sequence. A canal confusion manoeuvre incorrectly applied can worsen BPPV.
For vestibular neuritis and other peripheral vestibular hypofunction, gaze stabilisation exercises — training the vestibulo-ocular reflex to maintain clear vision during head movement — are the cornerstone of VRT. These involve progressively more challenging head movements while maintaining visual focus, systematically promoting the central compensation that allows the nervous system to adapt to the asymmetric vestibular input. Balance retraining under increasingly challenging conditions — eyes closed, unstable surfaces, dual-tasking — progressively restores postural control.
For PPPD, habituation exercises — progressive exposure to the movement and visual environments that provoke symptoms — combined with relaxation strategies and activity pacing address the central sensitisation that maintains symptoms beyond the acute vestibular event.
Cervicogenic dizziness is treated with cervical manual therapy, deep cervical flexor retraining and postural correction targeting the upper cervical proprioceptive dysfunction.
Our physiotherapists Yulia Khasyanova and Mauricio Bara both have experience in vestibular disorders and VRT and are members of the Australian Physiotherapy Association. Yulia's specialist experience in complex neurological and connective tissue conditions is particularly relevant for vestibular presentations in the context of hypermobility and cranio-cervical instability.
To book or find out more, call us on 07 3706 3407 or book online below. We see patients from across Brisbane's southside including Tarragindi, Coorparoo, Holland Park, Greenslopes and Mt Gravatt.
