How to find a vestibular health care provider
Even though dizziness and vertigo impact anywhere from 15% to 35% of us at some point in our lives, it can be challenging to find help for these symptoms.
One study found that more than 40% of people with vestibular disorders seek medical care within one week of their symptoms starting, but for more than 50% it takes more than 5 months to get a diagnosis. Only 20% of people felt their diagnosis was accurate and timely.
Another study of people with vestibular disorders found that it takes on average 33 weeks to seek care, and it takes on average 63 weeks from the first visit to get a diagnosis.
Many people who have experienced imbalance or falls never actually get referred to a vestibular specialist, and never have their vestibular function properly assessed.
Vestibular disorders can be very challenging to diagnose and treat. Even though up to 80% of people with true vertigo have an inner ear disorder, dizziness, vertigo, and imbalance can have many different causes. For example, dizziness can be caused by heart or lung issues, neurological conditions, problems with heart rate or blood pressure regulation (dysautonomia), low blood sugar (hypoglycemia), low iron (anemia), anxiety and panic, or dehydration. As a result, you may be sent for many different tests or be referred to several different specialists, only to be told that the tests are normal or do not show a cause for your symptoms.
Many people do have more than one vestibular disorder contributing to their symptoms, and eventually end up having multiple diagnoses. For example, it is very common to have both Meniere’s Disease and BPPV, or vestibular migraine and PPPD. It is also very common to experience anxiety, depression, or other mental health issues as a result of chronic vestibular symptoms. Having multiple concurrent diagnoses can make it even more challenging to understand your symptoms, and can further complicate your treatment options.
Most people see multiple health care providers about their problems with dizziness, vertigo, and balance and still struggle to get a comprehensive evaluation and effective treatment plan. Wait times to see specialists can be quite long, making it even more difficult to access care.
Health care professionals who provide vestibular care
These are some of the different professions and specialists you might encounter for assessment and treatment of dizziness and vertigo.
Audiologist: A regulated health care professional who provides assessment and treatment of hearing, tinnitus, hyperacusis, and auditory processing. Some audiologists sub-specialize in assessment and treatment of vestibular disorders, and perform vestibular function testing (like VNG, VEMP, and vHIT).
ENT (otolaryngologist): A doctor who specializes in problems of the head and neck, specifically the ear, nose, and throat. ENTs provide medical and surgical treatment. Not every ENT specializes in inner ear problems (e.g. they may instead focus on nose and sinus issues, voice and airway issues, oncology, or face/neck reconstruction).
Otologist or neurotologist: A doctor who specializes in disorders of the ear and skull base. This is a subspecialty of ENT focused on the inner ear hearing and balance (vestibular) systems, and the connection between the ear and the brain.
Neurologist: A doctor who specializes in medical treatment of disorders of the brain and nervous system. Some neurologists provide subspecialty care focused on migraine/headache disorders or brain injury.
Ophthalmologist: A doctor who specializes in vision and eye care. They provide medical and surgical treatment of diseases and disorders of the eye.
Neuro-opthalmologist: An ophthalmologist and/or neurologist who subspecializes in eye and vision problems related to the brain.
Physiotherapist (physical therapist): A physiotherapist provides assessment and treatment to restore, maintain, and make the most of your mobility, function, and wellbeing. Physiotherapy helps through physical rehabilitation, injury prevention, and health and fitness. Physiotherapy can evaluate and diagnose problems associated with physical dysfunction, pain, or injury to the neurological, musculoskeletal, or cardiorespiratory systems. Although physiotherapy can help improve mobility and balance, not every physiotherapist has training in vestibular rehabilitation.
Psychiatrist: A doctor who focuses on diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders. Psychiatrists assess the mental and physical aspects of psychological conditions, and provide medical treatment of mental health conditions.
Psychologist: A regulated health care professional who provides assessment, diagnosis, and treatment of mental health conditions. Psychologists have a Master’s or Doctorate level degree and extensive clinical training.
Psychotherapist: Psychotherapy focuses on counselling or ‘talk therapy’ to address emotional, behavioural, and mental health issues. Psychotherapy may be provided by a registered nurse, occupational therapist, social worker, physician, or registered psychotherapist.
