Vestibular Rehab in Brampton

Vestibular rehabilitation (VR) is a specialized, exercise-based program designed to reduce dizziness, vertigo, gaze instability, and imbalance caused by inner-ear (peripheral) or brain-based (central) vestibular dysfunction. At Platinum Physiotherapy, vestibular rehabilitation is delivered by Registered Physiotherapists with post-graduate certification through recognized vestibular rehabilitation programs (Herdman, APTA, AIB, or Concussion Rehabilitation Training). The evidence base is strong: the 2015 Cochrane review (Hillier & McDonnell, 39 trials, n=2,441) confirms moderate-to-strong evidence that vestibular rehabilitation is safe and effective for unilateral peripheral vestibular dysfunction, and the 2016 APTA Clinical Practice Guideline (Hall et al.) provides specific dose and progression recommendations.

We treat the full range of vestibular disorders. Peripheral vestibular disorders include Benign Paroxysmal Positional Vertigo (BPPV) - the most common cause of vertigo, driven by displaced otoconia (calcium carbonate crystals) in the semicircular canals - vestibular neuritis, labyrinthitis, Meniere's disease, perilymph fistula, superior canal dehiscence syndrome, bilateral vestibular hypofunction (often from gentamicin ototoxicity or aging), and post-surgical states (vestibular schwannoma/acoustic neuroma resection, labyrinthectomy, stapedectomy). Central vestibular conditions include vestibular migraine (Neuhauser criteria), cerebellar dysfunction, Persistent Postural-Perceptual Dizziness (PPPD - Barany Society 2017 consensus), Mal de Debarquement Syndrome (MdDS), and post-stroke balance dysfunction. Cervicogenic dizziness, in which upper-cervical proprioceptive dysfunction generates dizziness, responds particularly well to combined cervical manual therapy and sensorimotor retraining (Reid 2014, Treleaven 2017).

Our assessment uses validated clinical tools: the Dix-Hallpike and Supine Roll (Pagnini-McClure) tests for BPPV canal localization, the Head Impulse Test (HIT) / video Head Impulse Test (vHIT) for semicircular canal function, Dynamic Visual Acuity (DVA) test for gaze stabilization deficits, Vestibular/Ocular-Motor Screening (VOMS) for post-concussion symptom provocation, Romberg and Tandem Romberg, Fukuda Stepping Test, Functional Gait Assessment (FGA) and Dynamic Gait Index (DGI) for gait-and-balance objective scoring, Timed Up-and-Go, and the Dizziness Handicap Inventory (DHI) and Activities-Specific Balance Confidence (ABC) Scale as patient-reported outcome measures. Infrared Frenzel goggles are used when available for nystagmus characterization.

• BPPV (Benign Paroxysmal Positional Vertigo) - brief (<60 s) vertigo triggered by specific head positions (rolling in bed, looking up, bending forward). Posterior canal BPPV resolves in 1-3 sessions with the Epley maneuver; horizontal canal uses Lempert roll or Gufoni.
• Vestibular neuritis or labyrinthitis - acute sustained vertigo, nausea, imbalance after viral illness. Rehabilitation accelerates central compensation (Strupp 1998).
• Meniere's disease - episodic vertigo + aural fullness + tinnitus + hearing loss. VR between attacks improves balance and fall risk.
• Bilateral vestibular hypofunction - oscillopsia (bouncing vision with head movement), gait ataxia; often from gentamicin ototoxicity or aging.
• Post-concussion vestibular dysfunction - persisting dizziness, motion sensitivity, and imbalance after mild TBI; Schneider 2014 shows combined cervical-vestibular rehab significantly accelerates medical clearance.
• Persistent Postural-Perceptual Dizziness (PPPD) - chronic (>3 months) non-vertiginous dizziness worsened by upright posture, visual motion, and active/passive movement. Habituation + SSRI + CBT is standard.
• Mal de Debarquement Syndrome - persistent rocking/swaying sensation after cruise or prolonged passive motion.
• Vestibular migraine - episodic vertigo with migrainous features (headache, photophobia, phonophobia). VR as adjunct to lifestyle and pharmacologic management.
• Cervicogenic dizziness - dizziness linked to neck movement or sustained neck posture, with upper-cervical joint dysfunction and impaired cervical proprioception.
• Age-related vestibular decline and fall risk - patients over 65 with unsteadiness, near-falls, or confirmed falls; VR reduces fall risk (Whitney 2016).
• Post-acoustic neuroma resection (vestibular schwannoma) or other vestibular nerve surgery - accelerates central compensation.
• Oscillopsia (visual instability with head movement) - gaze-stabilization and substitution training.
• Motion sensitivity / visual-vertical dependence - habituation and optokinetic exposure.

