Practice

Treatment planning

There is no one-size-fits-all protocol. Therapy is built from the diagnosis, the deficit, the goals and the comorbidities — then dosed, monitored, and adjusted on objective measures.

Baseline assessment — classify the deficit
Gaze instability↓ VOR gain · ↓ DVA
Gaze stabilisation — X1 / X2
Motion / visual sensitivityhigh VVAS
Habituation + visual desensitisation
Postural imbalance / fallsCDP · BBS · TUG
Balance & gait training
Blend modules · individualise · progress on re-assessment (4–6 weeks)
The baseline is what makes VRT a targeted therapy rather than a generic balance class: each deficit domain selects its module, and the programme is blended and re-tuned on repeat testing.

Programmes by condition

Unilateral hypofunction — gaze stabilisation (X1/X2) for VOR adaptation, two to three times daily, ~10–15 minutes, over 4–6 weeks, with balance retraining in visually busy settings.1 Bilateral loss — substitution leads: saccadic and remembered-target strategies, balance from a wide to a narrow base on firm then foam, gaze anchoring, and real-world tasks; assistive devices and home modifications where needed.2

Central disorders — wide-based gait, visual-flow and mirror cues, and dual-task training for attention-demanding mobility. PPPD — graded visual-motion desensitisation (busy aisles, escalators, streets; VR where available) with CBT for the anxiety and hypervigilance that maintain it.3 Older adults — static and dynamic balance, targeted strength (quadriceps, ankle dorsiflexors), cautious dual-tasking, and environmental fall-prevention.4

Duration, frequency & monitoring

  1. wk 0Baseline assessment
  2. wk 1–3Establish HEP · low intensity
  3. wk 4–6Re-assess · progress
  4. wk 7–11Higher intensity · dual-task
  5. wk 12Discharge or review

Home exercise programme: 2–3 ×/day, 10–20 min, split across gaze, habituation and balance tasks. Intensity rises with tolerance; the same outcome measures are repeated at each marked review.

Most programmes run 4–12 weeks. Neuroplastic change needs consistent, repeated practice — so dosing favours brief, frequent bouts over occasional long sessions.

Most programmes run 4–12 weeks; longer with chronic or comorbid presentations. A home exercise programme is usually performed two to three times daily, ~10–20 minutes, split across gaze, habituation and balance tasks to limit fatigue and flare-ups. As tolerance grows, frequency and intensity increase. Monitor with a weekly symptom diary plus standardised measures (DHI, ABC, TUG, BBS) at baseline, ~4–6 weeks and discharge — the data justify continuation, modification or discharge.

Barriers — and how to clear them

  • Poor adherence. Often from fear that exercise-induced dizziness means harm. Educate early that a mild, temporary flare signals compensation; gamified or VR tools sustain motivation.
  • Psychological comorbidity. Anxiety and depression amplify dizziness through hypervigilance. Screen routinely and add CBT — combined with VRT it outperforms either alone, especially in functional dizziness.5
  • Cognitive impairment. Simplify and structure: short commands, repetition, visual aids, and caregiver involvement to supervise and sustain the home programme.
  • Severe bilateral loss. Shift the goal from recovery to compensation and safety — assistive devices, fall-prevention training, supportive footwear, lighting, and confidence-building progression.

Key points

  • Tailor by diagnosis and deficit; unilateral → adaptation, bilateral → substitution/safety.
  • HEP 2–3×/day; programmes typically 4–12 weeks; reassess every 4–6 weeks.
  • Symptom exacerbation ≠ failure — front-load patient education to protect adherence.
  • Add CBT for anxiety/PPPD; involve caregivers when cognition limits independent practice.