Unsteadiness has many causes, and they need separating before they can be treated. Balance depends on three systems working together — the inner ear, vision, and the sensation coming from your feet and joints. When one is disrupted, the others have to compensate, and rehabilitation works by retraining that compensation deliberately.
When dizziness needs urgent medical assessment
Go to hospital straight away if vertigo comes on suddenly alongside any of the following: double vision, slurred speech, weakness or numbness on one side, a severe or unusual headache, or difficulty walking that is worse than the dizziness alone would explain. Vertigo can occasionally be caused by a stroke affecting the back of the brain, and that needs emergency assessment rather than a physiotherapy appointment.
Short of that, if dizziness is new, severe, or comes with hearing loss or ringing in one ear, please see a doctor first so the cause can be identified. Where the cause has been established and is suitable for rehabilitation, physiotherapy can be an effective part of management.
BPPV and repositioning manoeuvres
The most common cause of true spinning vertigo is BPPV — benign paroxysmal positional vertigo — where tiny crystals in the inner ear move out of place and send false movement signals when you turn your head, roll over in bed or look up.
BPPV is unusual among the conditions we treat because it often responds to a specific repositioning technique rather than a course of exercise. Your physiotherapist first identifies which ear and which canal is involved through positional testing, then performs the appropriate repositioning manoeuvre — the Epley manoeuvre being the best known. Please check availability when you book. You may feel briefly worse during the manoeuvre itself; that is expected, and your physiotherapist will talk you through what to expect beforehand.
Not all vertigo is BPPV, which is why the positional testing comes first. Where the cause is different, the treatment is different. For a fuller explanation of how vertigo happens, see our guide to vertigo and dizziness.
Assessment
Rather than judging balance by eye, APARC uses dynamic posturography — a system that measures how well you hold balance under different sensory and surface conditions. That shows which of the three systems is contributing to the problem, so training can target the right one, and it gives a measurement to re-test against later.
Treatment
Programmes use evidence-based balance training including the Otago programme, virtual-reality balance systems and force-platform training, chosen according to what the assessment shows. Work is graded so it is challenging enough to drive change while staying safe, and it is progressed as steadiness improves.
What vestibular rehabilitation actually trains
Where the balance problem is not BPPV — where an inner ear has been damaged or is underperforming — the treatment is not a manoeuvre but a programme. Vestibular rehabilitation works by driving the nervous system to recalibrate, and it does that through three kinds of exercise.
- Adaptation. Exercises that ask the eyes to stay fixed on a target while the head moves, which retrains the reflex that keeps vision steady during movement. Blurring or mild dizziness during these is expected — it is the stimulus the system adapts to.
- Habituation. Controlled, repeated exposure to the specific movements that provoke your symptoms, so the response reduces over time.
- Substitution and balance work. Training vision and the sensation from feet and joints to take on more of the work when the inner ear cannot.
Feeling briefly worse is part of it
This is the single most important thing to understand before starting, and the most common reason people give up. These exercises are designed to provoke a manageable amount of the symptom, because that is what drives adaptation. Avoiding the movements that make you dizzy keeps you comfortable and keeps you dizzy.
“Manageable” is defined with you and monitored — symptoms that settle within a reasonable time after the exercise, not symptoms that wipe out your day. If you are getting the second one, the programme is too hard and should be adjusted rather than endured.
Why balance loss deserves attention on its own
Dizziness and unsteadiness lead people to move less and go out less, and that reduction in activity itself weakens balance and confidence — a loop that ends in falls and isolation well before the original problem would have caused them. Treating the balance system and rebuilding confident movement are the same job.
After BPPV has been treated
Repositioning often resolves the spinning quickly, but some people are left feeling off-balance or uneasy for a while afterwards, and BPPV can recur. Neither means the treatment failed. Residual unsteadiness generally responds to a short course of balance work, and a recurrence can be re-tested and treated again.
Booking an assessment
Vertigo and balance rehabilitation is available across APARC’s centres, with home visits for people at high risk of falling, and connects closely with our geriatric physiotherapy and neurological physiotherapy services. Call +91 98189 11195.
