Advanced Vestibular Rehabilitation

“When we first get into space, we feel sick. Your body is really confused. You’re dizzy. Your lunch is floating around in your belly because you’re floating.  What you see doesn’t match what you feel, and you want to throw up.”

Chris Hadfield, Astronaut

Vestibular Rehabilitation

Cobblestone’s highly regarded Dizziness Clinic, has been helping thousands of patients recover successfully since 2011. We are proud to be the clinic of choice for many hospitals, specialists (otolaryngologists and neurologists), medical practices, and other physiotherapists throughout the Brant County Area. Our registered physiotherapists and chiropractors have undergo extensive training and continuing education and are experienced in treating especially complex vestibular disorders.

Treatment for Vestibular Dysfunction

Do you often feel dizzy or experience vertigo, motion intolerance, a persistent sense of imbalance, or unsteadiness? If so, there’s a chance you may have vestibular dysfunction. The good news is that these symptoms can be treated and you can regain your quality of life.

Vestibular dysfunction is more common than you may realize. A recent epidemiological study estimates that as many as 35% of adults over the age of 40 have experienced some form of vestibular dysfunction in their lives. Fortunately, most causes of dizziness can be detected through a comprehensive eye exam. It has been found that 85% of cases are due to inner ear disturbance (vestibular dysfunction) and can be treated using Vestibular Rehabilitation.

Neuro-rehabilitation therapy allows us to retrain your brain and eyes to regain functionality and quality of life for those suffering from visual problems due to vestibular rehabilitation. It works by using a variety of methods and techniques to get both eyes to work as a team and see visual space accurately. This form of therapy, known as neuro-optometric rehabilitation therapy, is an effective treatment for reducing or resolving symptoms associated with vestibular dysfunction.

If you have (or suspect you have) vestibular dysfunction and/or suffer from dizziness, unsteadiness or motion intolerance, talk to our team of specialized therapists. We can help!

But First, What is Vestibular Dysfunction and What Causes It?

Tired man with Vestibular DysfunctionThe vestibular system is made up of the peripheral vestibular organ (located in the inner ear), the vestibulocochlear nerve, the central vestibular organ and neural connections situated in the brainstem. When the inner ear sends the brain the wrong information or conflicting signals, the person tends to feel dizzy. As a result, the natural response is to limit movement in order to minimize the rocking or spinning sensation.

What Causes Vestibular Dysfunction?

Vestibular dysfunction is caused by damage to the vestibular system by disease, viral infection, high doses of certain antibiotics, stroke, degeneration of the inner ear’s balance function, blows to the head (such as concussions, brain trauma, whiplash) or some other unspecified cause(s). This results in a series of symptoms that impact all aspects of daily living.

If the system is damaged, vestibular disorders can result in one or more of these symptoms:

  • Dizziness and vertigo
  • Imbalance and spatial disorientation
  • Cognitive and psychological changes
  • Hearing changes
  • Vision disturbance

Concentration, memory loss and fatigue can often accompany vestibular dysfunction. In order to keep the body upright, the brain needs to work extra hard and therefore compromises on other brain functions. Some people with vestibular dysfunction find it difficult to get out of bed, function properly at school and work or perform routine tasks in environments heavy in visual stimuli (think grocery stores, traffic, shopping malls). Thankfully, by undergoing Vestibular Rehabilitation Therapy these symptoms disappear along with the dizziness.

How is Vestibular Dysfunction Diagnosed and Treated/Rehabilitated?

Because inner-ear problems cause diverse symptoms such as vertigo, nausea and blurred vision, people with vestibular dysfunction spend years going from physician to physician, only to have their symptoms misdiagnosed as sinus, eye, neurological or psychological problems.

Vestibular Therapists specialize in understanding how specific visual and vestibular dysfunctions relate to a patient’s symptoms and performance. At Cobblestone Medicine and Rehab Centres, our patients undergo a comprehensive evaluation.

During the comprehensive eye exam, the therapist will evaluate many functions of the visual system, such as:

  • How well the eyes work together
  • Whether the eyes are struggling to focus
  • Eye scanning and tracking ability
  • How the patient processes his/her surroundings and moves through it
  • The connection between vision and balance
  • Complex visual perceptual ability (how one organizes and interprets visual information and associates meaning and visual memory to it)
  • Visual acuity, refraction, eye health evaluation, and peripheral vision testing

Following the examination, the vestibular therapist will provide the patient with an individualized treatment plan, also known as neuro-optometric rehabilitation therapy. This therapy rehabilitates the visual, perceptual, and motor disorder and is great for patients of all ages.

