Principles

Clinical indications

VRT spans peripheral, central and functional disorders. It works best after a diagnostic workup pins down the deficit — so the exercises target the right mechanism rather than a generic “balance programme”.

Unilateral hypofunctionneuritis, labyrinthitis, post-opadaptation
Bilateral hypofunctionoscillopsia, high fall risksubstitution
Post-BPPV residualimbalance after repositioningadaptation
PPPDvisual dependence, anxiety — add CBThabituation
Ménière's (interictal)between attacks, not acutemixed
Central disorderscerebellar, MS, TBI, strokesubstitution
Presbyvestibulopathyage-related decline, fallsmixed
Post-concussionmTBI, sports concussionmixed
Vestibular migraine (interictal)staged, between attackshabituation
VRT spans peripheral, central and functional disorders. The dominant mechanism — colour-tagged — shifts with the deficit, but real programmes blend all three and individualise to the patient.

Peripheral hypofunction

Unilateral hypofunction — typically after vestibular neuritis or labyrinthitis — is the flagship indication: gaze stabilisation plus balance training accelerates central compensation and outperforms drugs or waiting.1 Bilateral hypofunction is harder: with no intact labyrinth to compensate, therapy pivots to substitution — visual and proprioceptive reliance, saccadic strategies, and safety.2

After BPPV, a subset — especially older or recurrent patients — have residual imbalance or motion sensitivity once the canaliths are cleared; VRT manages those lingering symptoms.

Functional and central disorders

PPPD is a functional disorder of chronic non-spinning dizziness, worsened by upright posture and visual motion. Therapy centres on habituation and visual desensitisation, weaning the patient off excessive visual dependence — usually with CBT alongside.3 Central disorders (cerebellar stroke, MS, TBI) gain less predictably, but targeted gait, dual-task and substitution work still improves mobility. Ménière’s benefits during interictal periods, not acute attacks.

Older adults and post-concussion

Age-related decline (presbyvestibulopathy) is an increasingly common indication: VRT reduces falls and improves functional mobility, with an emphasis on safety, strength and proprioception.4 Post-concussive dizziness — gaze instability, visual-motion sensitivity and imbalance after mTBI — responds well to early, customised VRT as part of concussion management.5

Where to stage or share care

VRT is not one-size-fits-all. Fluctuating conditions (active Ménière’s, vestibular migraine) often need episodic or staged programmes. Significant anxiety or depression can be worsened by exposure unless supported by psychological care — a multidisciplinary approach (neurology, physiotherapy, audiology, mental health) gives the best outcomes in complex cases.

Key points

  • First-line for unilateral hypofunction; substitution-focused for bilateral loss.
  • PPPD needs habituation + visual desensitisation + CBT, not exercise alone.
  • Strong fall-reduction evidence in older adults; early VRT helps post-concussion.
  • Stage therapy in fluctuating disease; share care when psychiatric comorbidity is present.