How soon after a concussion should vestibular rehab start?

Evidence supports starting active, symptom-guided vestibular rehabilitation early rather than waiting for spontaneous resolution, particularly in patients with dizziness, gaze instability, or an abnormal VOMS finding. The specific starting point should be individualized by the treating clinician based on symptom severity and exam findings.

Can a patient do vestibular rehab without seeing a physical therapist?

Basic gaze-stabilization and balance exercises can sometimes be initiated directly by the treating physician or QHP for milder, clearly resolving cases. However, referral to a vestibular-trained physical therapist is generally recommended for BPPV (which requires an in-clinic repositioning maneuver, not a home exercise), a cervicogenic component, or symptoms persisting beyond about two weeks.

Is dizziness after concussion always a vestibular problem?

Not necessarily. Dizziness can stem from a peripheral vestibular issue (including BPPV), a cervicogenic source tied to whiplash, or overlap with headache, mood, or exertion-related symptoms. A targeted exam — including VOMS and a cervical spine screen — helps differentiate the driver before prescribing a home program.

How does vestibular symptom resolution relate to return-to-play clearance?

Vestibular and balance findings are commonly part of the clinical picture reviewed before advancing a patient through the graduated return-to-play protocol, alongside symptom-limited activity tolerance and other domains. See the return-to-play decision criteria guide for the full framework.

What if vestibular symptoms aren't improving after a few weeks of home exercises?

Persisting vestibular symptoms beyond the expected recovery window warrant reassessment rather than continuing the same home program indefinitely — this may mean escalating to (or re-engaging) a vestibular-trained physical therapist, evaluating for an unaddressed cervicogenic or BPPV component, or broadening the workup per the managing persistent post-concussive symptoms guide.

What Does At-Home Vestibular Rehab Look Like After Concussion?

At-home vestibular rehab after concussion typically includes gaze-stabilization exercises (VOR x1), habituation exercises for motion sensitivity, and progressive balance training, usually 2-3 times daily for brief sessions. It's indicated for patients with dizziness, gaze instability, or abnormal VOMS findings, and works best when prescribed and progressed by a vestibular-trained physical therapist rather than done as pure self-treatment.

Who Needs Vestibular Rehab After Concussion

Not every concussed patient needs vestibular rehab — it's targeted at the subgroup presenting with dizziness, gaze instability, motion sensitivity, or an abnormal finding on the Vestibular/Ocular Motor Screening (VOMS) exam. This subgroup tends to have a longer expected recovery if managed with rest alone; evidence from systematic reviews of randomized controlled trials supports early, active vestibular rehabilitation over rest as both safe and effective at reducing time to medical clearance for return to sport (PMC systematic review; IJSPT systematic review). Dizziness and vestibular symptoms in the acute phase are also independently listed among the risk factors associated with prolonged recovery, which is part of why clinic-based screening (SCOAT6-era assessment, not just the sideline SCAT6) increasingly includes a targeted vestibulo-ocular exam rather than relying on symptom checklist alone.

Clinicians should distinguish true peripheral vestibular pathology from concussion-related vestibular dysfunction before prescribing a home program. Benign paroxysmal positional vertigo (BPPV) requires an in-clinic canalith repositioning maneuver (e.g., Epley) performed by a trained clinician — it is not a home self-exercise, and treating it as generic "vestibular rehab" will not resolve the underlying otolith displacement. Cervicogenic dizziness, common after the whiplash mechanism that frequently accompanies concussion, also needs its own targeted cervical spine exam and manual therapy rather than a standard gaze-stabilization protocol alone.

The Core Exercise Categories

A typical home vestibular rehab program, once prescribed, is organized around three exercise categories that a vestibular-trained physical therapist scales to the individual patient's tolerance and progresses over successive visits:

Gaze stabilization (VOR x1). The patient fixates on a stationary target while rotating the head horizontally or vertically, training the vestibulo-ocular reflex to keep the target in focus during head movement. Sessions are typically brief — commonly on the order of one to two minutes per direction, two to three times per day — with speed and duration of head movement progressed as symptoms allow.

Habituation exercises. These use repeated, controlled exposure to symptom-provoking head movements or visual motion to desensitize the vestibular system over time. Brandt-Daroff-type maneuvers and structured optokinetic (visual motion) stimuli fall into this category. The principle is graded exposure rather than avoidance — patients who avoid all symptom-provoking movement tend to habituate more slowly.

Balance and postural control. Static-to-dynamic progressions move the patient from feet-together standing to tandem stance to single-leg stance, and from a firm surface to foam, and from eyes open to eyes closed, as tolerated. This category overlaps with what a clinic-based BESS or SAC exam is measuring, and improvement on balance tasks at home is one of the more visible signs of functional recovery a clinician can track between visits.

A related category — habituation to visual motion in real-world environments such as busy stores, screens, and crowded hallways — is often layered in as tolerance improves, since return to school, work, or sport requires functioning in exactly those visually complex settings.

Dosing, Progression, and Who Should Prescribe It

Home vestibular exercises are generally low-intensity and brief by design — the point is frequent, tolerable exposure rather than exhaustive sessions that provoke prolonged symptom flare. A common structure is short bouts several times per day rather than one long session, with progression (longer duration, faster head speed, more complex balance surface) driven by the treating clinician based on symptom response at follow-up, not by the patient escalating unsupervised.

This is why vestibular rehab is best framed as a prescribed and progressed therapy, not a generic home-exercise handout. Referral to a vestibular-trained physical therapist is particularly indicated for BPPV, a meaningful cervicogenic component, or symptoms persisting beyond roughly two weeks. For patients with milder, resolving symptoms and a normal VOMS exam, a clinician may reasonably start basic gaze-stabilization and balance exercises directly and reassess at the next follow-up visit.

How Vestibular Rehab Fits Into the Broader Recovery Timeline

Vestibular symptoms are one of several domains a clinician tracks across the post-concussion recovery timeline, alongside cognitive, mood, sleep, and headache symptoms. Resolution of dizziness and normalization of the VOMS exam is commonly a component clinicians look for before clearing a patient through the graduated return-to-play or return-to-learn progression, since unresolved vestibular dysfunction can affect balance-dependent activity and visually demanding cognitive tasks like reading. Patients with persisting dizziness alongside other lingering symptoms beyond the expected recovery window may also be reasonable candidates for referral for formal neuropsychological testing if cognitive complaints are disproportionate to the physical picture, or for exertion testing if the plateau involves exercise intolerance more than dizziness specifically.

How Kavera Handles This

At-home vestibular exercises are assigned in Kavera after the VOMS exam and tracked with the weekly check-in so dizziness and symptom provocation are reviewed against the exercise program at the next visit. Self-Serve practices run this with their own staff. On Managed, Juliet Mott's team runs it and bills it under your credentials.