The vestibular system helps us control balance, eye movements, and our sense of position in space. The peripheral vestibular apparatus is located in the inner ear and consists of the bony labyrinth—made up of three semicircular canals, the utricle, and the saccule. Conditions affecting this part of the system are referred to as peripheral vestibular disorders.
When the vestibular system is disrupted, people may experience vertigo—commonly described by patients as dizziness, spinning, swaying, or disequilibrium.
Common Peripheral Vestibular Conditions
There are many medical causes of dizziness, so it is important that a medical evaluation by a GP, neurologist, or ENT specialist is undertaken. Some of the most common vestibular-related conditions include:
- Benign Paroxysmal Positional Vertigo (BPPV)
Caused by dislodged calcium carbonate crystals (otoconia) moving into the semicircular canals. This leads to brief episodes of vertigo triggered by changes in head position such as rolling in bed or looking up. - Menière’s Disease
Thought to result from an abnormal build-up of endolymphatic fluid in the inner ear, causing episodes of vertigo, fluctuating hearing loss, tinnitus, and a sensation of fullness in the ear. - Labyrinthitis
Inflammation of the entire inner ear (labyrinth), usually viral, affecting both balance and hearing. It typically presents with acute vertigo, nausea, and hearing loss. - Vestibular Neuritis
Inflammation of the vestibular nerve, usually viral, impairing balance but not hearing. It is characterised by sudden onset of severe vertigo, nausea, and unsteadiness that may last for days.
Physiotherapy and Vestibular Care
Physiotherapists who have completed additional vestibular training play a vital role in the assessment and management of peripheral vestibular conditions.
The most common cause of vertigo seen in physiotherapy practice is BPPV.
BPPV and the Modified Epley Manoeuvre
BPPV is typically diagnosed with a positional test (e.g. Dix-Hallpike), in which vertigo is reproduced and nystagmus (involuntary, repetitive eye movement) is observed. The direction, duration, and type of nystagmus—along with the head position—help determine which canal is affected.
Treatment usually involves a Canalith Repositioning Manoeuvre (CRM) (e.g. Modified Epley) which involves moving the head in particular position sequentially to move the otoconia (crystals) into the correct position. These choice of which manoeuvres is used to treat the BPPV is dependent on which canal is affected. Success rates for CRM for BPPV have been shown to be as high as 85% after one treatment and up to 95% resolution within 1–3 sessions. There is minimal risk of recurrence or complications when performed correctly
Vestibular Rehabilitation for Other Conditions
Other vestibular conditions (e.g. Menière’s disease, vestibular neuritis, labyrinthitis) may lead to vestibular hypofunction—where the sensory input from one or both vestibular apparatus is impaired, resulting in reduced balance function and dizziness.
In these cases, physiotherapists use Vestibular Rehabilitation Therapy (VRT) to help the brain compensate, habituate, and adapt to altered sensory input. This typically includes:
- Balance retraining
- Gaze stabilisation exercises (to retrain the vestibulo-ocular reflex)
- Habituation exercises (to reduce motion sensitivity)
- Graded exposure to movement and visual complexit
Systematic reviews and clinical guidelines show moderate to strong evidence supporting VRT for improving balance, reducing dizziness, and restoring function in vestibular hypofunction.
Conclusion
Peripheral vestibular conditions are a common cause of vertigo and dizziness. Many are highly treatable, sometimes with near-complete symptom resolution. With accurate diagnosis and evidence-based physiotherapy, patients often experience significant improvement in both symptoms and quality of life.
If you are experiencing persistent dizziness or balance issues, consider booking an assessment with a physiotherapist trained in vestibular rehabilitation.
References
- Neuhauser, H. K. et al. (2005). The epidemiology of dizziness and vertigo. Journal of Neurology, Neurosurgery & Psychiatry, 76(5), 710–715.
- Bösner, S. et al. (2018). Dizziness in primary care: diagnostic accuracy of clinical tests. BMC Primary Care, 19(1), 33.
- Agrawal, Y. et al. (2009). Vestibular dysfunction in older individuals. Archives of Internal Medicine, 169(10), 938–944.
- Hilton, M. P., & Pinder, D. K. (2014). The Epley manoeuvre for posterior canal BPPV. Cochrane Database of Systematic Reviews, (12).
- Li, J. C. et al. (2023). Modified vs standard Epley manoeuvre: RCT. Frontiers in Neurology, 14, 1328896.
- McDonnell, M. N. et al. (2015). Vestibular rehabilitation for unilateral vestibular hypofunction: Cochrane Review. Cochrane Database of Systematic Reviews, (1).
