Part III: Intervention or Treatment for Vestibular Disorders in Children

Children with vestibular disorders respond well to individualized rehabilitation. Treatment is built on three evidence-based pillars, each addressing a distinct aspect of vestibular-related impairment (Hall et al., 2022).

Pillar	What It Addresses
Gaze Stabilization Exercises	Difficulty seeing clearly during head movement (oscillopsia); blurry or bouncing vision
Static Balance Training	Unsteadiness when standing still; difficulty maintaining posture
Dynamic Balance Training	Difficulty with movement, walking, transitions, and participation

 

The shared goal of all three pillars is to reduce dizziness, improve balance, and restore full participation in school, sports, and daily life.

How does recovery happen?

The Science Behind Vestibular Rehabilitation

The brain adapts following vestibular damage through neuroplasticity — a process called vestibular compensation. Four key mechanisms drive this recovery:

• Adaptation: The brain recalibrates the VOR using a mismatch signal generated when the eyes drift during head movement. Gaze stability exercises directly drive this process — both challenge AND successful performance are needed.
• Habituation: Repeated exposure to symptom-provoking movements teaches the brain that movement is safe. Symptoms are mildly provoked, then allowed to settle — dizziness with movement gradually decreases.
• Substitution: When VOR function cannot be fully restored, the brain learns to use rapid compensatory eye movements (saccades) to redirect gaze. Gaze shifting exercises train this strategy specifically.
• Sensory Reweighting: The nervous system increases reliance on vision and somatosensory (foot/joint) input when vestibular signals are unreliable. Balance training progressively challenges all three sensory systems.

Key Point: Children born with vestibular loss (congenital) must build compensatory strategies from the ground up and typically require longer, more intensive treatment. Children who acquire vestibular loss after age 6 tend to recover more quickly.

WHO PROVIDES VESTIBULAR REHABILITATION?

Vestibular rehabilitation is provided by a physical therapist (PT) or occupational therapist (OT) with specialty competency training in vestibular rehabilitation. The clinician designs an individualized program based on the child’s diagnosis, assessment results, age, developmental level, and functional goals. Caregivers are critical partners — daily home exercise programs are an essential part of treatment.

GAZE STABILITY EXERCISES

Gaze stability exercises train the vestibulo-ocular reflex (VOR) — the system that keeps the eyes steady during head movement. When this reflex is impaired, the world appears to blur or bounce, affecting reading, navigation, and sports. Your child’s therapist will teach the specific exercises; the tips below help make them fun and effective at home.

X1 Viewing — Making It Fun for Kids

X1 viewing — moving the head while focusing on a stationary target — is the foundation of gaze stability training. For kids, swap the plain letter for a favorite sticker, animal picture, colorful character or favorite book as the target. Try patterned backgrounds such as wrapping paper or game boards to increase the challenge as your child improves. Eye-hand coordination games — catching a balloon, batting a birdie, or throwing a ball at a target — naturally incorporate head movement with visual focus and are often more motivating than formal exercises.

X2 Viewing

X2 viewing, where the target and head move in opposite directions, is a more advanced version used for older children with partial vestibular function. Your therapist will let you know when your child is ready to progress to this level.

Gaze Shifting — Making It Fun for Kids

Gaze shifting exercises train the brain to use rapid eye movements to redirect gaze. At home, set up targets (stickers, pictures, toys) in different spots around the room and make a game of quickly ‘finding’ each one with the eyes, then turning the head to match. A scavenger hunt format works well for younger children. Another strategy is to tape index cards on either side of a narrow hallway and have the child walk while turning the head to identify the word, letter or picture on the card. 

Habituation Exercises for Motion Sensitivity

For children who feel dizzy or nauseated with certain movements or busy visual environments, habituation exercises work by mildly provoking those symptoms through controlled, repeated exposure — teaching the brain that movement is safe.

• Habituation exercises mildly provoke dizziness through repeated movement — this is expected and part of recovery
• Your therapist will identify the specific movements or visual environments (scrolling screens, busy backgrounds, crowds) that trigger your child’s symptoms
• Symptoms should be mild and settle within a few minutes of stopping; if severe or prolonged, reduce the intensity at the next session
• The goal is gradual desensitization — not pushing through severe discomfort

Progressing the Exercises Over Time

As your child improves, the therapist will gradually increase the challenge by adjusting target size, adding complex or patterned backgrounds, increasing head speed, and changing the stance from sitting to standing — and eventually to standing on foam or on one leg. These small, systematic changes keep the brain adapting. Your therapist will prescribe a specific home program — typically gaze stability exercises 3 times daily, building from about 12 minutes total per day to 20 minutes as your child progresses (Hall et al., 2022).

Important: Work at the upper limit of ability — as fast as possible while keeping the target clear. Mild symptom provocation during exercises is expected and is part of recovery. Vestibular suppressant medications slow adaptation and should be avoided when recovery is the goal.

