1 Introduction
Unilateral vestibular hypofunction (UVH) is a common peripheral vestibular disorder characterized by partial or complete loss of function in the vestibular end organs and/or nerve on one side
[1,
2]. The resulting asymmetry disrupts vestibulo-ocular reflex (VOR) function, postural control, gait, and spatial orientation. Acute presentations typically include sustained vertigo, spontaneous nystagmus, nausea, and postural instability. Incomplete peripheral recovery or central compensation may lead to persistent dizziness, oscillopsia, visual-motion sensitivity, gait impairment, and difficulty in visually or proprioceptively challenging environments
[3,
4].
Peripheral vestibular disorders are important causes of dizziness and vertigo
[5]. Population estimates should be interpreted cautiously because epidemiologic studies use different definitions. In adults aged 40 years or older, 35.4% failed a modified Romberg condition interpreted as vestibular-related balance dysfunction, and symptomatic participants had substantially greater odds of falling
[6]. A German population survey estimated a lifetime prevalence of vestibular vertigo of approximately 7% and a 1-year prevalence of approximately 5%
[7]. These estimates describe broad vestibular dysfunction rather than UVH specifically.
UVH arises from diverse etiologies, including acute unilateral vestibulopathy, Ménière disease (MD), labyrinthitis, vestibular schwannoma and its treatment, labyrinthectomy, and temporal bone trauma
[8–
10]. It differs from bilateral vestibular hypofunction in its dynamic course, often progressing from acute asymmetry to varying degrees of recovery and compensation, necessitating stage-specific rehabilitation strategies.
Persistent UVH is associated with impaired mobility, reduced quality of life, and increased risks of falls, deconditioning, and psychological distress
[11–
13]. Notably, objective deficits and patient-reported disability may diverge, underscoring the need for comprehensive assessment encompassing gaze stability, balance, gait, fall risk, and patient-centered outcomes.
Vestibular rehabilitation therapy (VRT) is an exercise-based intervention that facilitates central compensation through VOR adaptation, habituation, sensory reweighting, and task-specific training. Robust evidence supports its efficacy across disease stages, improving dizziness, balance, gait, and functional independence
[8,
14]. However, clinical practice remains heterogeneous, with inconsistencies in diagnosis, staging, treatment timing, exercise prescription, and outcome evaluation.
To address these gaps, this guideline provides evidence-based recommendations for the diagnosis, staging, and rehabilitation of UVH, aiming to standardize care and optimize patient outcomes across clinical settings.
Terminology and scope: acute unilateral vestibulopathy/vestibular neuritis (AUVP/VN) has formal Bárány Society diagnostic criteria, whereas chronic UVH does not have a single universally accepted diagnostic standard. In this guideline, UVH is used as an operational rehabilitation term for adults with a compatible clinical phenotype, objective unilateral peripheral vestibular dysfunction, and no better central or alternative explanation. Benign paroxysmal positional vertigo (BPPV) may coexist with UVH but isolated BPPV is treated with canalith repositioning and is not classified as UVH. Ménière disease is included only when the acute attack has resolved and a stable residual vestibular impairment or chronic imbalance is present.
2 Methods
This guideline was developed in accordance with established methodological standards for clinical practice guidelines and the definition proposed by the Institute of Medicine (IOM)
[15]. The process was guided by the 2014 WHO Handbook for Guideline Development, second edition
[16]. Appraisal of Guidelines for Research and Evaluation II (AGREE II) informed methodological rigor and transparency
[17], and the final guideline was reported in accordance with the Reporting Items for Practice Guidelines in Healthcare (RIGHT) statement
[18]. A prespecified protocol was developed before evidence review and recommendation formulation. The overall process is shown in Fig. 1.
2.1 Guideline initiation and methodological support
In July 2025, this guideline was initiated by the Eye and ENT Hospital of Fudan University. The Center for Evidence-Based Medicine, Fudan University, provided methodological guidance and technical support.
2.2 Guideline registration
The guideline was registered with the International Practice Guideline Registry and Transparency Platform (PREPARE-2025CN1147).
2.3 Objectives and scope
This guideline provides evidence-based recommendations for identifying and staging UVH for rehabilitation; phenotype-directed etiologic and differential evaluation; timing and indications for VRT; multidomain rehabilitation assessment; individualized exercise prescription and dosage; treatment supervision, reassessment, and discontinuation; and selected adjunctive technologies.
The target population is adults with suspected or objectively confirmed UVH, including AUVP/VN, stable residual hypofunction associated with Ménière disease, vestibular schwannoma and its treatment, labyrinthectomy, temporal-bone trauma, labyrinthitis, and other unilateral labyrinthine or vestibular-nerve injuries. Acute vestibular syndromes must undergo appropriate assessment for stroke and other central causes before entering a routine rehabilitation pathway. Isolated BPPV, active Ménière disease attacks, unstable acute hearing loss, and untreated central vestibular disorders are outside the primary VRT pathway.
The guideline is intended for otolaryngologists, neurotologists, neurologists, rehabilitation physicians, general practitioners, physical and rehabilitation therapists, audiologists, nurses, and other professionals involved in vestibular care. It applies to tertiary and secondary hospitals, specialist rehabilitation hospitals, primary-care institutions, and community rehabilitation settings with appropriate expertise and safety provisions.
