Procedures · Balance
Vestibular rehabilitation and manoeuvres for BPPV
BPPV occurs when small calcium crystals become displaced within the labyrinth and provoke brief attacks of vertigo on changing position. Treatment is carried out in the consulting room, with manoeuvres that reposition those crystals. Where imbalance persists for other reasons, vestibular rehabilitation comes in: a programme of exercises delivered in sessions.
Medically reviewed by Prof. Aline Bittencourt, MD, PhD, CRM-MA 7562 · RQE 1832 Updated on
Two different things, in the same place
This page brings together two procedures that are often confused:
- Otolith repositioning manoeuvres treat one specific cause of vertigo, BPPV, and resolve the problem mechanically, in the consulting room.
- Vestibular rehabilitation is a programme of exercises that trains the brain to compensate for a balance disturbance that a manoeuvre cannot resolve.
BPPV: what happens inside the ear
In one part of the labyrinth there are small crystals of calcium carbonate, the otoliths, which help detect the position of the head. When they come loose and migrate into the semicircular canals, they begin to move with every change of position and send the brain a signal of rotation that does not correspond to what is actually happening.
The result is characteristic: attacks that are strong, brief — under a minute — and always triggered by a movement. Lying down, turning in bed, getting up, looking up at a shelf.
What a session involves
- Diagnostic manoeuvre. The clinician positions your head in a specific way and observes your eyes. The involuntary movement that appears, nystagmus, indicates which canal is involved and on which side.
- Treatment manoeuvre. Based on that finding, a sequence of position changes guides the crystals back to where they belong, using gravity.
- Reassessment. At the end, the test is repeated to check the response.
Each position is held for a period, and the whole session usually takes thirty to forty-five minutes, including assessment.
Vertigo during the manoeuvre is expected and is part of the procedure.
When vestibular rehabilitation comes in
When the problem is not BPPV, or when imbalance persists after the acute cause has settled. This applies to people who have had vestibular neuritis, people with loss of function in one labyrinth, and people with persistent unsteadiness when walking.
The programme uses gaze stabilisation exercises, static and dynamic balance work and habituation to movement, adapted to the case and progressed across sessions, with continuation at home.
One important note: medication for dizziness taken continuously for months interferes with that compensation. The subject is covered in detail on the page on dizziness and vertigo.
Who should tell us beforehand
The procedure involves rapid changes of head and body position. Anyone with significant neck pain, a cervical disc problem, restricted neck movement, spinal instability or recent surgery in the area should say so beforehand, so the clinician can assess how best to proceed or adapt the technique.
Where it is carried out
At Clínica Rhinus, in the Renascença district of São Luís, as part of neurotologic follow-up.
The manoeuvres and the rehabilitation sessions are carried out on a self-pay basis only. The consultation and the balance tests follow the rules of your health plan. Contact our team to arrange booking.
How should I prepare for this test?
- Bring the medical request: it is required.
- Come accompanied if possible: the manoeuvre provokes brief vertigo during the session.
- Avoid a heavy meal in the two hours beforehand.
- Wear comfortable clothing that allows you to lie down and turn easily.
- Tell us if you have neck pain, a cervical disc problem, restricted neck movement or recent spinal surgery.
- Bring your balance test results and a list of your current medication.
Sources: Brazilian Association of Otorhinolaryngology and Cervico-Facial Surgery (ABORL-CCF) · Flint PW, Francis HW, Haughey BH, et al. Cummings Otolaryngology: Head and Neck Surgery. 7th ed. Elsevier; 2020. · Bento RF, Bittencourt AG, Voegels RL. Seminários em Otorrinolaringologia. Fundação Otorrinolaringologia.
Frequently asked questions
Questions about balance
What is BPPV?
Benign paroxysmal positional vertigo. Small calcium crystals that normally sit in one part of the labyrinth become loose and migrate into the semicircular canals. With each change of position — lying down, turning in bed, looking up — they move and provoke a brief, intense attack of vertigo lasting less than a minute.
How does the repositioning manoeuvre work?
It is a sequence of head and body position changes, performed by the clinician, using gravity to guide the crystals back to where they came from. It is preceded by a diagnostic manoeuvre that identifies which canal is involved and on which side — because the treatment manoeuvre changes according to the response.
Will I feel dizzy during the session?
Probably yes, and that is expected. Both the diagnostic and the treatment manoeuvres reproduce the vertigo under controlled conditions; it is precisely that response which guides the procedure. The sensation usually lasts less than a minute in each position and passes after the session.
How many sessions are needed?
It varies. Some cases improve within the first sessions, others need repetition, and BPPV can return months or years later. Reassessment is carried out at each session, with the diagnostic manoeuvre, to check whether a positive response is still present.
What is the difference between the manoeuvre and vestibular rehabilitation?
The manoeuvre treats one specific cause, BPPV, by repositioning the crystals. Vestibular rehabilitation is a programme of exercises that trains the brain to compensate for a balance deficit, used in conditions such as vestibular neuritis or persistent imbalance. Both may be indicated at different points in the same treatment.