Vertigo Exercises - Treat Vertigo with These Specific Vestibular Rehabilitation Exercises

A part of the vertigo treatment plan is learning how to live with it, or to be more precise - learning how to bring back the balance into the life. Bringing back the balance for those suffering vertigo often mean putting it to a whole another level, compared to those who do not have such problems.

The exercises presented in this article are designed to challenge every single aspect of body balance (from the inner ear to proprioceptors in the joints), put the body „out of the comfort zone“ preparing it for the everyday tasks.

Before jumping in into the workout routines keep in mind one thing- take it slowly. It’s not a competition, you are not trying to get better in this so you could beat somebody, but to train your brain how to compensate vertigo as much as possible.

Vertigo refers to a specific type of dizziness. It is characterized by a sensation of movement even while you are standing or sitting still, or a feeling that the environment is moving around you. It can occur simultaneously with other types of dizzy feelings like light-headedness.

There are four main conditions that commonly cause vertigo:

1. Benign Paroxysmal Positional Vertigo

• Most common cause of vertigo
• Movement of the head causes short episodes of vertigo because dislodged pieces of inner ear “crystals” send mixed signals to the brain.

2. Labyrinthitis

• Ongoing vertigo with uncontrollable eye movements
• Caused by inflammation of the inner ear, often due to a virus.

3.  Ménière's Disease

• Sudden attacks of vertigo that last 1 – 6 hours after a build-up of pressure in the ear.

4. Vestibular Neuritis

• Can occur with hearing loss or tinnitus, and uncontrollable eye movements.
• Caused by inflammation of the vestibular nerve within the inner ear. 

Good news – rehabilitation exercises can help all of these causes of vertigo. But first, it's important to know why you have vertigo so you can pick the exercises that will best help your condition. 

Need help identifying why you feel dizzy? Read our Dizziness 101 guide → 

All of these conditions affect the “inner ear” or vestibular labyrinth – a series of fluid-filled canals, a large nerve, and a part of the brain that are in charge of monitoring your motion, balance, and proximity to other objects. Any motion within the fluid of the vestibular labyrinth is conducted via the vestibular nerve and interpreted by the brain as

Vestibular rehabilitation exercises can help the brain to find balance even when there is an issue with the inner ear. Classically, vestibular exercises were only safe to be performed by a physician but there have been new developments in exercises that are prescribed to be performed at home. 

What You Need to Know About Vertigo Rehabilitation Exercises

1. Diagnosis is essential before performing vertigo rehabilitation exercises. With so many causes of vertigo, exercises that will help one person can be harmful to another. Seek medical advice before performing any of these exercises.
2. Vertigo rehabilitation exercises won't trigger an attack of vertigo, but they will initially cause a flare up of some symptoms. It is normal to feel unsteady and dizzy during and shortly after performing the exercises – they are designed to push against your limits of balance and co-ordination to re-teach the vestibular network how to send appropriate signals to the brain. 
3. Physicians will prescribe exercises within the limits of your abilities. As you repeat the exercises, your symptoms will improve and you will be able to practice more exercises with a wider range of motion. Exercise-induced symptoms will disappear when you're ready to advance to more difficult exercises.
4. Rehabilitation exercises have been proven to reduce or even eliminate symptoms of dizziness between acute vertigo attacks. Stable vestibular disorders like labyrinthitis and neuritis have the best opportunity to have symptoms resolved with exercises, while it can be more difficult to see improvement in fluctuating conditions like Ménière's disease. In fluctuating conditions, vertigo exercises are most effective at reducing any symptoms of dizziness between acute attacks but not the attacks themselves.
5. To be successful at vertigo rehabilitation exercises, you need to be motivated and to have realistic expectations. You may feel worse when you begin the exercises – this is a confusing sign that the exercises are working!

CAUTION: Some vertigo rehabilitation exercises are safe to perform at home without the supervision of a physician, but others are dangerous and could lead to serious injury. Follow your physician's recommendations.

Exercises for Vertigo

The brain relies on signals from three things for balance – muscles, eyes, and the inner ear. Dizziness and balance issues arise when there are issues with any of these three. Rehabilitation exercises engage the eyes and muscles to train the brain to compensate for any problems with the inner ear. 

1. Cawthorne-Cooksey Exercises

Cawthorne-Cooksey exercises are designed to develop vestibular compensation. Vestibular disorders often affect only one ear, but the nervous system is unable to compensate for this imbalance. Instead, it reacts as if both inner ears are working correctly, resulting in symptoms of poor coordination and dizziness when moving the head. Luckily, the nervous system can be taught to adapt to the imbalance between inner ears, through a process called vestibular compensation. By repeating Cawthorne-Cooksey exercises, the nervous system learns to adapt.