2.4 Guideline development groups
A multidisciplinary structure comprising a Steering Committee, Guideline Development Group, Secretariat, evidence-review teams, and an independent External Review Panel was established in July 2025. Membership included experts in otorhinolaryngology–head and neck surgery, neurotology, neurology, rehabilitation medicine, vestibular rehabilitation, clinical epidemiology, biostatistics, evidence-based medicine, and medical editing, with geographic representation from six regions of China.
The Steering Committee oversaw scope, methods, conflicts of interest, consensus procedures, and final approval. The Guideline Development Group prioritized questions and outcomes, interpreted evidence, and formulated recommendations. The Secretariat coordinated the protocol, evidence searches, extraction and synthesis, patient involvement, documentation, and manuscript preparation. The External Review Panel assessed clinical relevance, clarity, feasibility, applicability, and evidentiary support. Full membership and roles should be provided in a suppl. appendix.
2.5 Declaration and management of conflicts of interest
All members completed written declarations of financial and non-financial interests before participation and updated them when necessary. The Steering Committee assessed the relevance of each declaration and determined management measures. Depending on the nature and magnitude of a conflict, members could be restricted from evidence appraisal, recommendation discussion, or voting. Declarations and management decisions should be published in a suppl. appendix.
2.6 Identification and prioritization of clinical questions
Potential questions were generated from existing guidelines, systematic reviews, and clinical-practice gaps. A structured survey was completed by 33 front-line clinicians, rehabilitation professionals, nurses, and researchers. Fourteen candidate questions were generated. After the first Delphi round and expert discussion, the 10 highest-priority questions were retained using a 1–7 importance scale. After a second Delphi round, overlapping questions were consolidated into six principal clinical questions comprising 19 recommendations. An integrated clinical pathway incorporating the key recommendations for assessment and diagnosis, individualized vestibular rehabilitation, emerging adjunctive technologies, and outcome evaluation and follow-up is summarized in Fig. 2.
Questions were structured using the PICO framework—population, intervention or index approach, comparator when applicable, and outcomes—or appropriate adaptations for diagnostic, prognostic, and implementation questions. Outcomes were prioritized according to clinical importance and patient relevance.
2.7 Evidence identification, appraisal, and synthesis
2.7.1 Search strategy and study selection
Separate search strategies were developed for each clinical question. MEDLINE via PubMed, Embase, Web of Science Core Collection, the Cochrane Library, SinoMed/CBM, CNKI, and Wanfang Data were searched from inception to December 31, 2025. Guideline repositories, professional-society websites, and reference lists were also examined. An update search was planned before final approval; the exact update date and full strategies should be reported in the supplementary materials.
Eligible evidence included clinical practice guidelines, consensus statements, systematic reviews and meta-analyses, randomized and non-randomized intervention studies, diagnostic-accuracy studies, cohort and case-control studies, qualitative studies, and relevant measurement-property studies. Two reviewers independently screened records and full texts using prespecified criteria. Disagreements were resolved by discussion or third-reviewer adjudication. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram and reasons for full-text exclusion should be provided in the supplement after final record counts are verified.
2.7.2 Data extraction and evidence synthesis
Data were extracted using standardized forms and independently verified. Extracted items included population, etiology, disease stage, diagnostic criteria, intervention content and dose, comparator, follow-up, outcomes, adverse events, and study limitations. Evidence was synthesized narratively because of substantial clinical and methodological heterogeneity; quantitative estimates from high-quality systematic reviews were used when applicable.
2.7.3 Methodological quality and risk-of-bias assessment
Systematic reviews and meta-analyses were assessed with a Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2)
[19] without calculation of an overall numerical score. Randomized trials were assessed with the Revised Cochrane Risk-of-Bias Tool for Randomized Trials (RoB 2)
[20]. Cohort and case-control studies were assessed with the Newcastle–Ottawa Scale (NOS)
[21]. Diagnostic-accuracy studies should be assessed with the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2), non-randomized intervention studies with the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I), and existing clinical practice guidelines with AGREE II when used as evidence sources. Two reviewers assessed each study independently, with disagreements resolved by consensus or third-party adjudication.
2.7.4 Evidence levels and recommendation strength
Levels of evidence were assigned according to the 2009 Oxford Centre for Evidence-Based Medicine framework. Recommendation strength was classified as strong, moderate, or weak using a modified framework developed by the Guideline Development Group. Evidence level and recommendation strength were determined separately. Recommendation strength reflected methodological quality, consistency, directness, benefits and harms, patient values and preferences, resource use, feasibility, acceptability, and safety. Accordingly, low-level evidence could support a strong recommendation when potential harm from not following the recommendation was substantial and the recommended action imposed minimal burden or risk.The operational definitions are presented in Table 1.
2.8 Patient and public involvement
Five patients with UVH at different disease stages, together with caregivers when appropriate, were purposively sampled for semistructured consultation. They commented on the clarity of recommendation language, acceptable home-exercise burden, preferred supervision and follow-up, and attitudes toward telerehabilitation, virtual reality, and wearable technologies. They also prioritized outcomes including dizziness, gaze stability, balance and gait, falls, driving, work, walking in darkness, visually complex environments, fear of falling, and quality of life. Feedback informed recommendation wording, educational materials, delivery options, and outcome selection but did not alter evidence levels.
