Atlas›Domain IX · Biomedical, neuro & digital›Guide 074
Guide IX-074

Vestibular rehabilitation

Cawthorne, Cooksey1940
A 15 · L 78 · M 720 interventions in the Trinity explorer
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[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: the Academy of Neurologic Physical Therapy (APTA) updated clinical practice guideline for peripheral vestibular hypofunction (Hall et al., 2022) for the rehabilitation itself; Popkirov, Staab and Stone (2018) for persistent postural-perceptual dizziness (PPPD) and its treatment combinations; the INVEST feasibility trial (Herdman et al., 2022) for cognitive-behaviourally informed vestibular rehabilitation.

Vestibular rehabilitation (also called vestibular physical therapy, VPT, or vestibular rehabilitation therapy, VRT) is an exercise-based treatment for dizziness, imbalance, blurred vision on head movement and gaze or gait instability after damage to the balance system. It is delivered by registered rehabilitation professionals: mainly specialist (vestibular) physiotherapists, and in some services audiologists. A psychotherapist does not deliver it. This guide is written for the psychotherapist working alongside the vestibular team. [source: Hall et al. 2022; Liverpool University Hospitals leaflet]

Core idea of change: the guideline describes three exercise mechanisms. Adaptation: head movement while keeping the eyes on a target produces long-term changes in the remaining vestibular response. Substitution: other strategies (vision, body sense, pre-planned eye movements) take over lost function. Habituation: repeated, graded exposure to movements or visual scenes that provoke mild to moderate symptoms makes the symptoms fade. [source: Hall et al. 2022; EyeWiki] In PPPD, a functional disorder, change is described as unlearning a stiff, vigilant, visually dependent balance strategy that persisted after the original trigger. Gentle habituation, CBT targeting vigilance, catastrophic beliefs and avoidance, and serotonergic medication from a prescriber are combined according to need. [source: Popkirov et al. 2018]

History: Cawthorne and Cooksey developed a series of vertigo exercises in the 1940s. These are the origin of the field, and many trials still use Cawthorne-Cooksey-based programmes as an arm. [source: EyeWiki; McDonnell & Hillier 2015] Current practice is individually tailored rather than a fixed exercise list. [source: Hall et al. 2022; Liverpool leaflet]

Who delivers it and regulation:

  • UK: "Physiotherapist" and "Physical therapist" are protected titles regulated by the Health and Care Professions Council (HCPC). The HCPC list does not include "audiologist" as a title; it does include clinical scientists and hearing aid dispensers. How audiology vestibular practitioners are registered varies by role. [source: HCPC professions page] [uncertain: not verified for audiology registers]
  • USA: the guideline is issued by the Academy of Neurologic Physical Therapy of the American Physical Therapy Association (APTA), the professional body. It is written for physical therapists and physical therapist assistants. State licensure of physical therapists [uncertain: not verified].
  • Ophthalmology and neurology sources also describe co-management with a psychiatrist or psychologist when anxiety, panic or depression is linked to the onset of vestibular symptoms. [source: EyeWiki]

Evidence status (as the sources state it):

  • APTA CPG 2022: strong evidence (Grade A) that vestibular physical therapy should be offered for acute, subacute and chronic unilateral hypofunction, and for bilateral hypofunction. Benefit in bilateral hypofunction is smaller. [source: Hall et al. 2022]
  • Cochrane review (McDonnell & Hillier, 2015): results favour vestibular rehabilitation over control on several dizziness and gait measures. [source: Cochrane 2015]
  • PPPD: evidence is limited, mostly open-label or small trials. A 2025 meta-analysis rated its certainty from moderate to very low. [source: Popkirov et al. 2018; Zheng et al. 2025]

2. Framework

Vestibular rehabilitation is an individually tailored programme, not a fixed protocol. The stages below describe the patient pathway, with the psychotherapist's role at each stage. [source: Hall et al. 2022; Liverpool leaflet; synthesis for the psychotherapist's role]

Stage 0. Recognition and medical diagnosis.

  • Goal: dizziness is diagnosed by a physician (GP, ENT, audiovestibular physician, neurologist) before any rehabilitation.
  • PPPD is a positive diagnosis based on the history: non-spinning dizziness or unsteadiness on most days for at least three months, worse when upright, with motion and with complex or moving visual scenes. It follows a triggering event, causes distress or impairment, and is not better explained by another disorder. It is "not a diagnosis of exclusion", and tests are done to check differential diagnoses. [source: Popkirov et al. 2018]
  • Psychotherapist: notices dizziness, falls or avoidance of movement, and suggests a medical review. [synthesis]

Stage 1. Vestibular assessment (first appointment, usually face to face).