Dizziness is a symptom, not a diagnosis
“Vertigo” and “dizziness” are used loosely, and the difference matters because the treatments differ completely. Vertigo is a false sense of movement — the room spinning, or yourself spinning. That is not the same as light-headedness, unsteadiness on the feet, or the swimmy feeling that comes with anxiety or low blood pressure, and it is not treated the same way.
Describing your symptom precisely is the single most useful thing you can bring to an assessment. Three questions do most of the work:
- What does it feel like? Spinning, tilting, floating, faint, or unsteady only when walking
- How long does an episode last? Seconds, minutes, hours, or constant
- What sets it off? Rolling over in bed, standing up, head turning, busy visual environments, or nothing identifiable
Common causes, and how they typically differ
The table below shows the patterns clinicians look for. It is a guide to help you describe your symptoms, not a way to diagnose yourself — several of these overlap, and more than one can be present at once.
| Cause | Typical episode length | Typical trigger | Other features |
|---|---|---|---|
| BPPV | Seconds to under a minute | Head position change — rolling over, lying down, looking up | Intense spinning; settles if you keep still; no hearing change |
| Vestibular neuritis | Days, then gradually easing | Comes on without a positional trigger | Severe constant spinning at onset, often with nausea; no hearing loss |
| Ménière’s disease | Twenty minutes to hours | Often unpredictable | Hearing change, ringing, or fullness in one ear alongside the vertigo |
| Vestibular migraine | Minutes to hours, sometimes longer | Varies; may follow migraine patterns | Light or sound sensitivity, headache history, visual disturbance |
| Persistent postural-perceptual dizziness | Constant, fluctuating | Upright posture, movement, busy visual scenes | Often follows an earlier vestibular event; worse in supermarkets or crowds |
Your assessment establishes which pattern fits, because the right first treatment differs sharply — a repositioning manoeuvre for BPPV, a graded exercise programme for a compensating vestibular loss, and referral back to medical care where the picture suggests Ménière’s or migraine.
What happens during a positional test
- You are asked to keep your eyes open. The diagnosis is made by watching your eyes, not by asking how you feel — so keeping them open matters, even when the instinct is to shut them.
- You are moved into a specific position. Usually turning the head to one side and lying back quickly, with the head supported below the level of the couch.
- The clinician watches for nystagmus. A particular flicking eye movement, whose direction and timing identify which ear and which canal is involved.
- You may feel the vertigo briefly. This is expected. It usually lasts under a minute and settles while you stay still.
- The other side is tested. For comparison, and because both sides can be affected.
People often dread this test. It is short, it is deliberately provocative, and the brief spin it triggers is what makes the diagnosis possible.
What a repositioning manoeuvre involves
If BPPV is confirmed, treatment is a sequence of controlled head and body positions that moves displaced crystals out of the semicircular canal, where they cause vertigo, and back to where they do no harm. It takes a few minutes. You may feel the vertigo during it, and briefly afterwards.
Some people are clear after one manoeuvre; others need it repeated at a second visit. Your clinician will retest to confirm it has worked rather than assuming it from symptoms alone.
Practical questions people ask but often do not raise
- Driving. If you experience unpredictable vertigo, discuss driving with your doctor. Do not drive during an active episode.
- Work. Ladders, scaffolding, machinery and shift work all need thought while symptoms are unsettled.
- Sleeping position. After a manoeuvre, your clinician may give specific advice for the first night. Follow it, and ask if it is not clear.
- Falls. Dizziness and balance loss raise the risk of falling, particularly for older adults. If you have already fallen or feel close to it, say so — it changes the priority of the programme.
What the evidence says
Vestibular rehabilitation is one of the better-evidenced things physiotherapy does. A Cochrane review of high-quality randomised trials concluded that there is “moderate to strong evidence that vestibular rehabilitation is a safe, effective management for unilateral peripheral vestibular dysfunction” (McDonnell & Hillier, Cochrane, 2015).
But the same review draws a distinction that matters a great deal if your vertigo is BPPV. For BPPV specifically, it found that “physical (repositioning) manoeuvres are more effective in the short term than exercise-based vestibular rehabilitation; although a combination of the two is effective for longer-term functional recovery.”