2.9 Formulation of recommendations and consensus development
For each question, the Secretariat prepared structured evidence summaries and evidence-to-decision worksheets linking evidence, benefits and harms, patient values, resources, acceptability, feasibility, and equity. Draft recommendations were developed through a modified Delphi process and deliberated at hybrid consensus meetings in December 2025 and May 2026.
Consensus was defined a priori as agreement by at least 80% of eligible voting members without a relevant conflict of interest. Recommendations failing to reach consensus were revised and subjected to a further anonymous vote. Dissenting views and reasons for unresolved disagreement were documented. The final recommendations are summarized in Table 2.
2.10 External review, quality assurance, and approval
The complete draft was reviewed independently by the External Review Panel, including clinical specialists, rehabilitation professionals, and guideline methodologists. Reviewers assessed scope, accuracy, recommendation clarity, feasibility, resource implications, and consistency between evidence and recommendations. The Guideline Development Group documented and responded to all comments. Final approval was obtained from the Steering Committee after methodological and content review.
2.11 Guideline updating
The guideline will be reviewed no later than 5 years after publication. Earlier updating will be initiated if diagnostic criteria change, important safety findings emerge, new high-quality evidence materially changes a recommendation, or major technologies become clinically available. Updating will include renewed searches, risk-of-bias assessment, evidence synthesis, patient and stakeholder consultation, and reconsideration of recommendations.
2.12 Dissemination and implementation
The guideline will be disseminated through peer-reviewed publication, scientific meetings, regional and multidisciplinary educational activities, and professional digital platforms. Implementation should be supported by tiered assessment checklists, clinical algorithms, exercise-prescription and progression tools, patient education materials, referral criteria, and quality indicators suitable for different levels of care. Pilot implementation and audit are recommended to identify barriers, monitor adherence, and evaluate safety and patient-important outcomes.
2.13 Funding and editorial independence
The guideline was supported by the “Common Disease Prevention and Control Research” Key Project of the National Key R&D Program of China (Nos. 2023YFC2508000 and 2024YFC2511100); The Win-Win Program, Eye & ENT Hospital of Fudan University. The funding body did not participate in question selection, evidence identification or appraisal, recommendation deliberation or voting, external review, manuscript approval, or the decision to publish. The Guideline Steering Committee retained final authority over all methodological and editorial decisions.
2.14 Availability of supporting materials
The protocol, registration record, detailed search strategies, study-selection flow diagram, evidence tables, risk-of-bias assessments, patient-consultation materials, consensus voting results, conflict-of-interest declarations, external-review comments, and implementation tools should be made available as supplementary material or through the registration platform.
3 Clinical Questions and Recommendations
3.1 How should UVH be identified, etiologically evaluated, and staged for rehabilitation?
Recommendation 1: Use a 3-part operational definition to identify adults with UVH for rehabilitation: (1) symptoms and/or functional limitations compatible with unilateral peripheral vestibular loss; (2) objective evidence of unilateral peripheral vestibular dysfunction on one or more appropriately interpreted tests; and (3) exclusion of central or other better explanations. Apply the Bárány Society criteria for AUVP/VN when appropriate (Level of evidence: 2b; Recommendation strength: Strong).
Evidence summary
This recommendation was informed by one clinical practice guideline, international classification and diagnostic-consensus documents, and observational and diagnostic studies
[14,
22–
34]. The evidence supports combining clinical phenotype, objective testing, and differential diagnosis; no universally accepted single diagnostic criterion exists for chronic UVH.
Rationale
UVH is best regarded as a rehabilitation-relevant functional state rather than a single disease. Symptoms may include acute vertigo, persistent dizziness, movement-induced visual blurring, postural or gait instability, visual-motion sensitivity, and activity limitation. The timing, triggers, associated auditory or neurological features, and functional impact should be established before interpreting laboratory results
[23,
24].
For AUVP/VN, the 2022 Bárány Society consensus requires an acute or subacute sustained vestibular syndrome lasting at least 24 hours, spontaneous peripheral vestibular nystagmus, unambiguous unilateral reduction in VOR function, absence of acute auditory or central neurological symptoms and signs, and no better diagnosis
[25]. The consensus does not require a universal vHIT gain cutoff; reduced gain and corrective saccades should be interpreted using device- and laboratory-specific normative values and the clinical examination.
Caloric unilateral weakness of approximately 25% or greater is a commonly used threshold for low-frequency horizontal-canal asymmetry
[27]. vHIT assesses higher-frequency canal function and identifies overt and covert corrective saccades
[28–
32]. Caloric and vHIT findings may be discordant because they examine different frequency ranges and disease patterns. An isolated abnormality should not be used without clinical correlation, quality-control review, and consideration of alternative causes.
In acute vestibular syndrome, central causes must be actively considered. Head-impulse, nystagmus, test-of-skew examination (HINTS) can outperform early MRI with diffusion-weighted imaging MRI-DWI in expert hands, but it is validated for continuous acute vestibular syndrome and should be performed by clinicians trained in eye-movement examination; it is not a general screening tool for all dizziness
[22,
33,
34]. New focal neurological findings, severe truncal ataxia, central ocular-motor signs, or atypical auditory findings require urgent evaluation.
