Patient Daily Living

Vestibular Rehabilitation: Fixing Balance Issues

Elderly people are often plagued with dizziness or other sensations that make them feel unsafe walking or moving and leave them worried about how to avoid falling. These problems might occur as a result of sedentary behavior and be resolved with physical activity or they may require the services of a vestibular rehabilitation therapist to help.

One such person, James Gurley, PT, DPT, NCS, sees a lot of patients whose "navigations systems" have gone awry. Gurley, who is Vestibular Program Director at H&D Physical Therapy and who also works at the James J. Peters VA Medical Center in the Bronx, NY, helps them regain their sense of equilibrium using various exercises and sometimes assistive devices such as canes.

The balance system is made up of vision, proprioception and the vestibular system (which is the inner ear). Proprioceptors—cells in muscles and joints that indicate their position in space—diminish in the elderly.

So how do you know if your problem requires a specialist's attention? "In general, if someone has a tough time keeping their balance, especially when turning their head and crossing the street, or walking on uneven sidewalks or in places where the lighting isn't good, that's when they see me," Gurley said. If balance is poor because of pain or weakness in the leg due to arthritis or pain in the hip, low back or knee, you could consider seeing a standard physical therapist.

According to Gurley, a true inner ear problem could happen at any time in a person's life, but many ailments that arise from aging can lead to equilibrium problems. Poor eyesight, glaucoma, loss of muscle strength and joint range of motion, loss of sensation in the feet and lack of stimulation to the vestibular system can all contribute to poor balance. People with unsteady gait can shun walking in open spaces because there's nothing to hold on to, and they may be frightened that dogs or small children will dart in their path and cause them to fall.

What To Expect At Your First Visit

When you see a vestibular rehabilitation therapist, your first visit will probably go like this:

  • You will have a gait and balance assessment. For that you might be asked to walk while turning your head, balance with eyes open or closed and stand on an uneven surface.
  • Your therapist will ask you about the things that make you dizzy.
  • Subsequent visits will focus on helping you improve your balance through exercises your therapist will teach you.

How To Avoid Falling

Gurley suggests these precautions to avoid falls:

  1. Use night lights or turn on the lights if you have to get up at night.
  2. Get up from lying in bed slowly and sit for 30 to 60 seconds before walking.
  3. Use a cane for stability if needed.
  4. Have yearly eye examinations and wear your glasses.
  5. If you wear bifocals, tilt your head down while descending stairs so your vision doesn't blur the steps.
  6. You may need orthotics for your feet.

A Discerning Guide for the Lightheaded

Many people lump all balance or dizziness issues together, but to a vestibular rehabilitation specialist, they are quite distinct and nuanced. These are some descriptions of common equilibrium problems from Manhattan vestibular rehabilitation therapist James Gurley:

Vertigo is the sensation of moving when you are not actually moving. This is a typically a spinning or whirling sensation, but can also be a rocking or floating feeling. Read about vertigo
Lightheadedness is feeling faint, as though you are about to pass out. It's usually caused by low blood pressure when you sit up too fast.
Dizziness is similar to lightheadedness, but while the sensation in your head doesn't feel right, you don't feel like you will pass out.
Imbalance is a sense of not being steady on your feet. "Many older patients say they are dizzy when they really mean off-balance, although they obviously can occur together. I usually ask them if they feel dizzy in their head or dizzy in their body," explained Gurley. That usually helps sort out the issues.

- Written By

Deborah Quilter

Deborah Quilter, writer, certified Yoga teacher and Feldenkrais® practitioner, is the Director of Yoga at the Martha Stewart Center for Living at Mt. Sinai Hospital in New York City and the president of Beyond Ergonomics, LLC. She is a partner at The Balance Center in New York City and presents regularly at the International Yoga Therapy Conference and the Rocky Mountain Institute of Yoga and Ayurveda. She is the author of The Repetitive Strain Injury Recovery Book and Repetitive Strain Injury: A Computer User's Guide and is currently working on a book about balance. Her website is