Abstract
This AOTA Position Statement defines the distinct role and value of occupational therapy in supporting vestibular functioning across the lifespan.
This AOTA Position Statement defines the distinct role and value of occupational therapy in supporting vestibular functioning across the lifespan.
The American Occupational Therapy Association (AOTA) affirms the role of occupational therapy in addressing the occupational needs of individuals with vestibular impairment. This Position Statement defines the distinct role and value of occupational therapy in supporting vestibular functioning across the lifespan. Because of its complex nature, the Occupational Therapy Practice Framework (4th ed.; AOTA, 2020b) categorizes the vestibular system as part of mental functions/perception/discrimination of sensations and as part of client factors/body functions/sensory functions/vestibular functions: sensation related to position, balance, and secure movement against gravity. Vestibular rehabilitation (VR) strategies are within the scope of practice of occupational therapists and occupational therapy assistants. Familiarity with VR strategies is vital for clinicians who work in settings across the continuum of care and the lifespan.
People with a wide variety of conditions may benefit from occupational therapy with VR. Some conditions affect the peripheral vestibular system, such as benign paroxysmal positional vertigo (BPPV), chronic labyrinthitis, postconcussion vestibular impairments, Ménière’s disease, and some autoimmune disorders. Some conditions affect the central vestibular system and related balance pathways, such as vestibular migraine, postoperative acoustic neuroma resection and postoperative posterior fossa tumor resection, aging and presbystasis, multiple sclerosis, lateral medullary syndrome, Parkinson’s disease, progressive supranuclear palsy, and traumatic brain injury (K. Li, 2023; Tramontano et al., 2022). Clients may need VR after cochlear implant surgery to treat residual vertigo and disequilibrium (Steenerson et al., 2001). Some may have bilateral vestibular hypofunction due to the use of essential but ototoxic prescription medications (e.g., some medications for cancer and some aminoglycoside antibiotics) or due to some autoimmune disorders, viral labyrinthitis, or unknown idiopathic pathology (Lucieer et al., 2016). Children may have congenital problems of the inner ear structures, including the vestibular labyrinth, as well as head trauma and migraine (van de Berg et al., 2021; Wiener-Vacher, 2008). In all cases, vertigo and/or disequilibrium have a significant impact leading to decreased occupational performance, safety, and social participation.
Definitions
This Position Statement uses the following definitions (Goldberg et al., 2012): ▪ Vestibular system: The vestibular system has sensory receptors located in the vestibular labyrinths, which are buried in the inner ears in the temporal bones. The vestibular labyrinth detects linear and rotational head acceleration. The three semicircular canals in each labyrinth detect rotational head movements, and the two otoliths in each labyrinth detect linear motion, including tilt with reference to gravity. The fluid mechanics of the labyrinth alter the input so that the signals ascending to the brain via the vestibular portion of cranial nerve VIII represent head velocity. After further processing in the vestibular nuclei and associated central brain pathways, signals ascend the medial longitudinal fasciculus to cranial nerves III, IV, and VI to control the vestibulo–ocular reflex (VOR) and take other pathways to participate in modulating some aspects of balance, spatial orientation, and vasovagal function (Cullen, 2019). ▪ VOR: An eye movement generated by the vestibular system to compensate for head movement; to stabilize gaze in space while the individual’s head is moving. The VOR allows the individual to see clearly even though the head is moving. If someone looks at a spot while simultaneously moving his or her head back and forth, that person can see the stationary spot clearly because the VOR counteracts the head movement, as if the eye were sitting still in space. Disorders of the vestibular system may cause an impaired or absent VOR, causing blurry, bouncy, or jerky vision. ▪ Balance: The ability to remain upright with reference to gravity while standing and moving around. Control of balance is multifactorial. Vestibulo–spinal tracts contribute to the control of balance, especially on unstable or slippery surfaces. For example, if you slip on a wet floor you can recover your balance quickly because the rapid movement of your head stimulates vestibulo–spinal responses, which help you keep your head upright and reorient your body. Disorders of the vestibular system may