A domestic aviation-medicine classification
[26] may be useful for descriptive phenotyping by etiology, end-organ involvement, and severity, but its proposed categories should not be presented as internationally validated diagnostic standards. The rehabilitation diagnosis should remain anchored to the clinical syndrome, objective unilateral dysfunction, and exclusion of better explanations.
Recommendation 2: For rehabilitation planning, classify UVH as acute (≤ 2 weeks), subacute (> 2 weeks to 3 months), or chronic (> 3 months). This staging should guide treatment goals and progression but should not replace etiologic diagnosis or assessment of disease activity (Level of evidence: 2b; Recommendation strength: Moderate).
Evidence summary
This recommendation was informed by the American Physical Therapy Association (APTA) guideline, consensus and observational evidence, and rehabilitation studies
[14,
35–
41]. The time boundaries are pragmatic rehabilitation categories rather than universally validated biological transitions.
Rationale
Static compensation develops predominantly during the early period after unilateral vestibular loss, whereas dynamic gaze, balance, and gait adaptation can continue for weeks or months
[36–
38]. The APTA guideline defines acute UVH as ≤ 2 weeks, subacute UVH as > 2 weeks to 3 months, and chronic UVH as > 3 months
[14]. These categories facilitate interpretation of natural recovery, treatment timing, and dosage.
Recovery trajectories vary according to etiology, completeness of the lesion, age, comorbidity, physical activity, medication exposure, and psychological or behavioral factors. A vestibular schwannoma resection with planned deafferentation differs from fluctuating Ménière disease or AUVP/VN. Stage should therefore be used together with disease activity and functional status, not as a stand-alone indicator of prognosis
[39–
41].
Symptoms persisting beyond 3 months may reflect incomplete dynamic compensation, residual VOR loss, visual dependence, deconditioning, anxiety, avoidance, persistent postural-perceptual dizziness (PPPD), or another coexisting disorder
[35]. Chronic classification should trigger reassessment of these factors rather than imply irreversible disability.
Recommendation 3: Perform phenotype-directed etiologic and differential diagnostic evaluation before VRT. Particular attention should be given to AUVP/VN, stable Ménière-related hypofunction, labyrinthitis or sudden hearing loss with vestibular involvement, vestibular schwannoma and treatment-related loss, labyrinthectomy, temporal-bone trauma, and other unilateral labyrinthine or vestibular-nerve lesions. BPPV may coexist with UVH but isolated BPPV should not be classified as UVH (Level of evidence: 2b; Recommendation strength: Moderate).
Evidence summary
The evidence included clinical practice guidelines, international diagnostic consensus, systematic reviews, an randomized controlled trial (RCT), observational studies, and narrative reviews
[24,
25,
34,
37,
40,
42–
53]. No comparative trial has established a single optimal etiologic work-up strategy.
Rationale
Etiology affects disease stability, spontaneous recovery, hearing, neurological risk, prognosis, and the appropriate timing and content of rehabilitation. AUVP/VN is characterized by an acute peripheral vestibular syndrome without acute cochlear or central neurological signs
[25,
43]. Acute hearing loss or tinnitus should prompt consideration of labyrinthitis, sudden sensorineural hearing loss with vestibular involvement, anterior inferior cerebellar artery (AICA) ischemia, or another cochleovestibular disorder rather than uncomplicated AUVP.
Ménière disease may leave stable unilateral hypofunction after recurrent attacks
[48]. VRT may be offered for chronic imbalance between attacks but is not the primary treatment during an active vertigo episode
[49]. Vestibular schwannoma and its surgical or radiotherapy treatment can cause gradual or abrupt unilateral deafferentation; available reviews support rehabilitation but indicate heterogeneous and generally low-certainty evidence
[40,
44,
45].
Temporal-bone trauma, labyrinthectomy, and other unilateral lesions may produce persistent UVH and may require audiological, neurological, and surgical follow-up
[37,
50–
52]. BPPV can occur after VN, Ménière disease, trauma, or surgery and should be treated with canalith repositioning. Persistent symptoms after successful repositioning warrant assessment for coexisting UVH, PPPD, or another diagnosis
[42,
47].
Posterior-circulation ischemia, particularly AICA territory disease, may present with acute vestibular and auditory symptoms and can mimic peripheral disease
[24,
34,
53]. VRT should not delay urgent vascular or neurological evaluation when central signs, sudden hearing loss, severe gait or truncal ataxia, or an atypical course is present.
Recommendation 4: Select audiological, vestibular, and imaging investigations according to hearing symptoms, neurological findings, disease course, and the differential diagnosis. Pure-tone audiometry should be obtained for hearing loss, tinnitus, aural fullness, or sudden or fluctuating auditory change. MRI of the brain and/or internal auditory canals, with vascular imaging when indicated, should be reserved for central red flags, atypical acute vestibular syndrome, asymmetric sensorineural hearing loss, unilateral tinnitus, or suspected retrocochlear disease. Delayed gadolinium-enhanced inner-ear MRI may be considered selectively when suspected endolymphatic hydrops remains diagnostically uncertain and the result would change management (Level of evidence: 2b; Recommendation strength: Moderate).
