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How NOT To Do Vestibular Rehab

Devon Konrad has been a practicing vestibular physiotherapist for 14 years. In that time, she has worked with many people with vestibular deficits who were given misleading, confusing or just poor advice in how to deal with their symptoms. In this blog, Devon highlights her biggest pet peeves in the world of vestibular rehab.

There’s a certain level of anger I experience when I walk into a new vestibular assessment and I can already feel the client’s walls are up. I then often learn that the person sitting in front of me has been through 1, 2 or more “vestibular therapists” who didn’t help or made things worse. They often come into this appointment with a lot of hesitation and reluctance, expecting the same treatment they’ve had in the past.

Here’s the problem: there is no official accreditation in Canada to call yourself a “Vestibular Therapist”. Anyone can say they are a vestibular therapist, no matter how many (or how few) courses they take or how much mentoring they have received. As a result, Canada is filled with people who highlight “vestibular rehabilitation” as a specialty without actually having the knowledge or expertise to do so.

Balance and Dizziness Canada is trying to change that. They have a list of curated professionals from across the country - physiotherapists, audiologists, occupational therapists - who have taken the gold standard courses in their field. If you are looking for someone who has expertise in vestibular conditions and vestibular rehabilitation, this is a great place to find them.

Until we have a system of accreditation, this will continue to be a problem. So this blog is for all the people out there in the vestibular rehab world, either as patients or practitioners - a What Not To Do, of sorts.

How NOT To Do Vestibular Rehab

1. Keep pushing through symptoms, no matter what

One of my biggest pet peeves is when people have been told they just need to keep pushing and ignore their symptoms; that their symptoms will decrease eventually as long as they just keep pushing.

This. Doesn’t. Work.

Not only does this often put people in a state of perpetual symptoms, it often drives anxiety. And while we don’t have the research yet to implicate poor treatment approaches in developing chronic forms of dizziness, we do know that about about a quarter of people with vestibular deficits go on to develop Persistent Postural-Perceptual Dizziness (PPPD). We also know there is a massive link between anxiety and developing PPPD.

By pushing people into a state of constant symptoms with no locus of control around those symptoms, I argue this is setting people up for longer term problems. Which leads me to my next point…

2. Not learning how to reduce symptoms

When I’m working with someone who has “failed” vestibular rehab, I’ll pick a task that I know will slightly increase their symptoms and then ask them to settle their symptoms.

More often than not, they look at me like I have three heads. Here’s the response I often get: “I don’t know how to settle them! If I knew that, I wouldn’t be here!”

Let me be clear: I’m very good at making people feel dizzy. But my job is to make them feel better and I cannot do that if I’m not teaching them HOW to feel better.

With vestibular rehab, we definitely want to introduce exercises that increase symptoms. You cannot drive the brain changes needed to feel better if you aren’t challenging the brain! But I’d argue it’s even more important for people to learn how to settle these symptoms after increasing them.

Here’s my cues in how to “ground out” and settle symptoms:

  • I want the person to look at something they are sure is not moving. This could be a light switch, the corner of a table, a lamp shade. Something inoffensive and stable. NOT the curtains, the dog or another human - those things cannot be trusted.

  • Next, I want the person to really feel their feet. I want them in a wide base of support and paying attention to what their feet are telling them. Some people like to weight shift, some people don’t - it’s whatever feels right for them.

  • Then, the biggest one - I want slow, deep breaths. The vestibular system and the autonomic system are highly intertwined: when dizziness starts, so does the fight-or-flight response. Breathing cues to the parasympathetic system to bring balance back to the autonomic nervous system, bringing symptoms down.

  • Finally, I don’t allow people to add more touch points while they recover (unless they’re a falls risk or safety risk - then, by all means, please sit!). If the exercise was done in sitting, they can keep sitting while settling their symptoms. If they were standing, they do not get to lean on a door frame or touch the counter for support. Their brains need to learn how to settle their symptoms without this additional touch point.

I give people about 5 minutes to settle their symptoms in this way. After that, I let them do what they’d like to get their symptoms under control - sit down, lie down, close their eyes, get some fresh air: whatever it is for them.

A good vestibular exercise should stimulate their symptoms enough to be uncomfortable and be able to get back to their pre-stimulated levels of symptoms within 5 minutes. If there’s no symptoms at all, we need to make it harder. If symptoms are taking way longer than this to settle, the exercise is too hard.

Whether they are doing their exercises in the clinic or at home, I drill into them that this “settling piece” is a non-negotiable piece of their rehab. They need to develop a locus of control around their symptoms and have strategies to get those symptoms down. In my opinion, this is the number one goal of vestibular rehab.

3. Not teaching people why things trigger them

A Triangle of Balance captured in the wild!

In my clinic, you’ll see a lot of triangles written on white boards with “vision”, “vestibular”, and “touch & proprioception” written on them. This is because we spend so much time teaching people about how their vestibular system works as well as how it interacts with their other balance systems. (Want to know more? Check out our other blogs on vestibular rehab!)

