Practice

Core exercises

A VRT programme is built from four modules. Each engages a different recovery mechanism; a real plan blends them by deficit and progresses each as the patient tolerates more demand.

AGaze stabilisationRecalibrate the VOR; abolish oscillopsia
  • X1 viewing
  • X2 viewing
  • progress sitting → standing → walking
BHabituationDesensitise to provocative motion/visual triggers
  • repeat provocative positions
  • busy-environment exposure
  • VR / simulator
CBalance & gaitImprove static and dynamic postural control
  • Romberg / tandem on firm vs foam
  • head-turn walking
  • dual-task gait
DFunctional & enduranceRestore conditioning and real-world tasks
  • sit-to-stand
  • stairs & reaching
  • aerobic walking / cycling
The four modules of a VRT programme. A real plan blends them by deficit and progresses each as the patient tolerates more demand.

A · Gaze stabilisation

Trainee

Gaze stabilisation recalibrates the VOR using two exercises. In X1 viewing, the patient fixates a stationary target while moving the head side-to-side or up-and-down, generating retinal slip. X2 viewing moves target and head in opposite directions for a greater demand, introduced once X1 is mastered. Progress from sitting to standing to walking, and add background complexity and head speed.1

Etargethead turns side-to-side
X1 viewing. The patient fixates a stationary target while turning the head. The mismatch the VOR cannot fully cancel — retinal slip — is the error signal that drives adaptation.
A clinician demonstrates X2 viewing, holding two targets that move opposite to the head.
X2 viewing: the targets in each hand move opposite to the head turn, increasing the demand on gaze stabilisation.From Practical Guide to Diagnosis & Management of Vertigo (Prahlada N.B).

B · Habituation

For dizziness provoked by specific movements or visual scenes, habituation desensitises through controlled exposure. Identify the provocative motions — lying down, rolling over, rapid head turns — and practise them deliberately, typically 3–5 repetitions, two to three times daily, with brief rests, over 7–10 days until the response wanes. Warn patients that mild, temporary worsening is expected and is the point.2

A patient repeatedly moves between sitting, side-lying and supine positions that provoke symptoms.
Habituation: the provocative positions are practised deliberately and repeatedly until the response fades.From Practical Guide to Diagnosis & Management of Vertigo (Prahlada N.B).
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Each day the same provocation produces less dizziness. Warn patients the early days feel worst — that transient flare is the response being trained down. Schematic.

C · Balance & gait training

Balance work engages the vestibulo-spinal pathways and sensory reweighting. Begin with static stances — Romberg, single-leg, tandem — on firm then foam surfaces, eyes open then closed. Progress to dynamic tasks: walking with head turns, over obstacles, and at varied speed and direction. Dual-task training (walking while counting backwards) restores the automaticity that daily life demands and reduces falls.3

A patient holds a single-leg and tandem stance on a foam mat to challenge balance.
Static balance is progressed by narrowing the base (single-leg, tandem), softening the surface (foam) and removing vision (eyes closed).From Practical Guide to Diagnosis & Management of Vertigo (Prahlada N.B).
A patient walks a slalom path between cones on grass for dynamic gait and dual-task training.
Dynamic gait — weaving between cones, with head turns or a counting task added for dual-task challenge.From Practical Guide to Diagnosis & Management of Vertigo (Prahlada N.B).

D · Functional & endurance training

Functional tasks rebuild independence: sit-to-stand drills, stair negotiation, reaching, and turning. Endurance work — treadmill or outdoor walking, stationary cycling — reverses deconditioning, supports neural recovery and builds tolerance for the more demanding modules. Integrated with the other three, this delivers a holistic, multi-domain programme.

A sequence of a patient performing a sit-to-stand and forward-bend functional movement.
Functional tasks model real life — sit-to-stand, bending and reaching — to rebuild independence and confidence.From Practical Guide to Diagnosis & Management of Vertigo (Prahlada N.B).
A patient negotiates a short flight of stairs with a therapist supervising at the handrail.
Stair negotiation under supervision trains coordination, strength and confidence for a common real-world hazard.From Practical Guide to Diagnosis & Management of Vertigo (Prahlada N.B).

Key points

  • Four modules: gaze stabilisation, habituation, balance & gait, functional & endurance.
  • X1 fixates a stationary target; X2 moves target and head oppositely — progress X1 → X2.
  • Habituation provokes mildly and deliberately; a transient flare is expected.
  • Balance training scales by surface, stance, visual input and dual-tasking.