The Basics of Vestibular Therapy

During my first internship, and before I learned much of anything about the vestibular system in school, I was introduced to the mystical world of vestibular therapy. At the time, it looked like some sort of voodoo ⁠— watching the eye movements of patients with dizziness while having them turn and roll every which way. Strangely enough, all of this turning and rolling seemed to help them improve quickly. Most of the time, the patients came in feeling like the room was spinning and left with their equilibrium restored.

I had never seen patients as appreciative after a visit or two as I had in these situations. Although all of the vestibular system lingo felt like a foreign language to me at the time, it piqued my interest, and I was ready to dive into the world of vestibular therapy. Now, a few years later, I’ve begun performing vestibular therapy in a hospital-based outpatient clinic, and the more I learn, the more it continues to intrigue me.

What is vestibular therapy?

Vestibular therapy (aka vestibular rehabilitation or vestibular rehabilitation therapy) is the use of specific techniques and exercises for the treatment of vertigo, dizziness, and balance deficits caused by both impairments of the vestibular system of the inner ear, as well as secondary causes related to the aforementioned symptoms.

Although physical therapy programs do currently feature a brief overview of the vestibular system and some basic vestibular therapy examination and treatment techniques, this is a specialization area. Ultimately, that means that becoming a vestibular specialist requires additional post-graduate training in order to competently manage these patients.

Why should I become a vestibular therapist?

Physical therapy, in general, is an incredibly rewarding profession, but as I pointed out in the opening paragraph, vestibular therapy can be one of the most rewarding areas of all. There are many possible vestibular diagnoses which require in-depth examinations and evaluations to determine the best treatment process, but many of the patients I see in the clinic are those with benign paroxysmal positional vertigo (BPPV). With this disorder, patients experience dizziness, vertigo, nausea, and even vomiting in severe cases.

These symptoms are set off by position changes and head movements due to otoconia becoming misplaced in the semicircular canals of the inner ear. Otoconia are calcium carbonate crystals that sit in the inner ear and allow us to sense gravity and linear acceleration. Everyone has them, and they are extremely necessary, but they can cause issues when they get dislodged from their regular location (the utricle and saccule) and travel into the semicircular canals. The silver lining with this disorder is that we are able to help these patients, often within one or two sessions1, with the use of canalith repositioning maneuvers.

Treating Benign Paroxysmal Positional Vertigo

After evaluating the patient and determining that BPPV is, in fact, the primary cause of their dizziness, these maneuvers can be performed in the matter of a few minutes. The most common maneuver used is called the Epley Maneuver. This is used for BPPV affecting the posterior semicircular canal of the inner ear, which is the most commonly affected canal. So common, in fact, that 83% of patients with BPPV have the posterior canal affected according to the Geisinger Vestibular & Balance Center. The Epley maneuver is broken down in the photo below, but is essentially a five-step move:

1. Start off with the patient sitting up with their legs out in front of them. Turn the patient’s head about 45 degrees to the involved side. Fun fact: the right side is more often involved than the left because people tend to spend more time sleeping on their dominant side, and there are more right-handed people than lefties!
2. Lie the patient on their back and tip their head into about 10 degrees of cervical extension, all the while keeping their head turned 45 degrees to the affected side. Wait for the dizziness to subside and then an additional 30 seconds to two minutes.
3. Keep the patient’s head in 10 degrees of extension and rotate it the other way 45 degrees. Again, wait for the dizziness to subside and then an additional 30 seconds to two minutes.
4. Assist the patient in rolling to their unaffected side while keeping their head rotated 45 degrees to the unaffected side. Have the patient tuck their chin to their shoulder while you’re assisting them with rolling. When performed correctly, the patient will be looking down at the bed when this step is complete. Again waiting for the same period.
5. Finally, assist the patient in sitting up on the side of the bed they rolled to, and have them look straight forward. This maneuver, and any of the other canalith repositioning maneuvers, may need to be performed more than once to properly migrate the otoconia back to where they need to be and eliminate the patient’s symptoms.