Why do we do this? Because people need to understand why they feel the way they do. They need to be able to figure out why their symptoms are up if they’re a passenger in a car, or watching their kid’s soccer game, or skiing in the alpine. By giving them that ability, they can use their strategies to immediately reduce their symptoms and keep them involved in their own lives and doing the things they love to do.

I’m a big believer in making myself obsolete. I want people to leave here filled with knowledge about their vestibular system and how to make their lives work for them. I want them to be able to use their tricks to enjoy the movies on the big screen and play on the playground with their kids.

4. Ignoring symptom burden with exercises and looking exclusively at performance

I see this a lot: instead of asking how people feel during and after their exercises, therapists watch their performance of a specific exercise and make it harder solely on that.

I can see the therapist’s point a bit more in this one - in order to learn new motor patterns, you need to make mistakes so the brain can learn how to correct them. With a perfect performance, you’re not learning much so it makes sense to make the exercise harder.

But what that therapist isn’t taking into account is how awful that exercise is making the person feel. For a lot of these clients, they have just learned how to perform an exercise while feeling awful.

This is not the goal! We are not just trying to make people perform. We are actively trying to strengthen the vestibular system so people feel better. By looking at performance alone, we often miss the most important piece.


This Not To Do list is far from complete but it’s a start! If you’re looking for a good vestibular therapist and don’t know where to start, head to Balance and Dizziness Canada for some great recommendations.

If you’d like to book with us, call us at (778) 630-8800, book online or email us.

Vestibular Exercises for Tired Caregivers of Little Ones

Does this story sound familiar? You go see your favourite physiotherapist who gives you a bunch of great, well-intentioned exercises perfectly targeted for you and your body. By the time you get home, life hits - the laundry needs attention, someone needs to make dinner and someone is crying. How are you supposed to get it all done?!

For caregivers of littles, this often presents a huge challenge - how do you get your exercises in while still managing everything you have going on at home?

When it comes to vestibular exercises, I have come up with a great list that you can try at home. As always, check in with your vestibular therapist to make sure these exercises are appropriate for you.

Devon’s Top Ten Exercises for Vestibular Stimulation With Babies & Toddlers

1. Create an obstacle course with tape

Grab some masking or painter’s tape and start taping lines on the ground. Tape a long, straight piece down and walk heel to toe on it; tape a zig-zag on the ground to walk along; tape some shapes to jump into - you are only limited by your creativity!

Bonus points if you use different colours of tape and assign different rules to different tape colours. For instance, move slowly on the yellow tape, fast on the green tape and backwards on the blue tape.

2. Play Floor is Lava

Grab all the pillows you can find and scatter them around the room. Go from one pillow to the next, making up rules as you go. Let your little one pick a pillow to “sink into the lava” or decide that all the blue pillows sunk.

3. Peak-A-Boo with movement

For the super-littles, a game of peak-a-boo is a great place to get some vestibular input. When you close or cover your eyes, move either forward/backward or up/down - that movement with eyes closed will give your vestibular system a nice kick. Remember to do this one in sitting if you’re quite off-balance with eyes closed in standing!

4. Ring Around the Exersaucer

If you have a little sitting in an exersaucer, jolly jumper or even on a blanket on the ground, walk around them in some kind of silly walk while making eye contact and having your head turned toward them. You could be a penguin, a hopping bunny, a gorilla - whatever you’d like! The bigger and more exaggerated the movement, the better!

5. The Hokey-Pokey

If you want to get your body moving, do the Hokey Pokey! You can move as much as you want and even close your eyes for parts of it to give you a real challenge. Putting your head in? Drop that head as far down as you can!

6. Toy handoff

A common vestibular exercise I prescribe is looking at something in your hand while moving your head. This is easy to do here - when you grab a toy to hand your kid, look at the toy as you turn and move towards your kid without allowing your eyes to come off of the toy.

7. Yoga

You may be thinking, how am I supposed to do yoga with little kids around? My kids and I started down Cosmic Kids Yoga together during the pandemic and they loved it. Give it a try! It even became a regular thing in our home before lunch.

8. Silly walks

Create your own silly walks with your littles! High kicks, wobbly knees, spins… take turns creating a silly walk and having everyone else copy it. If you have one walking little and one non-walking little, holding the baby while doing your silly walk gets your bonus points!

9. Tickle fights

Honestly, the vestibular system and spontaneous movement are made for each other. Tickle fights are such a great way to engage in unpredictable movement patterns and react to their movements. Add some rolling around and you’ve got the whole package!

10. Patty Cake

When playing patty cake, keep your eyes switching back and forth between your hands - this gives your vestibular system some great stimulation.

Remember - make sure you’re safe to do any and all of these exercises, especially ones in which you are closing your eyes and moving through space. The last thing you need is a fall! If in doubt, check in with a vestibular therapist about which exercises are appropriate for you.

If you need the help of a vestibular therapist, call us at (778) 630-8800, book online or email us.

