Vestibular Rehabilitation (VRT)
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Direct answer
Rolling over in bed and the room spins for under a minute — that is the signature of posterior canal benign paroxysial positional vertigo, the commonest cause of vertigo and the one a physiotherapist cures with a positioning manoeuvre in a single session: a positive Dix-Hallpike test (latency of a few seconds, torsional upbeating nystagmus, fatigability) is treated with the Epley canalith repositioning manoeuvre or the Semont liberatory technique, both rolling the displaced otoconia out of the canal. Beyond BPPV, vestibular rehabilitation addresses unilateral and bilateral hypofunction with gaze-stabilisation exercises (VOR ×1 and ×2), habituation through graded symptom exposure, and balance and gait retraining, with Cawthorne-Cooksey and Brandt-Daroff as classical home frameworks. Central vertigo is the referral boundary: in acute continuous vertigo, a normal head impulse test with direction-changing nystagmus and skew deviation — the HINTS exam — points away from the inner ear and toward the brainstem, and out of the physiotherapy department.
What you must remember
- Canal arithmetic: three semicircular canals per side; BPPV most often affects the posterior canal — commonly quoted around 80-90% of cases — diagnosed by Dix-Hallpike; the horizontal canal form (supine roll test) is second, anterior rare.
- BPPV test signs: Dix-Hallpike with head hanging and turned provokes geotropic-torsional nystagmus after a latency of 2-10 seconds, fatiguing within about a minute and weakening on repetition — the positional, brief, fatigable triad.
- Repositioning menu: Epley (posterior canal, success commonly above 80% after one to two sessions), Semont liberatory (an alternative), barbecue 360-degree roll and Gufoni for horizontal canal, Brandt-Daroff as the home sequence — 5 repetitions, 3 times daily for about 2 weeks.
- Post-manoeuvre advice: traditionally cautious head positioning for 24-48 hours (evidence for strict restriction is weak — saying so is a mark of currency), one-week retest, and treatment of recurrence.
- Hypofunction training: gaze stabilisation with VOR ×1 (fixating a target while turning the head) and ×2 (target moves with the head), saccadic and cervical substitution strategies, plus balance progressions from firm to foam to eyes-closed.
- HINTS in acute vertigo: head impulse test normal, nystagmus direction-changing with gaze, or skew deviation present — any of these "central" findings in continuous vertigo outranks dizziness severity for danger and demands referral.
- Differentials to respect: vestibular migraine; Meniere disease (vertigo with fluctuating hearing loss, tinnitus, aural fullness); vestibular neuritis (acute continuous vertigo without hearing loss — brief steroids plus early rehabilitation); orthostatic dizziness.
One clinic morning, two different vertigos
A 58-year-old teacher reports a week of five-second spins turning right in bed; Dix-Hallpike to the right reproduces her torsional nystagmus after seconds, fatiguing within half a minute. The Epley follows in the same session — head-hanging rotation into side-lying and upright in the canal's plane, held at each step — and she is re-tested free of positional nystagmus, leaving with Brandt-Daroff homework. Across the curtain, a 45-year-old with six weeks of floaty imbalance after a presumed neuritis tests differently: no positional nystagmus, but a positive head impulse to the left and unsteadiness on foam with eyes closed. Her programme is the slow cure — VOR ×1 and ×2 for gaze steadiness, balance progressing from floor to foam, walking with head turns, three daily sessions in the symptomatic-but-tolerable zone, reviewed fortnightly for six to ten weeks — compensation is a learning process, not a mechanical reset. Same symptom word, two diseases, two physiotherapies: that distinction is the topic in one morning.
Exam angles and Indian practice notes
Theory papers ask for the assessment of vertigo, the diagnosis and manoeuvre treatment of BPPV, and the components of vestibular rehabilitation — scoring answers name the canal, the test, the nystagmus and the manoeuvre sequence, not just "vertigo exercises". Short notes recycle Dix-Hallpike, Epley, Brandt-Daroff and Cawthorne-Cooksey; viva panels probe the HINTS red flags and why BPPV nystagmus fatigues (otoconia inertia, central adaptation) while central nystagmus does not. The Indian context adds honest epidemiology: clinics are full of patients labelled "cervical vertigo" and given traction or multivitamins — modern evidence finds cervical-origin vertigo rare, and saying so, then treating the posterior canal instead, demonstrates exactly the judgement the examiner is purchasing. Peripheral disorders here also ride on diabetes-related vestibulopathy and aminoglycoside ototoxicity from tuberculosis treatment — two locally weighted differentials.
Frequently asked questions
Which canal is most commonly affected in BPPV and how is it tested?
The posterior canal in the large majority of cases, tested with the Dix-Hallpike manoeuvre, which provokes brief fatigable torsional nystagmus after a short latency.
What does the Epley manoeuvre do?
It repositions displaced otoconia out of the posterior canal through a sequence of head and body rotations, curing most posterior canal BPPV within one to two sessions.
What is the Brandt-Daroff exercise?
A home habituation sequence — sitting to side-lying with the head turned, holding until dizziness settles, then the other side — five repetitions, three times daily for about two weeks.
What are VOR ×1 and ×2 exercises?
Gaze-stabilisation drills: fixing a stationary target while oscillating the head (×1), or a target moving with the head (×2), training the vestibulo-ocular reflex.
Which bedside findings suggest central rather than peripheral vertigo?
In continuous acute vertigo, a normal head impulse test, direction-changing nystagmus, or skew deviation on the HINTS exam indicates a central cause requiring urgent referral.