There are several other maneuvers that can be performed depending on what the patient’s symptoms are, but that is beyond the scope of this introductory article. As stated previously, the technique above is used only for posterior canal BPPV, which is the most common form. If the patient is physically capable (and you believe they can safely perform the maneuver alone) you can even instruct them on how to perform the maneuver independently should symptoms arise in the future.

These patients are often so appreciative and thankful for what you’ve done, and helping a patient improve their quality of life in such a short time is among the most rewarding parts of my job!

Additionally, despite vestibular therapy being such a rewarding area in our field, there is a relatively scarce number of physical therapists across the country who treat vestibular disorders. This means that adding vestibular therapy techniques to your skill set can make you a huge asset to a company! Learning these skills will improve your employability and earning potential due to the increased patient population you will attract.

How much continuing education is necessary and where can courses be found for vestibular therapy?

As Nidhi Sharma, MPT, MCMT points out in Why New Grads are Falling for Vestibular, it often only takes a course or two to attain the skillset necessary to begin treating patients with vestibular disorders. I’ve also taken several excellent courses on MedBridge through their extensive CEU library. (CovalentCareers readers can receive $175 off a yearly subscription with code COVALENT).

If you are an APTA member, you can find online and in-person courses through the APTA Learning Center CEU Catalog. Additionally, Vestibular.org is one of the best resources for evidence-based vestibular information, a hub for vestibular conference sign-ups, and training. This has been an excellent resource for me as I advance my knowledge in the specialty of vestibular therapy.

As I began my journey as a vestibular therapist, I was recommended two excellent, introductory CEU courses that provided a wide base of information in easy-to-digest formats. Both courses can be found on MedBridge and are presented by Jeff Walter, PT, DPT, NCS.

1. The first course is called, “Vestibular Rehabilitation: Bedside and Office Examination of the Vestibular System.” This course begins with education on the relevant anatomy of the vestibular system, which transitions smoothly into an in-depth discussion of how to perform a comprehensive vestibular examination and best determine the cause of a patient’s symptoms. It also reviews what treatments need to be performed to help the patient as well.
2. The second course is called, “Vestibular Rehabilitation: Identification and Management of BPPV.” This course also begins with relevant vestibular system anatomy but then transitions into the screening, examination, and treatment of BPPV.

Both of these courses provide tremendous visual demonstrations and animations of anatomical structures, examination techniques, and treatments throughout. As someone who was brand new to vestibular therapy, having these constant visuals made the concepts much easier to understand and apply. Since these are video courses on MedBridge, they may also be accessed and replayed as often as needed! The courses are priced at $100 each for anyone who does not have a MedBridge subscription and are available at no additional cost for those who do.

Is there a vestibular therapy certification?

Currently, there is no vestibular therapy certification sponsored by the APTA. There are individual companies that offer their version of a vestibular therapy certification, but as with any certifications offered through private companies, make sure you do your research to determine if the price is worth the admission. The APTA does co-sponsor a competency-based series of vestibular courses with Emory University.

Whichever route you choose to take as you learn more about vestibular therapy, you will find an excellent variety of beginner, intermediate, and advanced courses depending on the level of training you wish to receive!

Conclusion

Vestibular therapy has proven to be a rewarding, intriguing, and pleasantly challenging specialty area for me as a new grad. Not only has it provided me with an expanded skillset that makes me an asset to the company I work for, it has also provided me with a more diverse patient population. An expanded skillset has also decreased feelings of professional burnout, and increased that warm, fuzzy, rewarding feeling we get after seeing a patient walk out of the clinic with an improved quality of life. Do you think vestibular therapy is for you? Let us know in the comments below!

References:

1. Hughes D, Shakir A, Goggins S, Snow D. How many Epley manoeuvres are required to treat benign paroxysmal positional vertigo? The Journal of Laryngology & Otology. 2015; 129(05):421-424. doi:10.1017/s0022215115000481.