How To Recognize A Concussion

Concussions have been getting a lot of media attention lately, and rightfully so. If you’re an ardent or casual consumer of American football, you likely heard about Tua Tagovailoa. The 24 year old quarterback of the Miami Dolphins seemed (to my eyes) to show symptoms of a concussion on Sunday, September 25th. He was cleared to play in the Thursday, September 29th game where he sustained a head injury, just four days later. Tagovailoa was carted off the field on a spine board and transported to hospital where it is reported he was diagnosed with a concussion. The NFL has since been under fire for its handling of Tagovailoa’s initial hit.

Repeated concussions within a short time frame are a big problem and can be fatal. Second Impact Syndrome occurs when someone suffers a second head injury before recovering from their first, leading to swelling of the brain. It is thankfully rare but it does happen.

Since this occurred, there’s been a lot of discussion around concussions. Can you tell from a video that Tagovailoa suffered a concussion? What signs are you looking for? Most importantly, what do we do about it?

Before We Start: Things To Know About Concussions

Parents, partners, friends and teammates need to be aware of the common signs and symptoms of a concussion. For people not in health care, the Concussion Recognition Tool is a handy document to have readily available. It lays out everything I review here: the basics of how to recognize a possible concussion and some basic tests anyone can do to help figure out if someone suffered a concussion.

These are hard and fast rules about concussions that everyone should know:

  1. When in doubt, sit them out. Concussions are no joke. They are brain injuries, full stop. Most heal well but they need to be given the time and space to heal. If you think a concussion has occurred, stop and seek medical help.

  2. You don’t have to hit your head to suffer a concussion. While most concussions occur through a blow to the head, a force to the body can produce enough jarring force to the head to cause a concussion. Do not blow off concussion symptoms simply because the head did not physically hit anything.

  3. You do not need to be knocked out to suffer a concussion. In fact, most concussions do not result in a loss of consciousness.

  4. We cannot see a concussion with imaging. While research is getting closer to finding something that can definitely diagnose a concussion, we aren’t there yet. X-rays, MRIs and CTs are not able to diagnose a concussion.

  5. Baseline testing is not needed to diagnose a concussion. A concussion can be appropriately diagnosed by trained medical professionals without baseline testing.

  6. Return to sport/work/play protocols are important to follow. Medical professionals involved in concussion care are well versed in these protocols.

  7. Always have your primary medical practitioner involved in concussion care. This may be a doctor or nurse practitioner, but they need to be involved from the start.

How To Recognize A Potential Concussion

If you have just witnessed someone hit their head or take a large, jarring force to their body and you’re concerned they have sustained a concussion, watch for these signs:

  • Unconsciousness or lying motionless after the hit

  • Slow to get up

  • Confusion, disorientation and inability to respond to questions

  • A blank or vacant look

  • Imbalance, poor coordination, stumbling and gait difficulties

  • Any facial or head injuries

If you see these signs, call 9-1-1:

  • Neck pain or tenderness

  • Double vision

  • Weakness, tingling or burning in the arms or legs

  • Severe or increasing headache

  • Seizure or convulsions

  • Loss of consciousness

  • Deteriorating conscious state

  • Vomiting

  • Increasingly restless, agitated or combative

Watch Tua’s first injury on September 25th - how many of these can you see in the video? Now watch his second injury four days later - what do you see?

Immediate Signs And Symptoms Of A Concussion

If you suspect someone has had a concussion, you should check in with them for their symptoms.

Signs and symptoms of a concussion can be cognitive, behavioural and/or physical. The most common signs and symptoms to watch out for include:

  • “Don’t feel right”

  • More emotional

  • More irritable

  • Sadness

  • Nervous or anxious

  • Neck pain

  • Difficulty concentrating

  • Difficulty remembering

  • Feeling slowed down

  • Feeling like “in a fog“

  • Headache

  • “Pressure in head”

  • Balance problems

  • Nausea or vomiting

  • Drowsiness

  • Dizziness

  • Blurred vision

  • Sensitivity to light

  • Sensitivity to noise

  • Fatigue or low energy

If they complain of or display any of the above, assume they have had a concussion and seek medical attention.

It’s not uncommon for people who have had a concussion to just waive everything off and say they’re fine, especially for athletes in the middle of the game. In this case, it’s important to check their memory with a few basic questions. Some great options include:

  • Where are we playing today?

  • Which half/inning/period is it?

  • Who scored last?

  • What team did you play last time?

  • Did your team win the last game?

If you are still unsure, remember Rule #1: When In Doubt, Sit Them Out.

After A Concussion

If it’s pretty clear someone has a concussion, they need to be seen by a medical professional. If symptoms aren’t severe, an appointment with their GP or NP can be made in the next few days.

People with concussions shouldn’t be left alone initially in case symptoms worsen. They don’t need to be woken up every 1-2 hours like we used to do but they do need to have someone keep their eye on them. People with concussions should not drive, drink or self-medicate with drugs. Seek medical attention from a GP, NP or pharmacist for recommendations on medications.

In the first two weeks after a concussion, most people heal well. We have come a long way in our understanding of how to treat a concussion, which you can read about in our blog So You’ve Had A Concussion, Part 1: The First 2-4 Weeks.

All of this information is laid out in the Concussion Recognition Tool and is free to download.

If you’ve suffered a concussion and need follow up care, book an appointment online, email us or give us a call at (778) 630-8800.