  • History of onset and course.
  • Eye and head movement examination.
  • Screening for benign paroxysmal positional vertigo (BPPV), which is treated with repositioning manoeuvres rather than exercise alone.
  • Standing and walking balance.
  • Agreed personal goals. [source: Liverpool leaflet; McDonnell & Hillier 2015]
  • Outcome measures in the trials include the Dizziness Handicap Inventory (DHI), the Activities-specific Balance Confidence scale (ABC), the Dynamic Gait Index, dynamic visual acuity, Timed Up and Go and gait speed. The CPG notes there is no consensus on a core set of measures. [source: Hall et al. 2022]

Stage 2. Active rehabilitation.

  • A tailored home exercise programme with supervised follow-up visits, which may be by phone or in person. The programme is updated at each visit.
  • The CPG recommends supervised therapy (strong evidence), taking patient preference into account.
  • It gives separate volume recommendations for acute or subacute unilateral, chronic unilateral and bilateral hypofunction. These are set by the vestibular therapist and are not reproduced here.
  • Programmes last from one to two weeks to several months.
  • For PPPD, exercises start more gently and progress more slowly, under an experienced vestibular therapist.
  • The INVEST CBT-informed programme used six sessions. [source: Hall et al. 2022; Liverpool leaflet; Popkirov et al. 2018; Herdman et al. 2022]

Stage 3. Discharge.

  • The CPG says therapy may stop when primary goals are met, symptoms resolve, balance and vestibular function normalise, or progress plateaus (moderate evidence). [source: Hall et al. 2022]
  • Psychotherapist: continues work on residual fear of falling, avoidance and mood, and supports maintenance. [synthesis]

When to move between stages:

  • Moving to active rehabilitation needs a medical diagnosis, BPPV screened or treated, and goals agreed.
  • Progression within the programme is decided by the vestibular therapist, based on symptom response and function.
  • Moving to discharge follows the criteria in Stage 3.
  • The CPG lists factors that may change the expected course: time since onset, comorbidities, cognitive function, medication use and age. [source: Hall et al. 2022]

Where the psychotherapist fits: alongside Stages 0 to 3. Typical tasks:

  • screening for anxiety and depression and for fear of falling;
  • CBT work on vigilance, catastrophic beliefs and avoidance, timed to support the exercise programme;
  • adherence conversations;
  • passing on observations to the team. Popkirov et al. recommend combining approaches "according to patient needs and preferences". [source: Popkirov et al. 2018; synthesis for sequencing]

3. Guiding principles

  • Diagnosis first. Practical meaning: never treat unexplained dizziness psychologically before a medical and vestibular assessment, and keep an eye out for red flags (insidious onset, a non-specific picture, progressive neurological signs). [source: Popkirov et al. 2018]
  • Stay in role. Practical meaning: the psychotherapist does not prescribe, dose or progress vestibular exercises. Exercise questions go back to the vestibular therapist, and medicine questions to the prescriber. [synthesis; rehabilitation scope per HCPC/APTA]
  • Movement is the treatment. Practical meaning: provoking mild to moderate symptoms in a graded way is expected in habituation, and avoiding movement maintains the problem. Reassure without encouraging avoidance. [source: Hall et al. 2022; Popkirov et al. 2018]
  • Gentle and graded in PPPD. Practical meaning: overly aggressive programmes cause flare-ups and early dropout, so support a slow pace rather than pushing. [source: Popkirov et al. 2018]
  • Home practice drives recovery. Practical meaning: adherence to the home programme is the main lever, and the psychotherapist can help with it. The Liverpool leaflet states that most improvement comes from doing the home programme. [source: Liverpool leaflet]
  • Supervision matters. Practical meaning: encourage the client to keep supervised follow-up rather than replacing it with self-taught internet exercises, unless the vestibular team endorses a self-managed format. [source: Hall et al. 2022]
  • Falls safety. Practical meaning: dizziness is a major falls risk factor, and doing the exercises can itself bring falls or near-falls. Safety comes before exposure goals. [source: Hall et al. 2022]
  • Real, not imagined. Practical meaning: PPPD is a functional disorder of the nervous system, not malingering. Inconsistent performance is typical of attention-modulated disorders and not evidence of inauthenticity. [source: Popkirov et al. 2018]
  • Untangle the timeline. Practical meaning: anxiety may predate the dizziness, follow it, or both. Do not label the problem as purely psychogenic, and do not assume trauma explains it. [source: Popkirov et al. 2018]
  • Psychological factors change outcome. Practical meaning: anxiety, fear of falling, fear of movement and the belief that improvement is impossible are negative prognostic factors that the psychotherapist can address directly. [source: EyeWiki; Hall et al. 2022]
  • Early is better. Practical meaning: refer early. Chronic cases still improve, but they bring more disability and more entrenched beliefs. [source: Popkirov et al. 2018]
  • Shared decisions. Practical meaning: the client chooses among the vestibular rehabilitation, CBT and medication options with the team. The psychotherapist informs and supports that choice and never steers medicine decisions. [source: Popkirov et al. 2018; synthesis]

