What exercises and training can help a patient with dizziness and balance issues improve their balance and reduce the risk of falls?

Balance Training and Exercise for Dizziness and Balance Issues

Vestibular rehabilitation therapy is the cornerstone of treatment for patients with dizziness and balance problems, with strong evidence showing it reduces both dizziness and improves balance, unlike general conditioning exercises or vestibular suppressant medications which only reduce dizziness without improving balance. 1

First-Line Treatment Approach

For patients with benign paroxysmal positional vertigo (BPPV), perform canalith repositioning procedures immediately - the Epley maneuver for posterior canal BPPV achieves 80-90% success rates after 1-3 treatments, and this should be done before considering any exercise program. 2 Do not prescribe vestibular suppressant medications as they provide no benefit for BPPV and may interfere with the brain's natural compensation mechanisms. 2

Vestibular Rehabilitation Exercise Components

After successful repositioning or for non-BPPV vestibular disorders, implement a structured vestibular rehabilitation program that includes three core components: 2, 3

1. Habituation Exercises

• Target symptoms provoked by specific head movements or visual stimuli 2
• Patients repeatedly perform movements that trigger mild-to-moderate dizziness to promote central nervous system adaptation 1
• These exercises work by facilitating compensation for peripheral vestibular dysfunction 1

2. Gaze Stabilization (Adaptation) Exercises

• Focus on improving visual stability during head movements 2
• Critical for patients experiencing dizziness with head turns or movement 4
• Help restore the vestibulo-ocular reflex function 3

3. Balance and Postural Control Training

• Progress through increasingly challenging balance positions 2
• Include exercises that challenge the vestibular system specifically, not just general conditioning 1
• Incorporate functional activities relevant to daily living 3

Specific Exercise Recommendations for Fall Prevention

For elderly patients or those at high fall risk, implement balance exercises that improve strength and stability: 5

• Tai chi - specifically recommended for improving balance and reducing fall risk 5
• Walking programs - structured ambulation training 5
• Resistance training - to improve lower extremity strength 5
• Tandem standing practice - ability to hold tandem stand for 10 seconds reduces fall risk 5

Treatment Algorithm by Condition

For BPPV Patients:

1. Perform appropriate canalith repositioning procedure first (Epley for posterior canal, Barbecue Roll for horizontal canal) 2
2. Add vestibular rehabilitation exercises after successful repositioning to reduce recurrence rates by approximately 50% 2
3. Patients treated with CRP plus vestibular rehabilitation show significantly improved gait stability compared to CRP alone 2

For Chronic Vestibular Dysfunction:

1. Start vestibular rehabilitation as primary treatment 1
2. Continue for at least 6 months for chronic symptoms 1
3. Avoid vestibular suppressant medications as they only reduce dizziness without improving balance 1

For Post-Stroke Balance Issues:

1. Identify specific risk factors including balance deficits, poor limb coordination, cognitive deficits, and sensory impairments 5
2. Implement balance activities during activities of daily living 5
3. Provide assistive devices as needed for reaching and walking 5
4. Work on safety with transfers and mobility 5

Critical Safety Considerations

Address fall risk immediately in all patients with dizziness and balance problems: 5, 2

• Remove loose rugs and floor clutter to create clear walking paths 5
• Ensure adequate lighting throughout the home, including night lights 5
• Recommend shoes with nonskid soles that fit properly 5
• Counsel patients to slow down movements during transfers or walking, as quick movements can trigger dizziness or falls 5
• Avoid slippery surfaces including spills and icy sidewalks 5

BPPV increases fall risk 12-fold, particularly in elderly patients - 9% of patients referred to geriatric clinics have undiagnosed BPPV, and three-quarters of those have fallen within the previous 3 months. 2

When to Refer to Physical Therapy

Refer patients to specialized vestibular physical therapy when: 2, 3

• Residual dizziness persists after successful canalith repositioning 2
• Postural instability or heightened fall risk remains after treatment 2
• Patients have contraindications to standard repositioning maneuvers (severe cervical stenosis, morbid obesity, severe rheumatoid arthritis) 2
• Symptoms persist after 2-3 properly performed repositioning procedures 2
• Multiple canal involvement or canal conversion has occurred 2

Self-Treatment Options

For motivated patients, teach self-administered exercises: 2

• Self-administered Epley maneuver shows 64% improvement rate (after at least one properly performed in-office treatment) 2
• This is significantly more effective than Brandt-Daroff exercises which show only 23% improvement 2
• Brandt-Daroff exercises require three times daily performance for 2 weeks to be effective 2

Common Pitfalls to Avoid

Do not prescribe vestibular suppressants (meclizine, antihistamines, benzodiazepines) as primary treatment - they cause drowsiness, cognitive deficits, increased fall risk in elderly patients, and interfere with central compensation mechanisms. 2 They may only be considered for short-term management of severe nausea/vomiting in severely symptomatic patients. 2

Do not impose postprocedural restrictions after canalith repositioning procedures - patients can resume normal activities immediately, as restrictions provide no benefit and may cause unnecessary complications. 2

Do not use general conditioning exercises alone - while they may reduce dizziness symptoms, only vestibular-specific rehabilitation improves balance function. 1

Psychological Considerations

Address anxiety and avoidance behaviors that can perpetuate dizziness: 6

• Provide detailed explanations of how symptoms are provoked and the adaptation process 6
• Help patients understand that anxiety and activity avoidance can exacerbate symptoms, creating a vicious cycle 6
• Enable patients to anticipate and manage their own symptoms through education 6
• Recognize that chronic dizziness frequently leads to panic, anxiety, health preoccupation, and avoidance of activities 6

Monitoring and Follow-Up

Reassess all patients within 1 month after initial treatment to confirm symptom resolution or identify persistent problems requiring additional intervention. 2 If symptoms persist, repeat diagnostic testing to evaluate for canal conversion (occurs in 6-7% of cases), multiple canal involvement, or coexisting vestibular pathology. 2