Evidence summary
This recommendation was informed by four guidelines, consensus evidence, a systematic review, observational studies, and reviews
[24,
26,
27,
33,
45,
49,
54–
63]. The evidence favors targeted testing rather than indiscriminate screening.
Rationale
History and bedside examination remain the foundation of etiologic assessment. Audiometry characterizes the degree, type, and asymmetry of hearing loss; tympanometry, otoacoustic emission (OAE), and auditory brainstem response (ABR) may be added when middle-ear, cochlear, or retrocochlear questions remain
[26,
49].
Vestibular tests answer different physiological questions. Bedside HIT and vHIT assess high-frequency canal function, caloric testing assesses very-low-frequency horizontal-canal function, and vestibular evoked myogenic potentials (VEMPs) assess otolith-related pathways
[27,
55–
57]. Results may be discordant and should be integrated rather than used to infer etiology from a single abnormality.
Routine imaging is not required for a typical peripheral presentation without red flags. Brain MRI is appropriate for central ocular-motor signs, severe truncal or gait ataxia, focal neurological findings, or atypical acute vestibular syndrome; magnetic resonance angiography (MRA) or computed tomography angiography (CTA) may be added for suspected vascular disease
[24,
33]. Early MRI-DWI can be falsely negative in posterior-circulation stroke, so imaging does not replace expert bedside assessment
[54].
Internal auditory canal MRI is appropriate for asymmetric sensorineural hearing loss, persistent unilateral tinnitus, progressive hearing loss, or suspected cerebellopontine-angle disease
[45,
58–
60]. Delayed gadolinium-enhanced MRI can demonstrate endolymphatic hydrops but should support, not replace, clinical and audiological diagnostic criteria for Ménière disease
[61–
63].
3.2 Who should receive VRT, and when should treatment begin?
Recommendation 5: Begin VRT as early as clinically feasible in adults with acute or subacute UVH once urgent central or otological causes have been addressed, severe nausea and vomiting are controlled, and the patient can safely participate. Initiation within the first 2 weeks is an evidence-based early-treatment window, not a requirement to delay treatment until day 14 (Level of evidence: 1a; Recommendation strength: Strong).
Evidence summary
One high-quality guideline, systematic reviews, randomized trials, and clinical studies support early VRT in acute or subacute unilateral peripheral vestibular loss
[14,
36,
39,
40,
65-
67].
Rationale
Early restoration of head movement, upright activity, and safe mobility supplies the sensory and motor experience required for compensation. Prolonged bed rest, excessive movement restriction, and prolonged use of vestibular suppressants may delay adaptation and reinforce visual dependence and avoidance
[36].
The APTA guideline strongly recommends VRT for acute and subacute UVH
[14]. A 2024 systematic review and meta-analysis of five trials involving 235 patients with peripheral acute vestibular syndrome found that VRT initiated within 2 weeks, in addition to corticosteroids, improved dizziness handicap inventory (DHI) at 1 and 12 months compared with corticosteroids alone, with no serious VRT-related adverse events reported
[64]. The evidence should not be interpreted as establishing corticosteroids as a prerequisite for rehabilitation.
Trials in AUVP/VN and postoperative unilateral deafferentation support early, progressive activity after diagnostic stabilization
[39,
40,
64,
65]. Treatment should begin with tasks the patient can perform safely and progress from bed mobility and sitting to standing, walking, head movement, and gaze-stability exercise. High fall risk or severe autonomic symptoms may require closer supervision and slower progression.
Recommendation 6: Offer VRT to adults with chronic UVH who continue to experience vestibular-related symptoms, impairments, activity limitations, or participation restrictions, regardless of the duration of symptoms (Level of evidence: 1a; Recommendation strength: Strong).
Evidence summary
Two clinical practice guidelines, a Cochrane systematic review, randomized trials, and intervention studies support VRT for chronic unilateral peripheral vestibular hypofunction
[8,
14,
37,
41,
66,
68–
70].
Rationale
Patients with chronic UVH are beyond the period during which the most rapid spontaneous peripheral recovery and early vestibular compensation usually occur. Nevertheless, the central nervous system retains the capacity for adaptation, substitution, sensory reweighting, and motor learning. Persistent dizziness, movement-induced visual blurring, postural instability, gait dysfunction, and activity limitations therefore do not indicate that VRT is no longer beneficial. Current clinical practice guidelines, systematic reviews, and intervention studies consistently support structured, progressive, and individualized VRT for improving symptoms, postural control, and daily function in patients with chronic UVH.
The 2016 and updated 2022 APTA clinical practice guidelines strongly recommend VRT for adults with chronic UVH
[14,
67]. These guidelines conclude that VRT improves dizziness, functional gaze stability, postural stability, gait, and health-related quality of life. A disease duration of more than 3 months should not, by itself, be regarded as a reason to withhold or discontinue treatment. Clinical decisions should instead be based on whether the patient continues to have modifiable impairments in gaze stability, balance, gait, mobility, or activity and participation. The Cochrane review by McDonnell et al.
[8], which included 39 randomized controlled trials, found moderate-to-strong evidence that VRT is a safe and effective treatment for unilateral peripheral vestibular dysfunction compared with no treatment, pharmacological treatment, or usual care. Benefits were observed in dizziness, postural stability, and functional performance, with few reported adverse events.