Sources for sections 1–3: Hall et al. 2022; Popkirov et al. 2018; McDonnell & Hillier 2015; EyeWiki; Liverpool University Hospitals leaflet; HCPC; Herdman et al. 2022; Zheng et al. 2025.

4. Intervention inventory

Part A describes, at a descriptive level only, what the vestibular physiotherapist or audiologist delivers, so that the psychotherapist can explain it and support it. No exercise prescriptions, volumes or progressions are given; these are individually set by the vestibular therapist. Part B covers the psychotherapist's own interventions.

Part A. Treatment as the vestibular team delivers it

A1. Vestibular assessment and goal setting

  • Purpose: to establish what is impaired (gaze stability, balance, gait, positional vertigo) and to set personal goals before any exercises are given. [source: Liverpool leaflet; Hall et al. 2022]
  • Steps (as delivered):
    • detailed history;
    • eye and head movement tests;
    • BPPV screening;
    • standing and walking balance assessment;
    • agreed goals and expectations;
    • standardised measures (e.g. DHI, ABC), described here without reproducing their items.
    • The CPG also lists possible modifying factors to evaluate: time since onset, comorbidities, cognition, medications and age. [source: Hall et al. 2022]
  • Example language (psychotherapist, illustrative): "The vestibular physio will check how your eyes and balance work together and agree goals with you. It would help to bring the list of situations you avoid that we made."
  • Watch for:
    • anticipatory anxiety about the assessment itself;
    • the client minimising avoidance to the team;
    • after the visit, whether the client understood the explanation and goals.

A2. Gaze stabilisation: adaptation exercises

  • Purpose: to drive long-term change in the remaining vestibular response so that vision stays clear during head movement. Used in unilateral and bilateral hypofunction. [source: Hall et al. 2022; EyeWiki]
  • Steps (as delivered, in general terms):
    • the client keeps the eyes fixed on a target while moving the head;
    • the therapist chooses the conditions and progression and reviews them at follow-up.
    • The CPG states (strong evidence, harm outweighing benefit) that saccadic or smooth-pursuit eye exercises on their own should not be used as specific gaze-stability exercises. [source: Hall et al. 2022]
  • Example language (illustrative): "These exercises often stir up the dizziness for a while. Your physio expects that and has set the level for you. If you're unsure, ask them rather than stopping."
  • Watch for:
    • catastrophic reading of the expected temporary symptom increase;
    • stopping early;
    • doing more than prescribed in order to "get it over with".
    • Signs it is working: clearer vision on head turns and more activity in daily life, as reported back to the team. [synthesis]

A3. Gaze stabilisation: substitution exercises

  • Purpose: to build alternative strategies when vestibular function is lost or reduced, such as pre-planned or compensatory eye movements (for example, moving the eyes to a target before the head turns) and greater use of vision and body sense. Especially relevant in bilateral loss. [source: Hall et al. 2022; EyeWiki]
  • Steps (as delivered): individually taught and progressed by the vestibular therapist.
  • Example language (illustrative): "Part of this is teaching your brain new tricks to make up for the inner ear. It's practice, not a test."
  • Watch for:
    • grief or hopelessness about permanent loss;
    • realistic expectations: the CPG notes smaller gains in bilateral hypofunction.
    • Mood and acceptance work may be needed. [source: Hall et al. 2022; synthesis]

A4. Habituation exercises (including visual motion)

