Vestibular rehabilitation: exercises for dizziness and balance problems

The vestibular system is the part of the inner ear and the nerve connections that tell the brain where your head is and how it is moving. When it is disturbed, for example by an inner ear infection, the result can be a spinning feeling (vertigo), unsteadiness and nausea. The NHS describes labyrinthitis as inflammation of the labyrinth, a maze of fluid-filled channels in the inner ear, and vestibular neuritis as inflammation of the vestibular nerve, the nerve that sends messages from the inner ear to the brain.

Vestibular rehabilitation is a structured set of exercises designed to help the body and brain readjust after that kind of disturbance. The NHS states that it is a series of exercises that can help restore balance and can help with dizziness, nausea and anxiety. It is a form of physiotherapy-style rehabilitation rather than a medicine, and the programme is usually tailored to the person rather than being one fixed set of movements.

The key safety point in the NHS wording is that these exercises should only be done under the supervision of a specialist such as a physiotherapist or audiologist. That is because the movements are chosen to bring on mild, controlled symptoms, and doing the wrong ones, or doing them without understanding the cause of the dizziness, can make things worse or hide a problem that needs different treatment.

Most inner ear attacks improve without exercises. The NHS says that with labyrinthitis or vestibular neuritis symptoms often ease after a few days, and you will usually get your balance back over 2 to 6 weeks, although it can take longer. Simple self-care during that period includes lying still in a dark room if very dizzy, drinking little and often if you are being sick, getting enough sleep and starting to go for walks outside as soon as possible, ideally with someone to steady you.

Rehabilitation is considered when the problem does not clear in the usual way. The NHS says that sometimes balance problems can last for much longer, for many months or even years, and it is in that situation that it points to vestibular rehabilitation. It may also be relevant where the cause is another inner ear problem. The NHS lists benign paroxysmal positional vertigo (BPPV), labyrinthitis, vestibular neuritis and Ménière’s disease as the most common inner ear causes of vertigo, and notes that migraine and some medicines can also cause it.

Because the cause matters, the first step is an assessment, not an exercise sheet. A GP will ask about your symptoms to try to find out what could be causing them, and the NHS says a simple test involving moving quickly from sitting to lying might be done to check your balance. You may then be referred to a specialist for further tests.

• Dizziness or unsteadiness that has not cleared after the usual few weeks following an inner ear infection.

• Vertigo that keeps coming back or will not go away, which the NHS says is a reason to see a GP.

• Balance problems that are affecting walking, work, driving or confidence.

• Anxiety about moving or going out because of dizziness.

The NHS pages do not set out a fixed timetable or list of exercises, and programmes differ between services, so the detail below is deliberately general. A specialist will usually begin by asking about your symptoms and examining your balance, then explain which movements to practise at home and how often. You can expect to be asked to report how your symptoms respond so the programme can be adjusted.

One thing the NHS does say about everyday coping is that, when you are out and about, it helps to keep your eyes focused on a fixed object rather than looking around all the time, and that walking outside again as soon as possible is encouraged. Those points reflect the broader idea behind rehabilitation: the brain relearns to cope with altered signals from the inner ear through gradual, repeated exposure to movement rather than by avoiding it entirely.

Mild dizziness during the exercises is generally expected to come and go, which is why supervision matters. If an exercise provokes symptoms that are severe or that come with any of the warning signs below, stop and seek advice rather than pushing through.

The NHS says you can ask a GP to refer you to a physiotherapist, or it may be possible to refer yourself directly. It also notes that waiting lists for accessing NHS physiotherapy can be long and that you may prefer to pay for private treatment, adding that most private physiotherapists accept direct self-referrals.

In general terms, the NHS route usually begins with a GP assessment and may involve a hospital specialist or an audiology or balance service for tests. A private route can shorten the wait and may allow direct access to a physiotherapist who treats dizziness, but it still makes sense to have a GP or specialist rule out causes that need medical treatment first. Whichever route you take, ask whether the therapist has particular experience with vestibular problems.

If you drive, the NHS says you must tell the DVLA about vertigo, and that you should not drive, cycle or use tools or machinery if you feel dizzy.

Medicines for dizziness are normally for short-term symptom relief and are not a substitute for rehabilitation. For labyrinthitis or vestibular neuritis the NHS says a GP may prescribe antihistamines, motion sickness tablets or anti-sickness medicines for up to 3 days, and warns not to take them for longer because they can slow down recovery. Antibiotics do not help a viral cause, although a GP may prescribe them if they think the infection is bacterial.

The NHS also advises against alcohol while recovering because it can make symptoms worse. For vertigo more generally it suggests moving your head carefully and slowly, sitting down straight away when you feel dizzy, turning on the lights if you get up at night, sleeping with your head slightly raised on two or more pillows, and getting out of bed slowly.

Dizziness is common and usually not serious, but some combinations need prompt attention. The NHS advises calling 999 or going to A&E if you have vertigo along with double vision or loss of vision, hearing loss, trouble speaking, or leg or arm weakness, numbness or tingling.

It advises asking for an urgent GP appointment or contacting NHS 111 if you have vertigo and a severe headache, you are being sick or feel very sick, or you have a very high temperature or feel hot, cold or shivery. Sudden hearing loss in one ear also warrants an urgent GP appointment or NHS 111, according to the NHS.

See a GP in the usual way if symptoms do not get better after a few days or are getting worse, or if you have been diagnosed and your symptoms have not improved within a week of starting treatment. A GP may refer you to a hospital specialist.

Persistent dizziness can be tiring and unsettling, and anxiety can make vertigo worse, as the NHS notes. Keeping active within your limits, sleeping well and having a plan for dizzy moments, such as sitting down immediately, tend to reduce the fear of going out.

If you are at risk of falling, the NHS suggests a walking stick may help. Tell the people you live with what to do when an attack starts, and keep a short diary of triggers and how long episodes last, which gives the specialist useful detail.