These exercises also aim to relax the neck and shoulders, practice good balance, improve coordination and unprompted movements.

Cawthorne-Cooksey exercises range from simple eye movements through to complex movements like throwing and catching a ball. These exercises are generally safe to perform if you take them slow, but for best results speak to a physician about which exercises are most appropriate for your condition. 

·        A forum user reported that “I was given the cawthorne cooksley exercises and had immediate relief" - https://patient.info/forums/discuss/has-anyone-please-got-some-advice-for-vertigo--73015

·        Another reports that symptoms can increase after performing Cawthorne-Cooksey excises: “Having carried out a 10 minute session of Cooksey this morning I felt dizzier but reading previous comments I guess this is the same for everyone whilst the brain and body readjusts.” - https://patient.info/forums/discuss/vestibular-neuritis-any-recovery-stories--338874 

Remember – if the exercises are not inducing any feelings of dizziness, it may be time to increase the level of difficulty!

TIPS:

• To see improvement, Cawthorne-Cooksey exercises must be performed daily.
• CAUTION: Some Cawthorne-Cooksey exercises involve moving about, including walking up and down stairs. Do not attempt these advanced exercises until you can safely and steadily walk (and don't attempt the walking exercises until you have mastered the standing exercises!).

Learn more about Cawthorne-Cooksey exercises here →

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2. Gaze Stabilising Exercises

Gaze stabilising exercises will help to improve your balance as you walk by first training your eyes to focus on a stationary object while your head is moving. These exercises begin by fixing your eyes on an object in the distance and then performing easy, slow head movements. Even a slight tilt of the head can trigger dizziness at first, but this will decrease with repetition. The exercises then increase in difficulty to train the vestibular network to tolerate movements of the head and eventually to reduce dizziness while walking.

·        A 2004 trial showed that all vertigo patients who at-home gaze stabilising exercises showed improved balance, co-ordination and gait [6].

·        A vertigo forum user reported their experience of gaze stabilising excises exercise: “To begin with I would look at a small object, on a playing card, only moving my eyes and then gradually building up to moving my head, slowly... I persevered with the exercises along with medication and a series of alternative treatments. I'm pleased to say, although I still suffer, that the vertigo gradually improved and I have been driving again and get out and about.” - https://patient.info/forums/discuss/vrt-exercises-385326

CAUTION: Perform gaze stabilising exercises with assistance until you feel confident to practice on your own. Do not advance to more difficult exercises without supervision.

Learn more about Gaze Stabilising Exercises here →

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3. Interactive Video Games for Balance

Many people with vertigo have been using games on consoles like the Wii to improve their balance, coordination and resistance against vertigo. 

Users on vertigo forums report improvement in their symptoms, with one user saying:

·        The Wii fit is wonderful. I noticed a decrease in my symptoms after playing the balance games. I love the soccer ball game. It seemed to help my motion sick/dizzy feeling. - https://www.mvertigo.org/t/wii-fit/966/3

·        I have the Wii Fit. My vestibular therapist also recommended it. The visuals on some of the exercises are too much for me...it all depends on how dizzy you are before exercising. I think it can indeed help with balance because it's kind of like the balance machines at the doctor's...you can see your center of balance and adjust it. – https://www.mvertigo.org/t/wii-fit/966/12

If anecdotal evidence isn't enough for you, there is a study that supports using the the Nintendo Wii Balance Board as a tool for vestibular rehabilitation [6]. In particular, the bowling game within the Wii Fit Plus bundle acts as a Cawthorne-Cooksey exercise, and a “table tilt” game mimics gait stabilising exercise. Other titles that exercise balance skills include Super Monkey Ball: Step and Roll, Shaun White Snowboarding.

While these video games can help, they won't necessarily have as much of an impact as traditional vertigo exercises. The most improvement seems to occur when video games are used in conjunction with traditional vestibular rehabilitation therapies that are prescribed by a physician for the patient's particular requirements. 

EXERCISES FOR BENIGN PAROXYSMAL POSITIONAL VERTIGO 

While all types of vertigo can improve with the exercises described above, only benign paroxysmal positional vertigo (BPPV) will benefit from the following exercises that aim to dislodge particles within the inner ear that are characteristic for BPPV.

BPPV is characterized by short episodes of vertigo that are triggered by movement of the head. This includes moving the head along the neck axis (as in nodding “yes”), lying down, turning over, or sitting up from a horizontal position.