How to choose the right vestibular care provider
Here are some questions to think about when searching for a health care professional:
Does this professional identify as a vestibular specialist?
Do they have education, training, or subspecialization in vestibular care?
Do they have expertise in an area relevant to my symptoms (e.g. hearing, vision, balance, mobility, mental health)?
How long have they been working with people with vestibular disorders?
What proportion of their practice is focused on people with vestibular disorders?
Are they part of a team? Will they refer to or recommend someone else if needed?
Do they take enough time to understand my history and complete a full evaluation?
Is their practice style a good fit for me?
How to choose a vestibular rehabilitation therapy provider
Vestibular rehabilitation is usually offered by a physiotherapist with additional post-graduate training. Some audiologists, occupational therapists, or other allied health/rehabilitation professionals do offer vestibular rehab as well. Regardless of their discipline, a vestibular therapy provider should be happy to talk with you and answer any questions you have about their training, qualifications, experience, and approach to treatment.
Training: Ideally, you want your vestibular rehab physiotherapist to have completed more than a 1 to 2 day introductory level course. Their training should include a practical component with hands-on practice (not just a virtual or online-only course). Most experienced vestibular therapy providers will have completed the competency certification course offered by the APTA through Emory & Duke Universities, or an equivalent intensive course. A provider who is dedicated to vestibular rehab may have also completed a mentorship program, or attended advanced-level courses, seminars on specific conditions or topics related to vestibular rehab, and professional conferences.
Equipment: If the therapist is serious about vestibular assessment and treatment, they must have a way to evaluate your eye movements with your vision blocked. This is most commonly done with infrared video goggles or optical Frenzel lenses.
Appointments & care plan: It takes time to do a comprehensive assessment, so your first appointment should be at minimum 1 hour to provide enough time to complete a thorough initial evaluation. The assessment should be focused on differential diagnosis - figuring out what impairments you may have in vestibular function, balance, and mobility, and what the cause of your problems could be. The physiotherapist should help you achieve a good understanding of your problem and your care plan, should give you advice and recommendations about exercises and strategies to use at home, and should connect you to additional resources if needed. Your sessions should be one-on-one with the physiotherapist - they should not be seeing several patients at one time. You should not be routinely seeing only support staff (e.g. physical therapy assistant) as you usually require ongoing re-assessment and tailoring of your exercise program which must be done by the physiotherapist directly. Treatment should focus on self-management and strategies to improve your symptoms outside of your appointments. Your physiotherapist’s goal should be getting you better as efficiently and effectively as possible.
Life-long learning: Your physiotherapist should provide evidence-based practice and understand how vestibular science applies to your condition, needs, and goals. They may be members of a professional association, attend or present at professional conferences, or be involved in research and teaching activities. A lot of learning occurs through mentoring and being mentored by others. You want a provider who is continually expanding their knowledge and keeps up to date on the latest research in vestibular medicine.
Team approach: Ideally, your vestibular rehabilitation physiotherapist should work in a multidisciplinary team or be able to send you to other professionals for consultation when needed. This might include referral to vestibular function testing, audiology, ENT, neurology, psychiatry, or psychotherapy.
Experience: Vestibular rehabilitation should be a large percentage of the therapist’s practice - ideally 100% of their patients should be people with vestibular symptoms! Some questions to ask might be: How many people like me do you see? What proportion of your patients have vestibular problems? Have you seen people with my diagnosis/symptoms before?
The Vestibular Disorders Association Healthcare Directory is a helpful resource to find a care provider near you.
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To-Alemanji J, Ryan C, Schubert MC. Experiences Engaging Healthcare When Dizzy. Otology & Neurotology. 2016;37(8):1122-1127. [link]
Grove CR, Souza WH, Gerend PL, Ryan CA, Schubert MC. Patients’ Experiences with Management of Benign Paroxysmal Positional Vertigo: Insights from the Vestibular Disorders Association Registry. PROM. 2022;Volume 13:157-168. [link]
Le A, Lelli DA, Van Katwyk S, Hogan D, Thavorn K, Tse D. Dizziness at a Canadian tertiary care hospital: a cost-of-illness study. J Otolaryngol Head Neck Surg. 2019;48(1):5. [link]
Vestibular Disorders Association Diagnosis & Treatment Resources [link]