In plain terms: if your dizziness is caused by BPPV, the right first treatment is usually a repositioning manoeuvre — often resolving symptoms in one or two visits — not a course of balance exercises. Being sold a multi-week exercise programme when a manoeuvre would have worked faster is a real risk in this area, and it is why the assessment comes first. Exercises still have a place afterwards, for confidence and longer-term steadiness.
Frequently asked questions
How do I know whether my vertigo is BPPV?
BPPV typically causes short, intense spinning triggered by a change in head position — rolling over in bed, lying down, or looking up. It is confirmed by a positional test during assessment, not by symptoms alone, which is why an examination matters before treatment is chosen.
How many sessions will I need?
For BPPV treated with a repositioning manoeuvre, often very few — sometimes one or two. For other causes of vestibular dysfunction, a structured exercise programme over several weeks is more usual. Your assessment determines which applies.
Is it normal to feel worse at first?
A temporary increase in dizziness during vestibular rehabilitation is common and expected — the exercises deliberately provoke the system so it can adapt. It should settle as you progress. Tell your physiotherapist if it does not.
Can vertigo be a sign of something serious?
It can. Dizziness with sudden severe headache, double vision, slurred speech, weakness or numbness, difficulty walking, or new hearing loss needs urgent medical assessment rather than a physiotherapy appointment.
Will the vertigo come back?
BPPV can recur, and recurrence is not a sign that the earlier treatment failed. If it returns, the same manoeuvre is usually effective again.
Terms you may hear
- Vertigo
- A false sense of movement — the room spinning, or yourself spinning. Distinct from light-headedness, faintness or general unsteadiness, and treated differently.
- BPPV (benign paroxysmal positional vertigo)
- Brief, intense positional vertigo caused by displaced crystals in a semicircular canal of the inner ear. “Benign” here means not dangerous, not that it is mild.
- Otoconia
- Tiny calcium crystals normally sitting in one part of the inner ear. When they become displaced into a canal, head movement makes the canal signal movement that is not happening.
- Nystagmus
- An involuntary flicking eye movement. Its direction and timing during a positional test is what identifies which ear and which canal is affected.
- Repositioning manoeuvre
- A specific sequence of head and body positions that moves displaced crystals out of the canal to where they no longer cause vertigo.
- Vestibular compensation
- The process by which the brain recalibrates after a vestibular loss. Exercises are designed to drive it, which is why they can provoke symptoms initially.
- Habituation
- Repeated, controlled exposure to a movement that provokes dizziness, so that the response gradually reduces.
- Gaze stabilisation
- Training the reflex that keeps vision steady while the head moves — often the difference between coping and not coping in busy environments.
Sources
- McDonnell MN, Hillier SL. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database of Systematic Reviews 2015, Issue 1, Art. No.: CD005397. doi:10.1002/14651858.CD005397.pub4
Authorship and review
Reviewed and approved for publication by: Dr. Dharam Pandey (PT), Director — Neurological Rehabilitation and Technology, APARC Health & Motion. Last reviewed: 2 August 2026
This page provides general information about vertigo, BPPV and vestibular rehabilitation. It is not medical advice and is not a substitute for individual assessment by a qualified clinician. See our Medical Disclaimer.
Find an APARC centre near you
APARC Health & Motion has 12 centres across Delhi NCR and Pune. Services, equipment and clinical teams vary by centre — please contact your nearest centre to confirm what is available there.
Medically reviewed by Anuj Kumar Mishra, MPT · Last reviewed: 2 August 2026 · Our clinical team
Where this is available
Specialist neurorehabilitation is provided at four designated APARC Advanced Neurorehabilitation Centres — ACNR Pitampura, Greater Noida, Janakpuri and Rohini Sector 22. Each provides specialist neurological assessment, technology-assisted rehabilitation and a multidisciplinary team, alongside the full range of APARC physiotherapy and rehabilitation services. APARC's other centres continue to provide general physiotherapy and rehabilitation. More about our neurorehabilitation service · All APARC centres.
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These videos are general education, not a substitute for individual assessment. Exercise selection after injury, surgery or a neurological event should be confirmed with a qualified physiotherapist before you begin.
More videos on the Dr Dharam Pandey & Team YouTube channel.