cause reduced input to the vestibulo–spinal tracts, thus causing poor balance, especially in the absence of vision or when somatosensory input is reduced. ▪ Spatial orientation: The ability to know where one is with reference to the gravitational vertical and with reference to a known location in space. ▪ Vertigo: A type of dizziness defined as the illusion of self-motion. Vestibular disorders can cause people to have the sensation of gentle rocking, bouncing, swaying, twirling, or otherwise moving. ▪ Oscillopsia: The illusory sensation of motion in the visual world or perception of bouncy vision while the self feels stationary. Although normal under some artificial conditions, such as in a dark movie theater when the large screen shows full-field movement, oscillopsia often occurs with reduced, especially bilateral, VOR function. ▪ Vasovagal: An adjective that refers to control of some autonomic nervous system functions, including nausea and vomiting; increased heart rate, blood pressure, and respiration; and diaphoresis. Vestibular disorders, especially acute disorders, can cause vasovagal symptoms. ▪ Adaptation: The ability to get used to something, perhaps to find a work-around or a new way of doing something. The plasticity of the nervous system allows people with balance problems to adapt their motor skills to perform balance challenges in new ways that are more appropriate for their current state of being. ▪ Habituation: The ability to reduce responses to a stimulus with practice over time. For example, when you get dressed in the morning you habituate to the sensation of your clothes immediately so that you do not spend your day paying attention to the sensation of your clothes covering your skin. When you wear a new garment that fits differently, however, you may need to wear it for awhile to habituate to the sensation. Special vertigo habituation exercises are used in VR when the client has vertigo and needs assistance to make the sensation go away.
Importance and Significance of the Topic
Approximately 2.8% of the adult population has vertigo (Yang et al., 2021), and it tends to increase with age. At least 7% of clients with traumatic brain injury have BPPV (Jensen & Hougaard, 2022). Mortality from all causes increases significantly when clients also have balance problems (Lin et al., 2024), some of which may be due to vestibular disorders. The prevalence of vestibular disorders in children varies from 4.1% in young children to 7.5% in older children (C.-M. Li et al., 2016) and is higher in children with hearing loss. Children who have otitis media with effusion, especially boys, are more likely to have impaired balance, although it may resolve when the disease state resolves (Cohen et al., 1997; Engel-Yeger et al., 2004). Some problems—for example, vestibular neuritis—may be temporary. Other problems, such as bilateral vestibular hypofunction and some autoimmune conditions, are permanent and limit occupational performance and participation, making these clients candidates for occupational therapy evaluation and intervention (Gronski, 2013).
Disorders of the vestibular system cause perceptual errors, including vertigo and oscillopsia, and misperception of the gravitational vertical. These symptoms can cause abnormal head, body, and eye movements during static sitting and standing and inappropriate balance corrections to the perceived tilt, with consequent slips, trips, and falls. Falls in particular have the potential to be fatal. Vestibular disorders may also cause blurred vision; vasovagal symptoms and anxiety; deficits in spatial orientation for wayfinding, especially path integration; and a decline in executive functioning (Bisdorff et al., 2009). Vestibular disorders may impair the performance of self-care skills, functional mobility, instrumental activities of daily living, and social participation (Aratani et al., 2020; Cohen, 1992; Cohen et al., 2000; Cohen & Kimball, 2003). Many of these performance skills and functional limitations can be remediated with occupational therapy interventions.
Occupational Therapy Role and Process
The occupational therapy evaluation begins with the Occupational Profile (AOTA, 2021) and assesses performance of and engagement in activities of daily living (ADLs), meaningful occupations, and social participation. Depending on the diagnosis and primary concerns, evaluations may or may not include cervical, trunk, and limb range of motion; motor control; vertigo and/or oscillopsia; obvious eye movement abnormalities, such as nystagmus during quiet sitting and during positional testing; abnormal VOR during head impulse screening; postural control and dynamic balance while sitting, standing, and walking; and screening for vasovagal functions, such as blood pressure, diaphoresis, and nausea.
