Introduction

Vertigo is a condition characterised by a disorientating sensation of spinning or dizziness that can significantly disrupt daily life.¹ Fortunately, there are strategies that can offer relief for vertigo. For example, it has been shown that performing specialised exercises for vertigo can help individuals manage their condition.²

This article provides guidance for individuals experiencing vertigo, outlining how exercises can be useful in managing their condition and enhancing their quality of life.

Understanding vertigo

Vertigo is more than just feeling dizzy. Feelings of nausea, loss of balance, and vomiting accompany it. Vertigo is a sign of an underlying health issue and is categorised as ‘peripheral’ or central’ depending on the root cause.

Peripheral vertigo 

Peripheral vertigo accounts for over 90% of vertigo cases. It is usually the result of a problem with the inner ear which is involved in balance regulation. 

The inner ear includes three small loops called semicircular canals that detect head movements in different directions. Inside these canals, there is a fluid that shifts when you move your head, triggering tiny hair-like cells to send signals to your brain to register movement. Other parts of the inner ear called the utricle and saccule, or otolith organs, sense gravity and changes in position, such as when you tilt your head or move. Together, all these parts send information to your brain, helping you keep your balance and stay upright.

Benign Paroxysmal Positional Vertigo (BPPV) is one of the most common causes of peripheral vertigo. It is a condition in which tiny crystals that are normally attached to balance-sensing hairs become detached and dislodged moving into the fluid-filled posterior semicircular canal of the inner ear causing a false feeling of rotational movement when none is happening. 

Other common causes of peripheral vertigo include Meniere’s disease, labyrinthitis and vestibular neuritis (types of inner ear infection).¹

Central vertigo

Central vertigo is caused by a disease or injury to the brain (part of the central nervous system along with the spinal cord), such as head traumas, brain tumours, strokes, illnesses or infections:

• Stroke: A sudden disruption of blood flow to the brain can damage areas that control balance, leading to vertigo 
• Multiple sclerosis (MS): An autoimmune disease where the body's immune system attacks the protective covering of nerves, including those involved in maintaining balance in the brain
• Brain tumours: Abnormal growths in the brain, especially in parts such as the cerebellum (the brain area that controls coordination)
• Infections: Infections such as encephalitis (inflammation of the brain) can damage the brain areas responsible for balance
• Trauma: Head injuries that damage the brain can interfere with balance and cause vertigo
• Medications: Some drugs, especially those that affect the brain or inner ear, can result in the side effect of central vertigo
• Vestibular migraine: A type of migraine specifically affecting the vestibular system (the system that helps control balance) 

These conditions disrupt the brain's ability to process balance and spatial orientation, leading to the symptoms of central vertigo.³

The role of exercises in vertigo management

Exercises have been shown to be beneficial for those suffering from vertigo. Performing specialised exercise protocols and specific appropriate exercises can help alleviate symptoms, improve balance and reduce the risk of falls. It is important to note that these exercises may only benefit those with peripheral vertigo with optimal efficacy. In contrast, for individuals with forms of central vertigo, exercise outcomes may vary.

Before attempting any of these exercise protocols, you should consult a healthcare professional, especially if your vertigo is severe or you have underlying health conditions. They should be performed under the guidance of a healthcare professional.

Vestibular rehabilitation

The exercises for vestibular rehabilitation can be categorized into two types. Firstly, physiotherapy for an under-functioning vestibular system, known as vestibular rehabilitation therapy (VRT) and secondly therapeutic canalith repositioning manoeuvres for benign paroxysmal positional vertigo (BPPV).

Vestibular rehabilitation therapy (VRT)

VRT constitutes an exercise regimen that can help improve the condition of those suffering from peripheral and mixed peripheral/central causes of vertigo.⁴ It is a type of physiotherapy aiming to help people with dizziness, vertigo, and balance problems. It involves retraining the brain to recognise and process signals from the vestibular system, which includes parts of the inner ear and brain that control balance and eye movements. 

Vestibular rehabilitation therapy includes:

• Assessment: A therapist first assesses your symptoms, balance, and how well your eyes, head, and body work in coordination to devise a program customised for your symptoms and needs
• Exercises: You’ll perform specific exercises that progressively challenge your balance and coordination. These may include:
  • Gaze stabilization: These exercises involve focusing on an object while moving your head. This helps the brain adjust to any mismatched signals between the eyes and the inner ear
  • Balance training: Activities are aimed at improving your ability to stand, walk, and move without feeling dizzy or unsteady
  • Habituation exercises: These involve repeatedly exposing yourself to movements or positions that trigger vertigo, so the brain learns to ignore or minimise the aberrant response
• Monitoring progress: As your symptoms improve, the exercises become more challenging, in order to help you return to your normal activities

Vestibular rehabilitation therapy is tailored to each person’s specific needs and is effective in reducing dizziness and improving balance, allowing people to regain confidence in the activities of their daily lives. The Cooksey-Cawthorne Exercises are a specific set of VRT exercises that under the advice of a health professional can be performed at home.