  • Purpose: repeated exposure to the movements or visual situations that provoke mild to moderate symptoms, so that symptoms decline over time. Newer variants use optokinetic stimuli (moving visual patterns) and virtual reality. A core component in PPPD. [source: Hall et al. 2022; Popkirov et al. 2018]
  • Steps (as delivered):
    • the therapist identifies the provoking movements or visual scenes;
    • grades the exposure;
    • progresses it according to the symptom response.
    • In PPPD the start is gentler and progression slower; aggressive programmes cause flare-ups and dropout. [source: Popkirov et al. 2018]
  • Example language (illustrative): "Feeling a bit dizzy during these is expected. It means the exercise is reaching the system it needs to retrain. We're aiming for manageable, not zero."
  • Watch for:
    • escape and safety behaviours during exposure (stiffening, gripping, fixing the gaze on a point);
    • post-exercise flare-ups being read as damage;
    • avoidance creeping back.
    • Signs it is working: provoking situations become tolerable and the client re-enters supermarkets, traffic, screens and crowds. [source: Popkirov et al. 2018; synthesis]

A5. Balance and gait training

  • Purpose: to retrain control of the centre of gravity, anticipatory and reactive balance, balance under changing sensory conditions, and walking. [source: Hall et al. 2022]
  • Steps (as delivered):
    • low-technology training in clinic and at home;
    • may be augmented by gaming, platform perturbations, vibrotactile feedback, virtual reality or augmented sensory feedback, for which the CPG reports moderate evidence. [source: Hall et al. 2022]
    • In PPPD, distraction tasks during standing and walking (motor tasks work better than mental arithmetic) and tandem stance or backward walking can normalise sway. Neurologists use these as demonstrations that the problem may be reversible. [source: Popkirov et al. 2018]
  • Example language (illustrative): "Your physio noticed you walk more steadily when you're not watching your feet. That's a sign your balance system can do it when attention gets out of the way."
  • Watch for:
    • fear of falling, which is more common in PPPD than fear of panic;
    • near-falls during practice, which the CPG lists as a possible harm.
    • Pass falls or near-falls on to the team. [source: Popkirov et al. 2018; Hall et al. 2022]

A6. Graduated walking for endurance

  • Purpose: a graduated walking programme within vestibular rehabilitation. The CPG notes that general conditioning without a balance component has not been shown to help. [source: Hall et al. 2022]
  • Steps (as delivered): set and progressed by the vestibular therapist; no targets are given here.
  • Example language (illustrative): "How did the walks your physio set go this week? Where did you notice yourself turning back?"
  • Watch for:
    • route restriction (only safe streets, always accompanied);
    • the gap between agreed and actual walking;
    • low mood reducing activity. [synthesis]

A7. Repositioning manoeuvres for BPPV (separate procedure)

  • Purpose: BPPV is screened at the vestibular assessment. Canalith repositioning manoeuvres performed better than Brandt-Daroff habituation exercises in BPPV trials. [source: Liverpool leaflet; McDonnell & Hillier 2015]
  • Steps: carried out by the trained clinician; not described here and not for psychotherapist use.
  • Example language (illustrative): "Spinning when you roll over in bed is something the vestibular team can test and often treat directly. Let's make sure they know."
  • Watch for:
    • positional vertigo that is reported but not yet assessed;
    • avoidance of lying down or turning over persisting after successful treatment. That residual avoidance is a target for psychological work. [synthesis]

A8. Self-managed balance retraining (booklet or online)

  • Purpose: to deliver vestibular rehabilitation exercises at home through a self-management booklet. It was developed by Professor Lucy Yardley (health psychologist, University of Southampton) and tested in primary-care trials (1998, 2004, 2006 in Ménière's disease, and 2012 with telephone support). The exercises use eye, head and body movements to promote adaptation and help people overcome fear and avoidance of disorienting activities. An internet-delivered version for older adults has also been trialled. [source: REF impact case study]
  • Steps: follow the booklet as published by the authors and the patient organisations that distribute it. Use it only when the client's dizziness has been medically assessed and the treating team agrees. [source: REF case study; synthesis for the team-agreement step]
  • Example language (illustrative): "There's a self-help balance retraining programme your GP or vestibular team may recommend. If they do, we can look at what gets in the way of doing it."
  • Watch for:
    • using self-help instead of an assessment;
    • unsupervised over-practice;
    • the CPG preference for supervised therapy where available. [source: Hall et al. 2022]