STATIC BALANCE TRAINING

Static balance training works by gradually reducing the sensory cues your child normally uses to stay steady. To challenge vision, the therapist uses a stable surface with a stationary target. To challenge the vestibular system, the therapist removes both visual and foot/joint cues — such as standing on foam with eyes closed. Children with vestibular hypofunction often struggle more with slow, controlled movements than fast ones; they benefit from reminders to focus on a target and engage the core. Most importantly, exercises must be both challenging AND achievable — the brain needs both to adapt.

Example Exercises

(Your Therapist Will Create a Personalized Progression)

• Two-foot and single-leg stance on a firm surface — first eyes open, then eyes closed
• Tandem (heel-to-toe) stance on firm and foam surfaces
• Standing on foam with eyes closed — the most demanding vestibular challenge
• Balance exercises combined with gentle head turns or a slowly moving visual target (a ‘Chinese lantern’ — a small picture or sticker moved side-to-side by the caregiver)

Creative Home Ideas

• Practice balancing while brushing teeth — start eyes open, progress to eyes closed
• ‘Freeze dance’ or statue games in a narrow or single-leg stance position
• Put on socks or pants without sitting down — a simple but effective functional balance challenge
• Watch a fun video while holding a balance position — this distorts the use of vision for balance and increases the vestibular demand!

DYNAMIC BALANCE TRAINING

Dynamic balance training progresses the child from controlled clinic exercises to real-world movement. Activities challenge gaze stability and postural control during walking, direction changes, and dual-task situations. Integration with play and peers is strongly encouraged — motivation drives compliance and neural learning.

Example Activities

• Tandem and semi-tandem walking along a path — use toys or puzzle pieces as motivation
• Walking with head turns — looking left and right while moving along a 20-foot path
• Catching a ball tossed over the shoulder while walking (caregiver throws from behind)
• Broad jumps and single-leg hops — sticking the landing builds postural control
• Backward walking with a narrow base of support along a marked path
• Stair climbing with alternating feet, progressing to add head turns during the task
• Obstacle courses of increasing complexity

Get Creative — Home and Community Ideas

• Beach or sand dunes: tandem walking on sand is a naturally unstable, challenging surface
• Park visits: balance beams, stepping stones, uneven ground, and climbing structures
• Dance and movement video games (Just Dance, GoNoodle, Wii Sports) — highly motivating and combine dynamic balance with gaze stability naturally
• ‘The floor is lava,’ Twister, stepping stone challenges — active games that build dynamic balance with social engagement; aim for about 5 minutes per day with a sticker chart for accountability

Special Populations

Core rehabilitation principles apply broadly, but the following populations have specific considerations that should guide treatment planning and referral decisions.

Peripheral Vestibular Hypofunction (Unilateral and Bilateral)

Children with unilateral vestibular hypofunction (one side affected) typically respond well and quickly — improvement is often seen within 4–6 weeks. Bilateral vestibular hypofunction (both sides affected) requires longer, more intensive treatment with greater emphasis on substitution strategies. Congenital bilateral loss requires the most sustained treatment. International guidelines recommend early initiation of vestibular rehabilitation for both groups, and virtual reality training adapted to the child’s age is also supported (Reynard et al., 2024; Hall et al., 2022; Ortega-Solis et al., 2023).

BPPV (Benign Paroxysmal Positional Vertigo)

Although less common in children, BPPV — brief, intense spinning triggered by head position changes — is highly treatable and should not be missed. It is particularly important to screen for BPPV after concussion, as its prevalence in children following head injury ranges widely (1.2%–29.4%) depending on the clinical setting (Brodsky et al., 2018; Wang et al., 2021). The canalith repositioning maneuver, performed by a trained clinician, is the first-line treatment and is highly effective (Bhattacharyya et al., 2017).

Vestibular Migraine of Childhood (VMC)

Vestibular migraine is among the most common causes of episodic vertigo in children (van de Berg et al., 2021). Rehabilitation does not prevent migraine attacks, but significantly reduces motion sensitivity, improves balance, and reduces disability between episodes (Hayward, Farrell & Sweeney, 2025; Vesole et al., 2024; Byun et al., 2020).

• Rehabilitation focuses on: Habituation exercises, balance training, aerobic exercise, and resistance training
• SEEDS lifestyle behaviors form the foundation: Sleep (regular schedule), Exercise (moderate-intensity aerobic and resistance training), Eat (stable blood sugar, avoid dietary triggers), Drink (stay hydrated, limit caffeine), Stress management (relaxation, mindfulness, psychotherapy) (Webster et al., 2023)
• Exercise dosing: Do NOT exercise on days with moderate or severe headache. Allow symptoms to return to baseline between exercise sets. Use reassuring language with your child: ‘You’re safe,’ ‘This will pass,’ ‘You’re strong.’
• Important: Rehabilitation is most effective when combined with appropriate medical management. Referral to a pediatric neurologist or headache specialist is often also needed (Webster et al., 2023).

Concussion / Mild Traumatic Brain Injury (mTBI)

Vestibular and balance symptoms are among the most common and persistent complaints after pediatric concussion. A clinical domain-based approach is recommended — no single protocol applies to all children. Early vestibular rehabilitation (within the first 1–2 weeks) is associated with significantly faster recovery and earlier return to sport and school (Schneider et al., 2022; Patricios et al., 2023; Davis et al., 2024).