Gaze-stabilization training is an important component of rehabilitation for chronic UVH. Reduced unilateral vestibular input may impair the vestibulo-ocular reflex during head movement and increase retinal image motion, resulting in reduced dynamic visual acuity and oscillopsia. In a prospective randomized double-blind study, Herdman et al.
[37] found that specific vestibular exercises improved dynamic visual acuity and functional gaze stability during head movement. The findings suggest that repeated and progressively challenging eye–head exercises may facilitate recovery through a combination of VOR adaptation and centrally programmed compensatory eye movements. They should not, however, be interpreted as evidence that peripheral vestibular function necessarily returns to normal.
Patients with chronic UVH frequently have concurrent impairments in balance, gait, and multisensory integration; VRT should therefore not be limited to gaze-stabilization exercises. In a prospective randomized study of 81 patients with chronic UVH, Lilios et al.
[69] compared adaptation exercises, habituation exercises, and a combined adaptation–habituation program. After 8 weeks, all three groups showed improvement in functional gait, balance, and perceived disability. The combined program produced faster or greater improvement in selected measures of static balance, dynamic postural stability, and self-perceived disability. These findings support the use of multimodal rehabilitation when patients present with impairments across several functional domains.
A structured home-exercise program combined with professional supervision is also a feasible model for chronic vestibular rehabilitation. In a randomized controlled trial, Tanaka et al.
[70] found that a booklet-based home VRT program with regular professional supervision improved dizziness and gait function in patients with chronic peripheral vestibular hypofunction. Because the study population was not restricted exclusively to patients with UVH, the evidence is indirect but supports the practical value of clearly prescribed home exercises, periodic reassessment, and individualized progression. Chronic UVH does not necessarily require frequent face-to-face treatment, but the program should specify exercise technique, dosage, progression criteria, and safety precautions. Follow-up should be used to assess exercise quality, symptom response, adherence, and the need for modification.
Exercise selection should be tailored to the predominant symptom and functional phenotype. Patients with postural instability, gait impairment, or increased fall risk may require greater emphasis on sensory-integration training, dynamic balance, turning, obstacle negotiation, and dual-task walking
[41]. Patients with visually induced dizziness or intolerance of complex visual environments may benefit from graded optokinetic stimulation or visual-motion exposure, provided that training is delivered safely and symptoms remain within a tolerable and recoverable range. Pavlou et al.
[68] reported that incorporating optokinetic exposure into customized VRT improved visual vertigo and postural symptoms in patients with peripheral vestibular disorders. As this evidence was not restricted to chronic UVH, it should be regarded as indirect support for visually targeted rehabilitation. Visual-motion exposure should be introduced progressively because excessive stimulation may produce prolonged symptom exacerbation and reduce adherence.
Available evidence indicates that VRT is generally safe. Systematic reviews and most randomized trials have not identified serious exercise-related adverse events
[8]. Some patients may experience transient dizziness, nausea, visual instability, or fatigue during or shortly after exercise; these symptoms usually resolve with rest or adjustment of the exercise dose. Mild-to-moderate, brief, and recoverable symptom provocation may be an acceptable response during adaptation or habituation training. By contrast, persistent or marked symptom worsening, unusually prolonged recovery, new auditory or neurological symptoms, or an increase in falls or near-falls should prompt reduction or temporary suspension of training and clinical reassessment.
In summary, high-quality clinical practice guidelines, systematic reviews, and clinical studies support VRT for adults with chronic UVH. Meaningful improvements remain possible despite a prolonged disease course through appropriately selected gaze-stabilization, habituation, balance, gait, and task-specific functional exercises. Rehabilitation should be individualized according to residual vestibular function, the predominant symptom and functional phenotype, fall risk, patient-centered activity goals, comorbidities, and exercise tolerance. Ongoing supervision and periodic reassessment are important for optimizing adherence, progression, safety, and treatment response.
3.3 How should rehabilitation assessment be conducted?
Recommendation 7: Perform a structured, multidomain baseline assessment before VRT and repeat a consistent set of clinically relevant measures during treatment, at discharge, and, when indicated, during follow-up. Use the results to set goals, select treatment modules, adjust dose and progression, monitor safety, and evaluate response (Level of evidence: 2b; Recommendation strength: Strong).
Evidence summary
The supporting evidence included a clinical practice guideline, systematic review, intervention studies, and cohort evidence
[11,
14,
69,
71–
73]. Direct trials of assessment strategies are limited, but multidomain assessment is essential for safe, targeted treatment. Reassessment is recommended during rehabilitation, at treatment completion, and during follow-up when clinically indicated, as summarized in Table 3.
Rationale
UVH may affect vestibular sensory function, functional gaze stability, postural control, gait, activities of daily living, and social participation. Subjective symptoms, laboratory measures of vestibular function, and real-world functional performance do not necessarily recover in parallel. A structured, multidomain baseline assessment is therefore required to identify the predominant impairments, rehabilitation needs, patient-centered goals, and safety risks, and to provide a reference for subsequent evaluation of treatment response.
The 2022 APTA clinical practice guideline supports assessment across multiple domains, including vestibular function, functional gaze stability, balance, gait, fall risk, symptoms, and activity limitations
[14]. No single test adequately characterizes the extent of vestibular impairment, central compensation, or functional disability. Clinical assessment should therefore integrate the history and symptom profile, objective vestibular findings, gaze stability, postural and gait performance, fall risk, patient-reported outcomes, and activity and participation rather than relying on an isolated laboratory test or questionnaire.