A9. Habituation-based vestibular rehabilitation adapted for PPPD

  • Purpose: to fatigue abnormal reflexive responses and reduce visual sensitivity in PPPD. It differs from rehabilitation for structural vestibular loss. [source: Popkirov et al. 2018]
  • Steps (as delivered): gentler start, slower progression, supervision by an experienced vestibular therapist. Combined with CBT and/or medication from a prescriber as needed and preferred. [source: Popkirov et al. 2018]
  • Example language (illustrative): "In PPPD, slow and steady really is the method. A flare doesn't mean you've broken anything. Let's tell your physio so they can adjust the pace."
  • Watch for:
    • flare-ups leading to dropout;
    • all-or-nothing practice;
    • hypervigilant symptom monitoring.
    • A 2025 meta-analysis reported that SSRI plus vestibular rehabilitation was favoured over vestibular rehabilitation alone, with moderate to low certainty. Home-based and hospital-based rehabilitation did not differ on DHI. [source: Zheng et al. 2025]

A10. CBT-informed (psychologically informed) vestibular rehabilitation

  • Purpose: to integrate cognitive-behavioural principles into vestibular rehabilitation for PPPD. The INVEST feasibility trial (Herdman, Norton, Murdin, Frost, Pavlou, Moss-Morris, 2022) compared six sessions of CBT-informed vestibular rehabilitation with time-matched gold-standard vestibular rehabilitation in 40 adults.
    • 80% completed all sessions, and acceptability was rated excellent.
    • Small to moderate effects favoured INVEST on dizziness handicap, negative illness perceptions, symptom focusing, fear avoidance and distress.
    • No intervention-related serious adverse events were reported.
    • The authors judged a full efficacy trial warranted. [source: Herdman et al. 2022]
  • Steps: the specific CBT techniques and the profession of the deliverers in INVEST [uncertain: not verified]. Separately, Popkirov et al. describe CBT for PPPD as targeting vigilance about dizziness, catastrophic beliefs and avoidance. They also report that CBT-informed physiotherapy may help secondary gait disorders. [source: Popkirov et al. 2018]
  • Example language (illustrative): "Your physio and I will be working on the same thing from two sides: they help your balance system relearn, and I help with the worry and the checking that keep it on high alert."
  • Watch for: contradictory messages between the professionals. Agree a shared formulation and shared wording with the team. [synthesis]

Part B. The psychotherapist's interventions

B1. Recognising dizziness and suggesting medical and vestibular review

  • Purpose: to make sure dizziness, unsteadiness or falls are medically assessed before, or alongside, psychological work. [source: Popkirov et al. 2018; synthesis]
  • Steps:
    1. Ask about dizziness, imbalance, blurred vision on head movement, positional spinning and falls when clients present with panic, agoraphobic avoidance or health anxiety.
    2. If these are unassessed, suggest a GP or physician review. Mention that vestibular physiotherapy exists and that the physician can refer.
    3. Advise urgent medical attention for sudden new neurological symptoms, using local emergency guidance. Neurologists flag insidious onset, a non-specific picture or progressive neurological signs as reasons for further follow-up. [source: Popkirov et al. 2018; synthesis for the urgency wording]
    4. With consent, write to the GP describing the symptoms and their impact.
  • Example language (illustrative): "Some of what you describe, like the spinning when you turn your head, sounds like it could involve the balance organs. That's worth a proper check. Would you be willing to see your GP about it?"
  • Watch for:
    • a premature "it's just anxiety" explanation from either side;
    • repeated investigations with no diagnosis named. PPPD is a positive diagnosis, so a question to the physician about it is reasonable.
    • Working: the client has a diagnosis and a referral pathway. [source: Popkirov et al. 2018]

B2. Psychoeducation about compensation, PPPD and the vicious cycle

  • Purpose: to give a credible, non-blaming model that makes movement and exposure make sense. [source: Popkirov et al. 2018]
  • Steps:
    1. Start from the diagnosis the physician gave. Popkirov et al. advise naming PPPD early rather than leading with negative tests, and using a recognisable typical history and a mechanism diagram.
    2. Sketch the cycle in the client's own words: after a trigger, a protective strategy (stiff stance, short steps, heavy reliance on vision, scanning) persists. Expecting dizziness, self-monitoring, fatigue, fear and avoidance then keep it going.
    3. Link it to the vestibular exercises: habituation and balance work retrain this strategy.
    4. Give the team's written information, or patient organisation information, rather than your own handouts on the medical details. [source: Popkirov et al. 2018; synthesis for steps 3–4]
  • Example language (illustrative): "Your balance system switched into emergency mode when you were ill, and it hasn't fully switched back. The checking and bracing made sense then. Now they keep the alarm on. The exercises and our work are about teaching it that it's safe to stand down."
  • Watch for:
    • the client hearing "psychological" as "imagined". Stress that PPPD is a real functional disorder of the nervous system and that inconsistent symptoms are typical, not evidence of faking.
    • Working: the client can explain the cycle back and predicts that avoidance will make things worse. [source: Popkirov et al. 2018]