First visit (60-75 minutes): detailed subjective history (onset, pattern, triggers, duration of episodes, associated symptoms such as hearing loss, tinnitus, aural fullness, migraine features, red-flag screen for central pathology - diplopia, dysarthria, dysphagia, dysmetria, drop attacks), medication review, fall history, functional impact on driving, working, climbing stairs. Clinical examination: cranial nerve screen, smooth pursuit, saccades, vergence, Head Impulse Test, head-shake nystagmus, Dix-Hallpike (both sides), Supine Roll Test, Romberg, Tandem Romberg, Fukuda Stepping, Functional Gait Assessment, Timed Up-and-Go, DHI and ABC questionnaires completed at baseline for objective tracking.

BPPV treatment: once the affected canal and affected side are identified by positional testing, the appropriate canalith-repositioning maneuver is performed in-clinic. For posterior canal BPPV (90% of cases): the Epley maneuver has an 80-95% success rate in 1-2 treatments (von Brevern 2006, Hilton & Pinder Cochrane 2014). The Semont liberatory maneuver is an equally effective alternative. For horizontal (lateral) canal BPPV: the Lempert 360-degree barbecue roll or Gufoni maneuver. For the rarer anterior canal BPPV: reverse Epley or deep head-hanging maneuver. Post-treatment we verify resolution with re-positional testing and issue home exercises (half-Somersault or Brandt-Daroff) for residual symptoms.

Vestibular hypofunction (unilateral or bilateral): 4-12 weeks of progressive exercises customized to your deficit profile. VOR adaptation exercises (x1 viewing, x2 viewing) retrain the vestibulo-ocular reflex to maintain gaze stability during head movement. Substitution exercises teach the nervous system to use visual and somatosensory cues to compensate for the vestibular deficit. Habituation exercises (Cawthorne-Cooksey, Brandt-Daroff, customized motion-provocative exercises) reduce motion-sensitivity. Balance retraining uses progressively challenging surfaces (firm, foam, tandem stance, single-leg, dynamic), dual-task conditions (head turns while walking, catching a ball while standing on foam), and environmental complexity.

Central and complex cases: PPPD, vestibular migraine, and central vestibular dysfunction require longer courses (8-16 weeks) and often multi-disciplinary coordination with otolaryngology (ENT), neurology, and - for PPPD - psychiatry or psychology for concurrent CBT. We maintain active communication with your referring specialist.

Outcomes: Cochrane-level evidence supports clinically meaningful improvement in DHI scores, gaze stabilization, postural control, and fall risk within 4-12 weeks of appropriately dosed VR. BPPV treatment produces immediate dramatic improvement (often within one visit). Home exercise adherence is the single strongest predictor of outcome - we provide video and photograph home exercise programs, and we track adherence and symptom response at every follow-up.

Coverage: vestibular rehabilitation is delivered under the physiotherapy benefit. Direct billing to all major extended health insurers. WSIB and MVA-SABS covered if the condition relates to a workplace injury or motor vehicle accident (very common post-whiplash). No doctor's referral required in Ontario.