The rehabilitation program incorporates in-office and at-home exercises for the remediation and management of the patient’s visual problems.

Vestibular Dysfunction often requires a multidisciplinary approach. In addition to neuro-optometrists, the rehabilitation team may include neurologists, rehab physicians, nurses, physical and occupational therapists, speech-language pathologists, neuropsychologists, and audiologists.

Neuro-Optometric Rehabilitation for Vestibular Dysfunction

After reviewing any relevant medical documentation from your neurologist, occupational therapist, physiotherapist, etc, our team of eye doctors will then perform a Neuro-Visual Assessment to identify and correct the underlying cause(s) of the disorder. The Cobblestone Medicine and Rehab specialized Vestibular Therapist will then craft a personalized treatment plan for your recovery.

Vestibular Rehabilitation Therapy (VRT)

Vestibular rehabilitation therapy (VRT) or vestibular rehabilitation (VR) is the more targeted therapies within the larger neuro-rehabilitation therapy umbrella. VR or VRT is a carefully designed exercise-based therapy used to alleviate both the primary and secondary problems caused by vestibular disorders. The customizable program is designed to diminish vertigo and dizziness, enhance gaze stability, enhance postural stability and to improve activities of daily living.

VRT therapists, often working alongside the neuro-optometrist, look to improve visual skills while slowly adding tasks with different sensory-driven concepts. This therapy is made up of various head, body, and eye exercises specifically designed to retrain the brain to recognize and process signals from the vestibular system and coordinate them with vision cues. These exercises differ from person to person – each according to their personal needs and conditions.

woman with vertigo and headacheVRT is based on the idea that the very movements that make the patient dizzy can eventually relieve the symptoms through repetition. By repeatedly bombarding the brain with incorrect messages, the brain ultimately adapts, and reinterprets the faulty signals as correct. As a result, the symptoms subside.

The VRT program includes a series of habituation exercises, such as jumping, sitting up and rapidly lying down, and spinning in circles. In addition to habituation exercises, vestibular rehabilitation patients are given eye exercises to retrain the vestibular ocular reflex, an adjustment controlled by the inner ear that ensures the eye keep the field of vision steady while the person is in motion. Eye exercises may involve moving the head from side to side or up and down repeatedly while focusing on a specific target in order to help steady the patient’s gaze.

The VRT exercise program is specifically built so that it can be performed at home. The better the patient complies with the home exercise program, the better the outcome and the quicker the rehabilitation.

Thanks to VRT, the vast majority of patients (80%) will experience a decrease in symptoms.


Agrawal Y, Carey JP, Della Santina CC, Schubert MC, Minor LB. Disorders of balance and vestibular function in US adults. Arch Intern Med. 2009;169(10): 938-944.

Herdman, S. J., & Whitney, S. L. (2007). Interventions for the patient with vestibular hypofunction. In S. J. Herdman (Ed.), Vestibular rehabilitation (3rd ed., pp. 309–337). San Francisco: Davis.


If you’re suffering from dizziness, vertigo or imbalance as a result of a head injury, viral infection, inner ear disorder, neurological disorder or sports-related injury and you’re searching for relief, you may benefit from vestibular rehabilitation. Using evidence-based assessment and treatment techniques, our knowledgeable and experienced healthcare providers can help you return to your normal activities sooner. Our team will complete an assessment and develop an individualized treatment plan that is designed around your specific needs and goals for the best possible outcome. We will also maintain ongoing communication with your physician and obtain the necessary medical clearance for your safe return to activity or sport.

In addition to developing and implementing a personalized vestibular rehabilitation treatment plan that meets your needs, we provide continuous evaluation and ongoing education every step of the way. We will work closely with you to progressively improve your cognitive-mental and physical functions and adjust treatment as needed for optimal results.


Your vestibular system and your eyes have a direct connection with each other. Problems with your vestibular system can result in changes to your eye reflexes, producing abnormal eye motion (called Nystagmus). Closely examining these nystagmus patterns of your eyes allows us to perform a more detailed assessment resulting in a more accurate diagnosis.

Vertigo and dizziness symptoms most often area a result of a dysfunction of the vestibular organ, which is a small but important structure in your inner ear. The vestibular organ is critical for balance, coordination, and movement and when it’s impaired, patients can experience spinning (vertigo), dizziness, nausea, imbalance, problems with vision, and light-headedness, anxiety, among other often debilitating symptoms.

Dizziness and vertigo are among the most common symptoms that send people to see doctors. After negative MRI and CT scans, patients are often prescribed medication that is of little help and sent to specialists, only to be told nothing can really be done.