Entry-Level Occupational Therapy Roles
As with all occupational therapy interventions, the goal of VR is always to help clients become safer, more independent, and better able to participate in meaningful occupations. This goal is based on an intervention plan that is grounded in sound theory and evidence-based practice and that accounts for underlying health conditions, the client’s personal goals, and the resources available. Without special training in VR, occupational therapists can evaluate and collaborate with occupational therapy assistants to intervene to improve performance of specific functional skills. For example, for clients who have a diagnosis of Ménière’s disease and are following a low-sodium diet, occupational therapists and occupational therapy assistants may work on meal planning and finding appropriate recipes and options for socialization with respect to meals outside the home. Occupational therapy interventions may also include lifestyle and environmental modifications (Byun et al., 2021), such as educating the client about wearing tinted sunglasses and brimmed hats to decrease glare and sun exposure outdoors and the use of natural light and full-spectrum lighting indoors.
Occupational therapy interventions may include recommendations for adaptive and safety equipment for the home; discussions of adequate lighting and the use of augmented lighting devices (e.g., small, bright flashlights) for use in dim indoor and outdoor environments; and consideration of equipment for mobility, such as canes with standard or extra-wide bases as well as rollators, when appropriate. When recommending mobility aids, clinicians should be aware of the limitations of these devices (Omana et al., 2021). Interventions should include not only the recommended equipment but also training clients in using that equipment.
Occupational therapy interventions may also include educating clients about the relationship among poor functional performance, poor balance, and foot problems. Referral to podiatry may be appropriate. Occupational therapists and occupational therapy assistants may advise clients about appropriate footwear (socks, shoes) and may instruct them in lower extremity dressing. Occupational therapists should consider the need for special insoles, such as for clients with diabetes, or for a special sensory substitution device (Oddsson et al., 2020), but the final determination must be made by the physician or podiatrist.
Occupational therapy interventions for individuals with persistent postconcussive syndrome (PPCS) include education-based interventions and a focus on graded return to a person’s preferred activities as the primary strategy alongside collaboration with the multidisciplinary team to address the complexities of specific impairments related to PPCS (Licciardi et al., 2025).
Occupational therapists and occupational therapy assistants provide training for safer transfers (e.g., sit- to-stand, floor-to-stand); bed-level motor skills; reaching skills while standing; training for negotiating stairs, ramps, and curbs; recommendations for improving safety and independence within the home; and recommendations for continued balance practice with avocational activities. When social participation is impaired, occupational therapy interventions should address strategies for improved participation, either by adapting to the environment, for example, sitting in the back of a large church rather than traversing a long, vertigo-inducing aisle, or by adapting the environment itself (e.g., with improved lighting).
Occupational Therapy With Advanced Training in VR
Occupational therapists and occupational therapy assistants with advanced training in VR may address specific symptoms of vestibular and balance disorders, using exercises and activities for vertigo habituation, gaze stabilization, and balance (Cohen, Kane-Wineland, et al., 1995; Cohen, Miller, et al., 1995; Hall et al., 2022). For clients who have been diagnosed with BPPV (von Brevern et al., 2015), occupational therapists and occupational therapy assistants who have been trained in providing repositioning maneuvers (Cohen & Kimball, 2005; Cohen & Sangi-Haghpeykar, 2010) should understand the nature of the underlying problem as well as the putative mechanisms of the treatment maneuvers and the supporting evidence, using images, models, and other inclusive approaches in client and family education.
Many clients have balance disorders related to vestibular impairments, including presbystasis (age-related balance impairment), mild peripheral neuropathy, or some combination of those factors, as well as other comorbidities. Clients with some central nervous system disorders, mentioned earlier, may also be referred to an occupational therapist who has advanced skills in VR. All of these individuals should be assessed for limitations in safety and occupational performance as well as for balance, vestibular function, and motor control. Balance problems can generally be treated with graded exercises and activities that gradually progress from static standing to dynamic walking with turns and multitasking. Strategies for treating vertigo can be used successfully with central nervous system disorders.
In some cases, such as Mal de Debarquement, a disorder of the central vestibular system, interventions are limited to education and explanation of the problem and guidance for avoiding provocative stimuli. Although a treatment protocol exists (Dai et al., 2017; Maruta et al., 2023), it requires highly specialized training and equipment that are unlikely to be available to most occupational therapists and occupational therapy assistants. A client who is referred with persistent postural–perceptual dizziness (PPPD)—a special type of situational anxiety (Staab et al., 2017)—needs a careful, detailed assessment to be sure that they do not have a physiologic vestibular disorder, such as BPPV or chronic labyrinthitis. If the occupational therapist finds demonstrable evidence of a vestibular impairment, which is often the case, the occupational therapist can treat that impairment and the related problems in occupational performance. In the absence of any evidence of physiologic vestibular impairment, a client with PPPD should be referred to behavioral health services. For clients with both physiologic vestibular impairment and PPPD, VR may be useful (Alahmari & Alshehri, 2025).