BPPV can be caused by calcium crystals inside the inner ear becoming detached and moving deeper into the canals where they trigger the vestibular nerve and send false messages of movement to the brain. Many of the exercises for BPPV are designed to dislodge and relocate these crystals to parts of the inner ear where they won't cause vertigo, or to reposition a part of the inner ear that may be “floating” in the wrong area.

·        A study in 2008 concluded that at-home exercises are a better treatment choice for chronic BPPV than medications [4]

Step 1: See a Doctor!

Before undertaking any exercises to treat BPPV, it is useful to know which part of the inner ear is affected so that you can choose the right exercise. Speak to your doctor about your symptoms of vertigo. They will likely perform a procedure called the Dix-Hallpike test to determine which canal of the inner ear is causing your vertigo, and whether you are experiencing canalithiasis or cupulolithiasis – find out more about these here →   

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1. EPLEY PROCEDURE FOR BPPV

The Epley Procedure is the go-to exercise to treat BPPV. It involves a series of movements designed to move dislodged crystals out of the canals of the vestibular network. Relocating the dislodged crystals can stop them from triggering vertigo.

·        In a 2015 prospective study, performing the Epley procedure was found to be more effective than medications in treating BPPV [5]

Epley maneuver is also used to treat BPPV, however, the one that affects posterior or anterior semicircular canals. The goal of the maneuver is also to relocate the crystals and provide relief from dizziness. Unlike Brandt-Daroff exercises that the patient may perform by himself, this maneuver is usually performed by a healthcare professional such as a medical doctor, occupational therapist, nurse or physical therapist. The maneuver is characterized by a very high success rate, ranging up to 95%. The maneuver was developed in 1980 by Dr. John Epley.

It is safest and most effective when performed by a physician, but there is a version of the Epley manoeuvre that is safe to do at home. It involves a series of movements involving lying down, turning the head side to side to a particular degree, and sitting back up.

The Epley Procedure is particularly effective for BPPV of the posterior and anterior canals, and can help to relieve canalithiasis but ask your physician if the Epley manoeuvre will be effective for you, and if is safe for you.

The Risks

Epley maneuver appears to be a safe and tolerable technique for long-term relief from vertigo in those who suffer from BPPV. Common adverse experiences may include mild and reversible nausea, vertigo or vomiting. In order to achieve maximum and sustainable results, three treatment sessions are recommended by experts.

CAUTION - Do NOT try the Epley Procedure if you have:

• Neck or back disease
• Vascular or heart conditions
• Retinal detachment

Effectiveness

Two randomized controlled clinical trials that investigated the effects of the Epley maneuver were mentioned above (2, 4). Both studies have demonstrated that Epley maneuver was most effective among several techniques. It also provided the best long-term results. It is important to emphasize that Epley maneuver was not tailored to be performed by the patient alone, but should be guided and monitored by a healthcare professional in order to allow the best possible results and ensure maximum patient safety.

Learn how to do at-home Epley procedure exercises  →

2. BRANDT-DAROFF EXERCISES FOR BPPV

These exercises are specifically tailored for the management of Benign Paroxysmal Positional Vertigo (BPPV). 

BPPV represents a condition where a tiny crystal is formed in the inner ear. This crystal shifts position during head movement, which sends confusing signals to the brain, inducing dizziness. Brandt-Daroff exercises represent a series of movements that aim to relieve dizziness and lightheadedness by breaking up the crystals or dislodging them.

What is the benefit of these exercises?

The exercises efficiently stop dizzy moments. Research demonstrated that repeated exposure to the feeling of dizziness causes the reduction in the severity of dizziness (8).

The Risks

The general idea behind these exercises is to produce the feeling of dizziness. Therefore, it is advised to perform the exercises in a safe environment, with another person on a side. There are instances when the exercises are challenging to perform due to the feeling itself, however, it is advised to proceed in such situations since there is a high probability that the exercises will bring relief (9).

Guidelines on how to perform the exercises

The Brandt-Daroff exercises are a series of rapid movements where moving the head and torso rapidly side-to-side dislodges any debris that has lodged in the inner ear canals.

You should start by sitting upright at the edge of a bed. Then the head should be turned 45 degrees to the left or as far as comfortable. After this movement, you should lie down on your right side and hold this position for approximately 30 seconds, or until the feeling of dizziness stops completely. Once the dizziness is gone, sit up and turn the head back to the center. Then the head should be turned 45 degrees to the right and you should lie down to your left side. Again, remain in this position for approximately 30 seconds and then sit up again and return the head back to the center (10).