Subjective recovery and objective function may differ substantially. Horak and colleagues
[71] demonstrated that patients with peripheral vestibular loss may retain deficits in postural control and sensory reweighting under challenging sensory conditions, even when they appear clinically compensated. These findings indicate that symptom improvement alone may underestimate residual balance impairment.
Guo et al.
[72] prospectively followed 16 patients with acute vestibular neuritis using caloric testing, the vHIT, rotational-chair testing, vestibular-evoked myogenic potentials (VEMPs), DHI, and a visual analogue measure of dizziness. Recovery differed across vestibular tests and stimulus-frequency ranges. Changes in patient-reported symptoms were not significantly correlated with the overall degree of objective vestibular recovery. These findings further support the complementary use of subjective, physiological, and performance-based outcomes.
Complex postural control and spatial-orientation deficits may require targeted functional testing. Batts et al.
[73] studied adults with vestibular hypofunction, most of whom had UVH, and found that performance on the Gait Disorientation Test was associated with the Sensory Organization Test composite, visual, vestibular, and visual-preference scores. The eyes-closed walking component showed particularly strong associations with balance under challenging sensory conditions. Although the study was not restricted to UVH and did not establish fall-prediction validity, it suggests that gait and balance tasks performed with reduced visual input can provide information not captured by routine vestibular laboratory testing.
Structured outcome measurement is also essential for evaluating treatment effectiveness and modifying the rehabilitation program. A Cochrane systematic review found that VRT can improve dizziness, balance, gait, visual stability, and functional performance in unilateral peripheral vestibular dysfunction
[8]. Because individual outcome measures represent different levels of functioning, treatment response should not be determined solely by symptom reduction or normalization of a vestibular laboratory measure. Evaluation should integrate symptoms, body functions, activity, participation, and patient-centered goals.
In an RCT of patients with chronic peripheral vestibular hypofunction, Tanaka et al.
[70] used the functional gait assessment (FGA), dynamic gait index (DGI), and DHI to evaluate a supervised home-based VRT program. Compared with usual physician care, the intervention produced greater improvements in gait performance and dizziness-related disability. Although the study population was not limited exclusively to UVH, it provides indirect support for using standardized baseline and follow-up measures to evaluate response, identify persistent impairments, and guide modification of exercise content, difficulty, and supervision.
Reassessment should be explicitly linked to clinical decisions. Early reassessment may be used to evaluate symptom tolerance, exercise safety, and the appropriateness of the initial dose. Interim reassessment can identify changes in the predominant impairment, inadequate adherence, insufficient progression, or an emerging therapeutic plateau. At discharge, assessment should determine goal attainment, residual disability, fall risk, and the patient’s ability to continue an appropriate program independently. Follow-up reassessment is warranted when symptoms persist, recovery is incomplete, fall risk remains elevated, or the clinical course fluctuates.
In summary, structured baseline assessment and serial reassessment provide a more complete account of vestibular impairment, symptoms, gaze stability, postural and gait performance, fall risk, and activity and participation in adults with UVH. Findings should be used directly to establish rehabilitation goals, select and prioritize exercise components, adjust dosage and progression, monitor safety, and determine short- and long-term treatment response.
Recommendation 8: Rehabilitation should be individualized according to the predominant modifiable impairments identified through structured assessment, including gaze instability, postural and gait dysfunction, visually induced symptoms, motion sensitivity, fall risk, and restrictions in activity and participation. Treatment priorities should be reassessed and adjusted according to clinical response (Level of evidence: 2b; Recommendation strength: Moderate).
Evidence summary
This recommendation was informed by one systematic review, one qualitative study, and one clinical practice guideline
[14,
46,
47,
74].
Rationale
Patients with UVH vary considerably in their symptoms, functional impairments, and rehabilitation needs. Individuals with the same underlying diagnosis or a similar degree of laboratory-confirmed vestibular loss may differ in functional gaze stability, postural control, gait, tolerance of complex visual environments, motion sensitivity, fall risk, psychological and behavioral responses, and restrictions in daily activities. Rehabilitation should therefore not be prescribed solely according to etiology, disease duration, or an isolated vestibular laboratory finding.
A systematic review and meta-analysis by Karabulut et al.
[46], which included 47 studies, demonstrated a broad spectrum of chronic symptoms in UVH. Chronic dizziness, imbalance, symptoms exacerbated by head movement, visually induced dizziness, worsening in darkness, and oscillopsia occurred with differing frequencies and combinations. Recurrent vertigo, fatigue, cognitive symptoms, and autonomic symptoms were also reported. The findings indicate that chronic UVH cannot be represented adequately by a single uniform functional phenotype and that the impairments most relevant to each patient should be identified individually.
In a qualitative study based on the International Classification of Functioning, Disability and Health (ICF) framework, Karabulut et al.