B3. Screening and monitoring anxiety, depression and fear of falling

  • Purpose: anxiety and depression often coexist with chronic dizziness and may affect recovery. Fear of falling and fear of movement are negative prognostic factors. [source: Popkirov et al. 2018; EyeWiki; Liverpool leaflet]
  • Steps:
    1. Use brief validated questionnaires: Popkirov et al. name GAD-7 and PHQ-9. Use them under their terms; items are not reproduced here.
    2. Ask specifically about fear of falling.
    3. Map the timeline of the anxiety relative to the dizziness (before, after, both).
    4. Share scores with the team, with consent; the vestibular team may track the DHI and ABC.
    5. Repeat at review points. [source: Popkirov et al. 2018; Hall et al. 2022; synthesis for steps 4–5]
  • Example language (illustrative): "Was the worry there before the dizziness started, or did it come after? Often it's a bit of both, and that helps us plan."
  • Watch for:
    • panic attacks;
    • depression with hopelessness about recovery;
    • suicidal thoughts, which need standard risk assessment and safety planning (see B9);
    • social isolation, which the Liverpool leaflet names as common. [source: Liverpool leaflet]

B4. CBT for dizziness-related vigilance, catastrophic beliefs and avoidance

  • Purpose: to target the three maintaining processes that Popkirov et al. name for CBT in PPPD. In a waiting-list-controlled study of 41 patients with chronic subjective dizziness, three CBT sessions produced significant improvement in 75%, sustained at six months. An earlier study in phobic postural vertigo showed short-term benefit that was not sustained at one year. [source: Popkirov et al. 2018]
  • Steps (clinician synthesis using standard CBT methods, aligned with the vestibular programme): [synthesis]
    1. Build a shared formulation from B2, listing the triggers, thoughts ("I'll collapse"), bodily focus, safety behaviours (holding on, fixing the gaze, avoiding busy places) and the consequences.
    2. Use attention training or attention-shifting work to reduce symptom monitoring. Keep it consistent with the team's observation that steadiness improves with distraction.
    3. Use cognitive work on catastrophic predictions about falling, collapse or permanent damage.
    4. Build a graded avoidance hierarchy of real-life situations (shops, escalators, screens, traffic). Agree it with the vestibular therapist, so that real-life exposure matches the physical programme and the falls-safety advice.
    5. Use behavioural experiments that test predictions while gradually dropping safety behaviours. Only drop movement-support aids the physio has cleared.
  • Example language (illustrative): "Let's write down what you expect will happen in the supermarket, how dizzy you'll be and whether you'll fall, then check it against what actually happens."
  • Exposure safety: do not run in-session movement provocation; the vestibular therapist sets the physical exercises. Confirm that BPPV and other conditions have been assessed. Address falls risk first (B6). Obtain informed consent for exposure tasks. [synthesis]
  • Watch for:
    • alexithymia, which a 2025 meta-analysis notes may hinder CBT in PPPD;
    • covert safety behaviours.
    • Working: less checking, wider activity range, lower distress scores. [source: Zheng et al. 2025; synthesis]

B5. Supporting home-programme adherence

  • Purpose: home practice is described as the main driver of improvement. [source: Liverpool leaflet; Hall et al. 2022]
  • Steps:
    1. Ask the client to bring the home programme to sessions.
    2. Explore ambivalence: the exercises cause short-term symptoms, while the benefit comes later.
    3. Problem-solve when and where to practise.
    4. Link practice to valued goals.
    5. Record barriers to pass on to the physio. Never change the programme yourself. [synthesis]
  • Example language (illustrative): "On the days you skipped them, what was going through your mind just before? … Would it help to tell your physio that the morning set leaves you too wobbly for work?"
  • Watch for:
    • silent dropout;
    • perfectionistic over-practice (perfectionism is listed among negative prognostic factors);
    • practice only when accompanied.
    • Working: regular practice and gradual widening of activity. [source: EyeWiki; synthesis]