Outcomes of occupational therapy may include decreased vertigo, oscillopsia, or both; improved balance; better oculomotor function; and improved cognitive and social skills, all of which may facilitate improved quality and increased frequency of meaningful occupational performance, safety, independence, and participation. Occupational therapy VR services are primarily provided in outpatient settings but can be provided during acute and subacute inpatient care; in-home health care; in chronic residential settings; and, for children, in schools.
Occupational Therapist and Occupational Therapy Assistant Collaboration
With specific collaboration and appropriate supervision from an occupational therapist (AOTA, 2020a; Accreditation Council for Occupational Therapy Education [ACOTE®], 2023), an occupational therapy assistant with entry-level training may instruct clients in safe processes for ADLs. An occupational therapy assistant with advanced training and whose continuing education and established competency have focused on vestibular and balance problems may administer canalith repositioning maneuvers for BPPV during follow-up visits and may perform training for clients who need vertigo habituation exercises, gaze stability training, functional mobility training, and general balance rehabilitation.
Ethical, Legal, and Regulatory Considerations
Occupational therapists and occupational therapy assistants should practice in an ethical manner (AOTA, 2025), within the constraints of their state laws and practice acts, in compliance with state and federal regulatory requirements, and within their levels of competence (AOTA, 2020a). Ethical occupational therapy practice emphasizes the Principle of Autonomy by affirming clients’ right to make informed decisions about their care (AOTA, 2025). In the context of VR, clients should give informed consent for all assessment procedures and physical positioning that involve hands-on, physical maneuvering of the client. Occupational therapists and occupational therapy assistants should consult the payer plan to determine relevant payer policies related to provision of vestibular services and the codes under which those services should be reported. They should determine when clients should be referred to other occupational therapists who have greater expertise.
Education and Training
All occupational therapists and occupational therapy assistants are trained at the professional entry level with the foundational education and training necessary to address occupational and functional needs related to vestibular system dysfunction (ACOTE, 2023). They must continue to update their knowledge and stay current in their skills through targeted professional development; by reading the literature; and by attending postentry continuing education courses available at national, state, and local conferences and from organizations that offer continuing education for occupational therapists and occupational therapy assistants.
Conclusion
Occupational therapy plays a crucial role in supporting individuals with vestibular impairments across the lifespan by improving safety, independence, and participation in daily activities. Through comprehensive evaluation and intervention, occupational therapists and occupational therapy assistants address functional limitations caused by vestibular dysfunction, including vertigo, balance deficits, and spatial orientation challenges. Collaboration with other health care professionals, adherence to ethical and regulatory standards, and ongoing professional development ensure safe and effective care.
Authors
Helen S. Cohen, EdD, OTR, FAOTA
Meredith Gronski, OTD, OTR/L, CLA, FAOTA, Chairperson, for the Commission on Practice
Revised by the Commission on Practice, 2025.
Adopted by the Representative Assembly Coordinating Council for the Representative Assembly, July 2025.
Note. This revision replaces the 2006 document “Specialized Knowledge and Skills in Adult Vestibular Rehabilitation for Occupational Therapy Practice,” previously published and copyrighted in 2006 by the American Occupational Therapy Association in the American Journal of Occupational Therapy, 60, 669–678. https://doi.org/10.5014/ajot.60.6.669
Copyright © 2025 by the American Occupational Therapy Association, Inc.
Citation. American Occupational Therapy Association. (2025). Vestibular rehabilitation and the role of occupational therapy. American Journal of Occupational Therapy, 79(Suppl. 3), 7913410240. https://doi.org/10.5014/ajot.2025.79S309
Footnotes
Acknowledgments
We thank all those who provided valuable review and feedback during the development of this Position Statement. We also acknowledge the foundational documents that served as the earlier versions of this Position Statement.