This is only one set of exercises, which should be performed in 5 repetitions three times a day (in the morning, during the day and in the evening). After the period of 2 weeks, one should experience relief and improvement.

Effectiveness

A randomized controlled study involving 50 patients that investigated the effect of Brandt-Daroff exercises demonstrated high efficiency of this method with a low rate of symptom recurrence (2). Another study investigating this type of exercises came to a similar conclusion. This was a controlled, randomized study that involved 60 patients. Brandt-Daroff exercises had a high success rate of 80 %, with a relatively low rate of symptom recurrence (11). Many patients find these exercises to be quite simple and comfortable to perform, which also contributes to their efficacy - people will more likely complete the exercise plan. Furthermore, these exercises are quite safe to perform at home without any previous training, guidance or education from a healthcare professional.

Research shows that the Brandt-Daroff exercises need to be performed daily for 10 – 12 days before symptoms disappear. Studies have found that in cases of BPPV that affect the posterior canal, the Brandt-Daroff exercises aren't as effective as the Epley procedures, but they still have some benefit and can be easier for some patients to perform [2]. 

Forum users report improvement with Brandt-Daroff exercises: “Thank you for the information [on Brandt-Daroff exercises], just tried it and feel better already” -https://patient.info/forums/discuss/dizzyiness-and-headaches-103953

It is prescribed not only for people with BPPV but also sometimes for patients with labyrinthitis.

Learn how to perform the Brandt-Daroff exercises →

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3. SEMONT MANEUVER

Another technique, although not as popular as the two previously mentioned is the Semont maneuver. This technique has also been named by its’ developer, Dr. Alain Semont. The basis of the procedure is to move the patient from lying on one side to another, thereby inducing the relocation of crystals responsible for dizziness (14).

The procedure

The procedure starts with a patient sitting upright at the edge of a bed. The patient is then instructed to lay down on the side provoking dizziness and then quickly on the opposite side. Then, the patient should return to sitting upright.

This maneuver is not performed so often since the quick position change may provoke anxiety. Furthermore, the Epley maneuver and Brandt-Daroff exercises have been proven to be more effective. This method is performed as an alternative when Epley maneuver was proven as ineffective.

It is recommended after the maneuver that the patients remain sedentary for 10 minutes prior to any activity. It is also advised that patients should sleep with the head elevated at 45 degrees. Also, one should practice caution when being over. Head should not be turned frequently to the side that provokes dizziness.

To ensure maximum safety, one should not perform this mender alone at home. Careful guidance and monitoring of a healthcare professional are recommended to mitigate the risks of the procedure.

At one week after the treatment, one should expect results. Once a week has passed the patient should be instructed to rotate his had slowly and carefully to the affected side. If the dizziness does not occur, the procedure can be considered as effective. There are no comprehensive data regarding the long-term effects of Semont maneuver.

4. PREVENT BPPV COMING BACK WITH REGULAR PHYSICAL EXERCISE

We're not talking about any specific exercise here – research has shown that women with sedentary lifestyles are 2.6 x more likely to suffer from BPPV than those who do regular physical exercise [1].

Anecdotal evidence from online community forums suggests that Yoga and Tai Chi are great forms of exercise to improve balance while in recovery for BPPV. 

A 2016 report backs this up and suggests that Tai Chi is a particularly effective exercise for older people who are at risk for falling [7].

CAUTION: Avoid any Yoga poses called “inversions” – this refers to any pose where the head is lower than the heart. The rush of blood to the head can affect the inner ear and trigger vertigo attacks. the 

5. OTHER EXERCISES FOR BPPV

Other exercises have been developed for the treatment of BPPV, but many of them are dangerous, and should only be performed by a qualified physician:

• Dix-Hallpike Manoeuvre – The Dix-Hallpike manoeuvre is used to diagnose BPPV and can only be performed by a physician. It does not treat BPPV but allows the physician to determine which ear is affected and whether these BPPV exercises will help relieve your symptoms. Do NOT attempt the Dix-Hallpike manoeuvre at home.

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• Proprioception Exercises. Besides the cerebellum, inner ear and eyes, there is another specialized system in the body that supports the balance. Without it, keeping upright body posture would be impossible. While the aforementioned inner ear and eyes have a function of body position „scanners“, a system of proprioceptors sends info to the brain about joints position at any given moment. Have you ever wondered how the brain „knows“ the position of the arms and legs? Even with closed eyes, you exactly know the position of your extremities in space. Proprioception! With these exercises, you will improve the proprioception- a very important instrument of body balance. Highly developed proprioception can compensate the impaired function of the inner ear, eyes or cerebellum helping those with vertigo (or any other kind of dizziness) to maintain the upright body posture.