B6. Falls safety conversations

  • Purpose: dizziness is a major falls risk factor. In the studies the CPG reviewed, 30% with unilateral and 50% with bilateral hypofunction had fallen since onset. Exercise can itself cause falls or near-falls. [source: Hall et al. 2022]
  • Steps:
    1. Ask about falls and near-falls since the last session.
    2. Distinguish realistic risk, as judged by the physio, from fear.
    3. Ask about the safety advice the vestibular team gave for doing exercises and daily activities, and support following it.
    4. Report new falls to the team or GP, with consent.
    5. Do not encourage dropping walking aids or support unless the physio has cleared it. [synthesis]
  • Example language (illustrative): "Your physio's job is to judge the real falls risk, and mine is to help with the fear. Let's keep those two separate. Have you had any actual falls or near-falls this week?"
  • Watch for:
    • injuries;
    • older age (the CPG notes higher falls risk and slower balance recovery in older adults);
    • fear of falling leading to inactivity and deconditioning. [source: Hall et al. 2022]

B7. Medication conversations: always route to the prescriber

  • Purpose: clients may take vestibular suppressants or antiemetics, or be offered antidepressants for PPPD. [source: Hall et al. 2022; Popkirov et al. 2018; Zheng et al. 2025]
    • The CPG states that acute-stage suppressants and antiemetics may be used, but evidence does not support medication for chronic hypofunction.
    • EyeWiki notes that symptom-control medicines used for longer can slow recovery.
    • For PPPD, Popkirov et al. describe SSRIs and SNRIs, from open-label evidence, as the main medication options, with a slow onset of effect and discontinuation due to side effects in about one in five people.
    • The 2025 meta-analysis lists reported SSRI side effects, including nausea, sleep problems, sexual dysfunction and possible early worsening of anxiety.
  • Steps:
    1. Ask what the client takes and what they were told.
    2. Explore beliefs and ambivalence about it.
    3. Encourage the client to bring questions about side effects, duration or stopping to the prescriber.
    4. Pass on reported side effects or worsening anxiety with consent.
    5. Never suggest starting, stopping or changing any medicine. [synthesis]
  • Example language (illustrative): "That's a really good question for your doctor: whether the travel-sickness tablets still make sense now you're doing the exercises. Shall we write it down for your appointment?"
  • Watch for:
    • long-term self-medication for dizziness;
    • early anxiety increase after starting an antidepressant;
    • unilateral stopping. Refer back to the prescriber. [source: Zheng et al. 2025; synthesis]

B8. Collaboration, shared decision-making and integration over time

  • Purpose: combinations are tailored "according to patient needs and preferences". The psychotherapist helps the client make and sustain those choices. [source: Popkirov et al. 2018]
  • Steps:
    1. Obtain consent to communicate with the GP and the vestibular therapist.
    2. Agree roles (exercises: physio; medicines: prescriber; anxiety, avoidance and mood: psychotherapist).
    3. Align the language of the formulation.
    4. Time the work. Before rehabilitation: psychoeducation and engagement. During: adherence, exposure to real-life situations, fear of falling. After discharge: relapse prevention and maintenance. [synthesis]
    5. Support informed choice among vestibular rehabilitation, CBT and medication by helping the client prepare questions for the team.
  • Example language (illustrative): "You have a few options the team has mentioned: the exercises, talking therapy and possibly medication. What matters most to you in choosing?"
  • Watch for:
    • mixed messages;
    • the client feeling passed between services;
    • delays. Early treatment is advised. [source: Popkirov et al. 2018]

B9. Crisis and safety planning

  • Purpose: chronic dizziness can bring depression, isolation and hopelessness. [source: Liverpool leaflet; EyeWiki]
  • Steps: use standard suicide risk assessment and collaborative safety planning when indicated, and involve the GP. Plan for practical safety around falls (B6). [synthesis]
  • Example language (illustrative): "Sometimes when dizziness goes on this long people start to feel there's no way out. Has that crossed your mind?"
  • Watch for: hopelessness about recovery, which EyeWiki also lists as a negative prognostic belief; withdrawal. [source: EyeWiki]

B10. Relapse prevention and support after discharge

  • Purpose: to maintain gains after formal therapy ends (CPG discharge criteria). [source: Hall et al. 2022]
  • Steps:
    1. Write a setback plan: flares after illness, fatigue or stress are expected, so the client resumes the practice the physio last advised and avoids avoidance.
    2. Agree when to re-contact the GP or vestibular team: new symptom types, falls, or a loss of function.
    3. Review residual avoidance. [synthesis]
  • Example language (illustrative): "If it flares after a cold, what's the first thing on your plan? And what would make you call the vestibular clinic again?"
  • Watch for: re-emergence of avoidance after a setback; confusing a functional flare with a new problem. If unsure, seek medical review. [synthesis]

5. Handling problems

Where a source is given, the point comes from it; otherwise the guidance is clinician synthesis.