Dizziness Clinic appointments in hospitals currently have wait times of several months. At Cobblestone we’ve successfully treated vestibular disorders since 2011, helping hundreds of patients each year.  We have vestibular physiotherapists and chiropractors certified. While our assessment procedures and treatment protocols are generally similar to those in hospital programs, and are based upon clinical and medical evidence, our wait times are significantly shorter — which means you can get better, faster.

We provide assessment and treatment for the following:

What we do.

Initial visits are one-hour, where we take a comprehensive history and perform a complete clinical assessment. Symptoms of dizziness can be from dozens of various pathologies, so special care is taken to rule out non-vestibular causes first.

The physical assessment involves a series of manual and functional tests to categorize the type of dizziness you’re experiencing. We then use special infrared goggle technology, which has been clinically demonstrated to be one of the most accurate ways to assess vestibular dysfunction. This involves recorded observation of irregular eye movement — which is physiologically linked to impaired vestibular function — and we create a treatment plan based on the results of the assessment.

What does Vestibular Rehabilitation Therapy (VRT) involve?

While treatment depends on our findings, it can involve education, manual therapy or head manoeuvres, a patient-specific exercise program, or a combination of these strategies. Certain types of vestibular disorders can resolve in 2-3 visits, whereas other types require more time and include a home exercise program.

Our assessment and treatment protocols are based upon sound evidence-based research and clinically proven techniques, and are customized for each patient.

What about the Epley manoeuvre?

Approximately half of all patients we assess receive a diagnosis of BPPV (Benign Paroxysmal Positional Vertigo), which is caused by calcium carbonate crystal displacement in the inner ear.  Certain types of BPPV can be successfully corrected using the Epley manoeuvre, which we perform often. However, BPPV exists in several different forms with each requiring different manoeuvres, determined by an accurate clinical assessment. We recommend if you perform your own Epley manoeuvre to do so with caution, as you can change a simple vestibular impairment into a more complicated one.  See our post on the Epley as a home treatment.

What do I need to know about my appointment?

Please arrive 15 minutes ahead of your appointment to complete the necessary intake forms, and bring any relevant medical documents with you — MRI/CT scan reports, specialist reports, caloric and hearing tests, and any other appropriate papers.

Vestibular GogglesOur assessment includes a thorough examination of your vestibulo-ocular reflex, where we look for evidence of irregular eye movement.  If you capture any of this irregular eye movement using your smart-phone at home, please bring the video as it can help with a more accurate assessment.

We ask that you not smoke ONE HOUR prior to your appointment, as this may affect the quality of the assessment.  If you’re currently on medications (including Gravol) to treat your dizziness, please continue taking it as prescribed by your doctor.

The assessment procedures do reproduce your symptoms, so you will likely experience an increase in dizziness and/or nausea following your first visit. Most patients are able to drive, return to work, and function normally following the assessment. However, if your symptoms are already quite acute, or if you don’t feel comfortable having them provoked, you may wish to have someone accompany you to the appointment.

Does insurance cover vestibular services?

At Cobblestone Medicine and Rehab Centre, registered physiotherapists and chiropractors perform our vestibular services. If you have extended health benefits for physiotherapy and/or chiropractic, your vestibular visits will be based on this coverage.

— Unsure if vestibular rehabilitation is right for you? —
Take advantage of our 10 min complimentary phone consult at (519) 442-2237.

vestib organ

Your personalized assessment may include:

  • Dizziness questionnaire
  • Posture analysis
  • Joint range of motion measurement
  • Balance testing in sitting and standing
  • Patterns of movement evaluation
  • Positional movement testing
  • Gait assessment
  • Fall risk assessment
  • Oculomotor function using videonystagmography
  • Medical history as it pertains to the condition
  • Neurological screening including coordination, sensation and proprioception

Treatments may include:

  • Habitual exercises
  • Education
  • Balance retraining (static and dynamic retraining)
  • Stretching
  • Gait retraining
  • Relaxation
  • Gaze stability exercises
  • Adaptation exercises (eye-hand coordination exercises)
  • Paroxysmal Positional Vertigo (PPV)

Can help the following conditions:

  • BPPV
  • Unilateral Vestibular Hypofunctioning
  • Bilateral vestibular hypofunctioning
  • Menieres Disease
  • Fistula/ Superior Canal Dehiscence – post surgery
  • Vestibular Schwannoma
  • Stroke
  • Concussion and head traumas
  • Vestibular Migraines
  • Persistant Postural Perceptual Dizziness (PPPD)