Vestibular Rehabilitation

Exercise protocols of the 1940s

The best-known early exercise protocols are associated with Cawthorne, dated to 1944, and Cooksey, dated to 1946, in a Brazilian study that applied both. A Cochrane review describes the original Cooksey and Cawthorne protocols as group activities arranged in a hierarchy of difficulty, intended to challenge the central nervous system. The sources reviewed do not give biographical detail about either clinician.

Later development

The Cochrane review describes vestibular rehabilitation as a group of exercise-based approaches that began with the aim of maximizing central nervous system compensation. Over later decades the field divided into named components such as adaptation, substitution and habituation, and more recent protocols are tested against the Cawthorne and Cooksey exercises in trials. A 2016 randomized trial compared a conventional Cawthorne and Cooksey protocol with a multimodal version in older adults with chronic dizziness.

The sources reviewed do not give a dated account of how the practice became part of physical therapy specialty education, so that history is not covered here. Readers seeking the history of training pathways would need sources beyond those reviewed for this page.

Names in use

The practice appears as vestibular rehabilitation, vestibular rehabilitation therapy and vestibular physical therapy. The 2022 American Physical Therapy Association (APTA) guideline uses vestibular physical therapy and does not give a single formal definition of vestibular rehabilitation. The Cochrane review defines it as an exercise-based group of approaches and excludes repositioning maneuvers for benign paroxysmal positional vertigo (BPPV) from that definition.

Exercise categories

The guideline defines gaze stabilization exercises as exercises built on adaptation and substitution of the vestibulo-ocular reflex. Habituation exercises systematically expose a person to a provocative stimulus. Substitution exercises promote alternative strategies for impaired vestibular function, and balance exercises are static or dynamic tasks meant to optimize the systems underlying postural control.

Other papers group the same elements slightly differently, so the terms should be read against the document in which they appear. The Cochrane review lists compensation, adaptation, substitution and postural or conditioning exercises as its categories.

Settings and providers

The Academy of Neurologic Physical Therapy states that all physical therapists receive baseline education on balance and vestibular problems, and that some have advanced skills and often attend competency-based coursework. It describes such therapists as working in specialty outpatient clinics, orthopedic outpatient practices and inpatient facilities. The page names the American Board of Physical Therapy Specialties neurologic clinical specialist designation but does not say it is required for vestibular work.

Components of a program

The 2022 guideline addresses clinic visits combined with a home program of gaze stabilization and balance exercises, and it recommends offering supervised vestibular physical therapy for adults with vestibular hypofunction. It also states that clinicians may consider time since onset, comorbidities, cognitive function and medication use as factors that could modify outcomes. This page does not reproduce dosing schedules, which are clinical decisions made by treating clinicians.

In a trial of adolescents after concussion, individualized vestibular physical therapy combined exercises for gaze stability, postural stability, ocular-motor control, habituation and aerobic activity, delivered at weekly clinic visits and through a home program.

Peripheral vestibular disorders

Clinicians and guideline authors describe vestibular rehabilitation as an approach for adults with dizziness, gaze instability or imbalance caused by unilateral or bilateral peripheral vestibular hypofunction, including after acute episodes or surgery. The guideline states that its recommendations cover people with confirmed vestibular hypofunction and may not apply to central vestibular disorders or to dizziness without such a diagnosis.

Other presentations

Reviews also describe its use in positional vertigo, in dizziness that persists after concussion, and in functional conditions such as persistent postural-perceptual dizziness (PPPD), often alongside psychological or other components. The BPPV guideline lists vestibular rehabilitation, self-administered or with a clinician, as an option in BPPV treatment, separate from repositioning maneuvers.

Unilateral peripheral vestibular dysfunction

A 2015 Cochrane review included 39 randomized trials with 2,441 adults with unilateral peripheral vestibular dysfunction. Pooled analysis of dizziness frequency favored vestibular rehabilitation over control or no intervention (odds ratio 2.67, 95 percent confidence interval 1.85 to 3.86; four studies, 565 participants). The authors rated the evidence as moderate to strong, while noting poor reporting of randomization methods, limited power in smaller trials and variation in comparators and follow-up.

The 2022 APTA guideline reviewed literature from 2015 to June 2020 and reported strong evidence for benefit in unilateral and bilateral peripheral vestibular hypofunction. A 2023 meta-analysis of 12 trials (542 participants) found that rehabilitation begun within 14 days of onset or surgery improved Dizziness Handicap Inventory scores, with eyes-closed balance and subjective dizziness also improving.

Delivery and comparisons

A systematic review of five trials plus one found from reference lists did not establish that supervised programs outperform unsupervised ones, because outcomes were self-reported and study quality varied. The guideline nonetheless recommends offering supervision, citing strong evidence and patient preference. For BPPV, the Cochrane review found repositioning maneuvers superior to exercise-based rehabilitation in the short term for rate of symptom resolution.

Concussion and persistent dizziness

A systematic review of vestibular rehabilitation in children after concussion included 12 studies, only three of them randomized, and concluded that it shows promise as part of a multimodal plan, with larger studies needed. A 2026 review of 12 trials (513 participants) in anxiety-related functional dizziness, including PPPD, reported small-to-moderate disability improvements with vestibular rehabilitation versus usual care, with larger reductions when combined with cognitive behavioral components. Certainty was rated very low to moderate. Findings from one condition should not be transferred to another.

Reported harms and care boundaries

The Cochrane review reported no adverse effects across its included trials, but it did not describe systematic harm monitoring in the passages reviewed, so absence of reports should not be read as proof of no effect. The guideline states that clinicians should not use voluntary saccadic or smooth-pursuit eye movements in isolation to promote gaze stability, based on strong evidence and a preponderance of harm over benefit.

Habituation approaches deliberately expose people to movements that provoke symptoms, so temporary symptom provocation is part of the method as defined. The guideline also notes that dizziness is a major risk factor for falls. The sources reviewed do not list formal contraindications.

Diagnosis and suitability

The BPPV guideline recommends differentiating BPPV from other causes of dizziness, assessing fall risk and reassessing within one month, and advises against routine vestibular suppressant medications. Dizziness can have central or non-vestibular causes that exercise therapy does not address, so assessment by a qualified clinician is described as the starting point. This page is educational and does not replace evaluation, and sudden severe symptoms need urgent medical assessment.