Repositioning manoeuvres for benign paroxysmal positional vertigo (BPPV)

If you experience Benign Paroxysmal Positional Vertigo (BPPV), the exercise methods described above are insufficient to resolve this type of vestibular disorder. The type of BPPV will be identified through evaluation, and depending on this different repositioning manoeuvres can be performed to help resolve the vertigo that happens during position changes. Later on, VRT may be beneficial.

Below we outline some of these specialised repositioning exercises which can be beneficial for BBPV-type peripheral vertigo:

Brandt-daroff exercise

The Brandt-Daroff Exercise involves moving from a lying position to a sitting position. To carry out this exercise, you can follow these steps:

1. Sit in the middle of a bed with your feet on the floor and turn your head 45 degrees to the right
2. Lie down on your left side without moving your head. Wait for the dizziness to pass, then wait 30 more seconds. If you don’t feel dizzy, pause for 30 seconds before continuing
3. Return to the starting position. Pause for 30 seconds
4. Turn your head 45 degrees to the left. Repeat steps two and three lying down on the right side
5. Return to the starting position. Pause for 30 seconds
6. Complete one set of five repetitions on each side
7. After completion, wait until dizziness has passed before standing up

It’s recommended that you complete two sets of this exercise every day (once in the morning and once at night) for 2 weeks.

Foster manoeuvre

The Foster manoeuvre exercise can be performed at home to alleviate symptoms of BPPV. For left-ear BPPV, follow these steps:

1. Kneel and tilt the head back, waiting for dizziness to subside
2. Place forehead on the floor, tucking chin
3. Turn your head 45 degrees left, holding for 30 seconds
4. Keeping the head at 45 degrees, raise it level with back and shoulders for 30 seconds
5. Return head to upright position
6. Repeat four or five times with 15-minute breaks between attempts for relief

If you have right-ear BPPV, you should perform this exercise on the opposite side.

Epley manoeuvre

This is another common manoeuvre for vertigo. Usually, the Epley manoeuvre is most effectively performed with you by a healthcare professional particularly as it can provoke dizziness and sometimes vomiting.⁵ Here we outline a modified version that can be performed at home, but it is recommended you seek guidance from a healthcare professional to ensure you perform it properly and on the appropriate side. Additionally, you should be assessed by them beforehand to eliminate any underlying issues.

For left-ear BPPV, follow these steps:

1. Sit upright in bed with legs straight and a pillow behind you
2. Turn your head 45 degrees to the left
3. Lie back quickly until your shoulders are on the pillow and your head is still at 45 degrees to the left but also tilted back 30 degrees over the edge of the pillow. Wait for any dizziness to subside before continuing
4. Turn your head 90 degrees without lifting it, so you are now looking 45 degrees to the right. Hold for 30 seconds
5. Turn your body until lying on the right side with the head still looking 45 degrees to the right. Wait for any dizziness to subside before continuing
6. Sit upright on the right edge of the bed

For right-ear BPPV, perform this exercise on the opposite side.

Semont manoeuvre

To perform the Semont manoeuvre:

1. Start sitting upright on the edge of the bed
2. Turn your head 45 degrees away from the affected ear
3. Lie down on your affected side so that you are looking up at the ceiling
4. Stay in this position for 30 seconds or until any dizziness has subsided
5. Sit up and return to the centre, then immediately lay down on the opposite side so that you are facing down to the floor
6. Remain in this position for 30 seconds 
7. Once the dizziness has subsided, sit up and turn your head back to the centre

Summary

Vertigo is a condition characterised by a sensation of dizziness that can also be accompanied by nausea, loss of balance and vomiting, all of which can significantly disrupt daily life. It is categorised as ‘peripheral’ or central’ depending on the cause – the former arising from problems with the inner ear balance sensors and the latter from diseases or injury to the brain disrupting nerve signals.

Benign Paroxysmal Positional Vertigo (BPPV) is one of the most common causes of peripheral vertigo and can be resolved by specific repositioning manoeuvre exercises. Other specific and customised exercises known as vestibular rehabilitation therapy (VRT) can help improve the condition in those suffering from peripheral and mixed peripheral/central causes of vertigo enhancing overall well-being and quality of life.