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TIPS FOR PRACTICING VERTIGO EXERCISES

• It's important to practice exercises regularly for a total of 60 minutes per day, but do not attempt them all at once. Break the total exercise time up into smaller segments throughout the day. Begin with twelve segments of 5 minute practice blocks, then work up to six 10 minute blocks. 
• Motivation and persistence are essential for success. Small improvements can go unnoticed, so keep track of your improvements by writing down your symptoms each time you perform exercises.
• Keep an alarm set to remind you to do your exercises. Don't hit snooze!
• Perform the exercises in a safe, quiet place that is unlikely to trigger vertigo – find a well-lit room with level flooring. You may like to begin all exercises bed and work your way up to performing exercises in a chair and eventually while standing.
• Do not attempt exercises if you are under the influence of drugs or alcohol.This may bring on an attack of vertigo and could result in a fall and/or serious injury.
• Do not attempt exercises beyond your abilities. If you are under the care of a physician, ask for their guidance before trying new exercises.

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FURTHER READING AND REFERENCES:

[1] Bazoni, J. A., et al. (2014) Physical Activity in the Prevention of Benign Paroxysmal Positional Vertigo: Probable Association. Int Arch Otorhinolaryngol., 18:4, 387 – 390. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4296996/

[2] Ibekwe, T. S. & Rogers, C. (2012) Clinical evaluation of posterior canal benign paroxysmal positional vertigo. Niger Med J., 53:2, 94 – 101. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3530256/

[3] Fife, T. D., et al. (2008) Practice parameter: Therapies for benign paroxysmal positional vertigo (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology, 70, 2067 – 2074. http://www.neurology.org/content/70/22/2067.long

[4] Kulcu, D. G., et al. (2008) Efficacy of a home-based exercise program on benign paroxysmal positional vertigo compared with betahistine. J Otolaryngol Head Neck Surg., 37:3, 373 – 379. https://www.ncbi.nlm.nih.gov/pubmed/19128642

[5] Guar, S., et al. (2015) Efficacy of Epley's Maneuver in Treating BPPV Patients: A Prospective Observational Study. Int J https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4606415/

[6] Sparrer, I., et al. (2013) Vestibular rehabilitation using the Nintendo® Wii Balance Board -- a user-friendly alternative for central nervous compensation. Acta Otolaryngol., 133:3, 239 – 245. https://www.ncbi.nlm.nih.gov/pubmed/23131174

[7] Furman, J. M., Raz, Y. & Whirney, S. L. (2016) Geriatric vestibulopathy assessment and management. Curr Opin 386 - 391. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4879828/

[8] National Health Service (NHS). Brandt-Daroff Exercises. Retrieved from: https://www.swbh.nhs.uk/wp-content/uploads/2012/07/Brandt-Daroff-Exercises-ML3094.pdf on 08 Aug 2018.

[9] Cetin YS, Ozmen OA, Demir UL, Kasapoglu F, Basut O, Coskun H. Comparison of the effectiveness of Brandt-Daroff Vestibular training and Epley Canalith repositioning maneuver in benign Paroxysmal positional vertigo long-term result: A randomized prospective clinical trial. Pak J Med Sci. 2018 May-Jun;34(3):558-563.

[10] NHS. Evidence Clinical Knowledge Summaries, ‘Benign Paroxysmal Positional Vertigo’, February 2011.

[11] Abdel Kader Hesham A, Abdel Halim Fathy N, Abdel Rahman Tayseer T. A comparative study on effectiveness of the rolling-over maneuver in rehabilitation of patients with posterior semicircular canal benign paroxysmal positional vertigo. Egyptian Journal of Otorhinolaryngology. 2014. 30: 88-93.

[12] Parnes, LS; Agrawal, SK; Atlas, J. Diagnosis, and management of benign paroxysmal positional vertigo (BPPV). 2003. CMAJ. 169 (7): 681–93..

[13] Herdman, S. (2000). "Vestibular rehabilitation". Physical therapy diagnosis for vestibular disorders (3rd ed.). Philadelphia: F. A. Davis Company. pp. 228–308.

[14] Levrat, E., et al. (2003). "Efficacy of the Semont maneuver in benign paroxysmal positional vertigo." Arch Otolaryngol Head Neck Surg 129(6): 629-633