• Vestibular/oculomotor rehabilitation: Gaze stability exercises, BPPV screening and repositioning, static and dynamic balance training
• Graded aerobic exercise: Begin 2–14 days post-injury at sub-symptom threshold intensity; early return to light activity is associated with faster recovery (Davis et al., 2024)
• Cervical rehabilitation: Address neck pain, stiffness, and proprioceptive deficits; early treatment (within 2 weeks) improves outcomes (McPherson et al., 2024)
• Convergence insufficiency: Brock string exercises; refer to neuro-ophthalmology or vision therapy when needed (Trbovich et al., 2025 RCT)
• Sleep hygiene and mood support: Education and behavioral strategies; referral for psychological support when indicated

Central Vestibular Disorders (Cerebral Palsy, Brain Tumors, Prematurity, Autism)

Children with central vestibular involvement can benefit from individualized rehabilitation. Goals are tailored to functional participation and family priorities. Gaze stability exercises and balance training can be adapted for the child’s cognitive and motor level. Interprofessional collaboration is essential for this population.

When to Refer to Another Specialist

Physical therapy and occupational therapy address functional vestibular rehabilitation. The following situations warrant co-management or referral to a medical specialist:

Condition / Situation	Recommended Specialist
Vestibular migraine requiring preventive or abortive medication	Pediatric neurologist or headache specialist
Suspected inner ear infection (labyrinthitis, vestibular neuritis)	ENT (otolaryngologist)
Cholesteatoma or other surgical condition of the ear	ENT surgeon
Convergence insufficiency, persistent oculomotor deficits, or visual problems	Neuro-ophthalmologist or vision therapist
Concussion with symptoms persisting > 4 weeks	Concussion specialist, sports medicine, or neurologist
Anxiety, depression, PTSD, or mood concerns impacting recovery	Clinical psychologist or neuropsychologist
Suspected perilymphatic fistula or superior canal dehiscence (SCD)	ENT surgeon (high-resolution CT recommended)
Severe or refractory vertigo not responding to rehabilitation	Neurologist and/or ENT neurotologist
Persistent sleep disturbances	Sleep specialist or developmental pediatrician
Cognitive dysfunction or neurocognitive concerns post-concussion	Neuropsychologist

Home Exercise Programs

Home exercise programs (HEPs) are a critical component of vestibular rehabilitation — children who practice daily make faster, more durable gains. Tips for caregivers:

• Supervise exercises on foam, single-leg, or eyes-closed conditions — safety first
• Turn exercises into games: sticker charts, logbooks, code-word challenges, and small rewards increase motivation and compliance
• For vestibular migraine: keep a daily exercise diary that also tracks SEEDS behaviors and symptom patterns
• Mild dizziness or unsteadiness during exercise is expected and safe — symptoms should settle within a few minutes of stopping
• If symptoms are severe, prolonged (> 20 minutes), or include vomiting — stop and contact your therapist or physician

A Note on the Evidence

Evidence for pediatric vestibular rehabilitation is growing rapidly. A PubMed search in April 2026 identified 178 studies on this topic, 86 of which were published in the last 5 years, including 12 systematic reviews. However, important gaps remain:

• Most vestibular rehabilitation research has been conducted in adults; pediatric-specific RCTs are still limited (Hall et al., 2022; Reynard et al., 2024)
• Dosing guidelines are largely extrapolated from adult research — pediatric studies are needed on optimal frequency, intensity, and duration by age group
• Evidence for children under age 6 is particularly limited, though pre-post studies demonstrate positive outcomes (Rine et al., 2004; Mohamed et al., 2024)
• Virtual reality (VR) training shows strong early promise in pediatric populations (Solis et al., 2023; Mohamed et al., 2024) — more research is underway
• No published clinical guidelines specifically address vestibular migraine treatment in children; recommendations are extrapolated from pediatric migraine and adult vestibular migraine literature
• Long-term outcomes data following pediatric vestibular rehabilitation are lacking — most studies report short-term improvements only

Despite these gaps, current clinical practice guidelines (Hall et al., 2022; Reynard et al., 2024) and a growing body of pediatric research consistently support early identification and individualized vestibular rehabilitation for children with vestibular dysfunction.

Conclusion

Children with vestibular-related impairments — whether from peripheral or central causes — can make meaningful improvements with individualized rehabilitation. Three evidence-based pillars — gaze stability exercises, static balance training, and dynamic balance training — work together to reduce dizziness, improve postural control, and restore participation in school, sport, and daily life. Early identification (see Parts I and II of this series) and early intervention are key. Treatment should be delivered by a PT or OT with specialty vestibular training; collaboration with other specialists is needed when medical or surgical management is also required. Families are essential partners: home programs, encouragement, and follow-through are critical to their child’s recovery.

Children who receive early, individualized vestibular rehabilitation show improvements in gaze stability, balance, motor development, and participation in daily life.

By Jennifer Braswell-Christy, PT, PhD, FAPTA and Rose Marie Rine, PT, PhD