  • Symptom flare-ups after exercises lead to stopping.
    • In PPPD, overly aggressive programmes cause flare-ups and early dropout. [source: Popkirov et al. 2018]
    • Response: normalise a temporary increase as expected in habituation (A4).
    • Ask the client to report the flare to the physio, so that the pace can be adjusted, rather than stopping silently.
    • Review catastrophic interpretations, e.g. "I'm damaging my ear". [synthesis]
  • "So you think it's all in my head."
    • Response: PPPD is a real functional disorder of the nervous system, and inconsistent function is typical and not malingering. [source: Popkirov et al. 2018]
    • Explain that psychological work targets the alarm system, not imagination.
    • Repair the rupture by acknowledging the client's experience of being dismissed by services. [synthesis]
  • Fear of falling blocks exposure.
    • Response: separate the physio-judged risk from the fear (B6).
    • Grade real-life exposure in steps agreed with the physio.
    • Treat fear of falling as a target in its own right; Popkirov et al. note it is more common than fear of panic in PPPD. [source: Popkirov et al. 2018; synthesis]
  • Plateau.
    • The CPG lists a plateau as one reason to stop formal therapy. [source: Hall et al. 2022]
    • Response: check for unaddressed modifying factors (anxiety, depression, medication, cognition, comorbidity) and raise them with the team.
    • Shift towards acceptance and valued activity if residual symptoms persist. [synthesis]
  • Bilateral loss: grief and frustration.
    • Expect smaller gains (CPG). [source: Hall et al. 2022]
    • Response: adjustment and grief work; realistic goal setting with the physio. [synthesis]
  • Fluctuating or episodic conditions (Ménière's disease, vestibular migraine) or new attacks.
    • Response: do not interpret new attack types as psychological. Prompt a medical review.
    • Note that PPPD can coexist with BPPV, vestibular migraine and other conditions. [source: Popkirov et al. 2018; synthesis]
  • Anxiety predates the dizziness (panic, generalised anxiety).
    • Panic and generalised anxiety are recognised PPPD triggers. [source: Popkirov et al. 2018]
    • Response: treat the anxiety disorder in parallel, and coordinate interoceptive and situational exposure with the vestibular team to avoid overload.
    • Avoid hyperventilation or spinning provocation tasks unless the medical and vestibular team agrees. [synthesis] [uncertain: not verified in vestibular sources]
  • Alexithymia, or difficulty engaging with cognitive work.
    • Noted as a possible barrier to CBT in PPPD. [source: Zheng et al. 2025]
    • Response: rely more on behavioural experiments, concrete monitoring and the physio's demonstrations (e.g. walking better under distraction) than on verbal cognitive work. [synthesis]
  • Cognitive impairment.
    • It may limit carryover of learning. [source: Hall et al. 2022]
    • Response: involve carers, use simple written plans, and liaise with the physio on format. [synthesis]
  • Non-attendance at supervised therapy (cost, travel, time).
    • The CPG names these barriers and mentions technology, telehealth or self-teaching as alternatives for some patients. [source: Hall et al. 2022]
    • Response: problem-solve the access barriers and ask the team about a telehealth or self-managed option such as booklet-based balance retraining (A8). [source: REF case study; synthesis]
  • The client wants to do internet exercises or devices on their own, without assessment.
    • Response: encourage an assessment first. The CPG recommends against isolated saccade or pursuit eye exercises for gaze stability, an example of why a tailored programme matters. [source: Hall et al. 2022]
  • The client asks the psychotherapist to change exercises or medication.
    • Response: decline warmly and route the request to the physio or prescriber. Help the client prepare the question. [synthesis]
  • Conflicting advice between professionals (a rupture with the team).
    • Response: with consent, contact the team directly and agree shared wording and a shared plan. [synthesis]
  • Trauma assumed as the cause.
    • Popkirov et al. caution against assuming trauma or adversity explains PPPD. [source: Popkirov et al. 2018]
    • Response: explore the client's history without imposing a causal story. [synthesis]
  • Depression and hopelessness.
    • Response: risk assessment and safety planning (B9); behavioural activation compatible with the falls advice; liaison with the GP. [synthesis]

Sources

Pages consulted:

Notes:

  • The original 1940s Cawthorne and Cooksey publications are referenced only via the sources above. [uncertain: not verified]
  • The detailed content of the INVEST intervention manual. [uncertain: not verified]
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