APTA’s recent Vestibular Rehabilitation Practice Guideline

The APTA’s recent Vestibular Rehabilitation Practice Guideline states clearly: “Vision training is not VRT.” And I completely agree.

But here’s the challenge: that statement has led some clinicians to question why our education—including
Certificate of Competency in Vestibular Rehabilitation (CCVR) 3.0 Course—embraces such an in-depth understanding of ocular motility beyond nystagmus assessment.

Here’s my answer: While most vestibular therapists understand visual-vestibular connections at a basic level, there’s immense opportunity to go deeper. And I see (no pun intended) that many practitioners want to—but the visual system’s complexity can feel overwhelming.

Don’t get me wrong—the visual system IS complex. That complexity has led some clinicians to avoid the deeper dive, treating ocular motility as optional in vestibular rehabilitation.

But it’s not optional.

When we ignore visual-vestibular neurophysiology, we limit our ability to differentiate peripheral from central pathology, identify red flags, understand WHY nystagmus patterns look the way they do, and make informed decisions about when eye movement exercises ARE appropriate.

The numbers prove why this matters: More neurons are dedicated to vision than all other senses combined. About 40% of nerve fibers connected to the brain link to the retina alone, with estimates suggesting up to 90% of information transmitted to the brain is visual.

For 20+ years, I’ve taught vestibular assessment to thousands of clinicians. The number one gap? Understanding the neurophysiological pathway from extraocular muscles → cranial nerves → VOR mechanics → nystagmus interpretation.

Clinicians know positional testing for BPPV and can perform a plethora of canalith repositioning maneuvers. But when things don’t fit the textbook—nystagmus patterns that don’t match, skew deviation, autonomic dysfunction overlapping with dizziness, vestibular assessment findings that don’t align with the patient’s level of disorientation—they’re lost.

Over the next few weeks, I’m sharing a 5-part framework we teach in CCVR:

Part 1: Primary EOM actions & conjugate gaze

Part 2: Individual cranial nerve actions → functional synergistic patterns

Part 3: Semicircular canal influence & VOR connection

Part 4: Neural asymmetry & pathological nystagmus

Part 5: Why posterior canal BPPV causes “upward” nystagmus when muscles pull DOWN

This isn’t beginner content. It’s for practitioners ready to think deeply about vestibular and visual neurophysiology—because it changes how we assess and treat patients.

 A quick note: Enrollment for our Certificate of Competency in Vestibular Rehabilitation (CCVR) 3.0 Course is OPEN! The CCVR 3.0 Course provides you with a convenient and flexible path to advanced training in vestibular rehabilitation through online coursework & live (or virtual) lab.

Part 1 drops next. If you want to understand the WHY behind vestibular assessment—not just the HOW—you’re in the right place.

What’s the trickiest visual-vestibular presentation you’re seeing in clinic?

By Bridgett Wallace, PT, DPT ~ 360 Neuro Health Co-Founder & Director of Clinical Education