[47] interviewed 15 adults with chronic UVH. Participants described physical, cognitive, and emotional symptoms, together with difficulties involving driving, darkness, crowded environments, sleep, fear of falling, and social participation. Commonly used patient-reported measures, including the Dizziness Handicap Inventory, Hospital Anxiety and Depression Scale, and EQ-5D-5L, did not fully capture these experiences. These findings support assessment across body function, activity, participation, and relevant personal and environmental factors rather than classification based only on dizziness severity.
The 2022 APTA clinical practice guideline recommends that VRT be individualized according to the patient’s specific impairments, activity limitations, participation restrictions, comorbidities, clinical course, and functional goals
[14]. Patients with movement-related visual blurring, oscillopsia, reduced dynamic visual acuity, or impaired VOR function may require greater emphasis on functional gaze-stabilization training. Those with postural instability, gait dysfunction, or impaired performance under sensory-conflict conditions may require progressive balance, sensory-integration, and task-specific gait training. Graded visual-motion exposure may be considered for patients with visually induced symptoms or excessive visual dependence, whereas individualized habituation exercises may be appropriate when reproducible head or body movements provoke brief and recoverable symptoms.
Visual dependence and psychological or autonomic factors may influence recovery independently of the magnitude of residual peripheral vestibular loss. Cousins et al.
[75] found that excessive visual dependence was associated with greater long-term dizziness-related disability after vestibular neuritis. In a subsequent prospective study, acute visual dependence and autonomic arousal predicted symptomatic recovery, while poorer outcomes were associated with visual dependence, anxiety or depression, and fear of bodily sensations rather than with vestibular reflex measures alone
[74]. These findings support assessment of visual, perceptual, psychological, and behavioral modifiers when symptoms persist or appear disproportionate to laboratory vestibular findings.
A large retrospective cohort of patients with chronic UVH further demonstrated substantial etiologic and clinical heterogeneity, including distinct patterns of onset and progression and frequent coexistence of benign paroxysmal positional vertigo and persistent postural-perceptual dizziness
[47]. Functional phenotyping should therefore complement, rather than replace, etiologic evaluation and differential diagnosis. Persistent positional symptoms, recurrent attacks, prominent visual-motion sensitivity, or disproportionate functional disability may require evaluation for coexisting disorders before the rehabilitation program is intensified or modified.
Fall risk and restrictions in meaningful activities should influence treatment priority and supervision. Patients with previous falls or near-falls, marked postural instability, impaired turning, reduced gait adaptability, or difficulty walking under dual-task or reduced-visual conditions may require earlier safety intervention, greater supervision, assistive-device assessment, and environmental modification. Rehabilitation goals should also address personally relevant activities such as driving, employment, household responsibilities, exercise, and social participation rather than being limited to normalization of laboratory or balance-test results.
Functional phenotyping is intended to identify treatment priorities, not to create mutually exclusive patient categories. A patient may simultaneously have gaze instability, sensory-integration impairment, visual dependence, motion sensitivity, psychological distress, and restricted participation. The relative importance of these impairments may change during recovery. Structured reassessment should therefore be used to revise treatment priorities, exercise content, dosage, progression, and supervision.
In summary, systematic-review, qualitative, observational, and guideline evidence supports substantial heterogeneity in the symptoms and functional consequences of UVH. Identifying the predominant modifiable impairments and patient-centered activity goals provides a clinically coherent basis for individualized VRT. However, direct evidence comparing formal stratification algorithms is lacking, and the proposed domains should be applied flexibly rather than as a fixed classification system.
Recommendation 9: In adults with movement-induced visual blurring, oscillopsia, or difficulty seeing during reading, walking, or head movement, assess functional gaze stability. Use standardized DVA or GST when feasible; use vHIT and bedside head-impulse testing to characterize VOR physiology when clinically indicated (Level of evidence: 2b; Recommendation strength: Moderate).
Evidence summary
The evidence included the APTA guideline, a symptom systematic review, prospective case-control evidence, and a review of dynamic visual testing
[14,
46,
47,
75–
78].Direct evidence comparing alternative assessment strategies remains limited.
Rationale
Functional gaze stability is the ability to maintain clear vision during head movement. It is supported primarily by VOR, together with compensatory saccades, predictive eye movements, and other centrally mediated strategies. Reduced unilateral vestibular input may result in impaired VOR responses and corrective saccades during head movement. Patients may consequently experience movement-induced visual blurring, oscillopsia, or difficulty seeing clearly while reading, walking, driving, or turning the head. Assessment of functional gaze stability can help quantify these limitations and guide the selection and progression of VRT.
A systematic review by Karabulut et al.
[46] found that symptoms exacerbated by head movement occurred in approximately 75% of patients with chronic UVH, whereas oscillopsia was reported in approximately 22%. These findings indicate that movement-related visual symptoms are clinically relevant, although subjective symptom severity does not necessarily correspond directly to the magnitude of laboratory-measured VOR impairment. Symptom history should therefore be interpreted together with functional visual and physiological vestibular measures.
The 2022 APTA clinical practice guideline identifies gaze stability as an important assessment domain and treatment outcome in peripheral vestibular hypofunction
[14]. DVA compares visual performance under static and head-movement conditions and provides a functional measure of the ability to maintain visual clarity during motion. The gaze stability test (GST) evaluates the highest head velocity at which a visual target can be identified accurately. Both measures are functionally relevant but are influenced by the testing protocol, static visual acuity, head velocity, viewing distance, patient attention, and the method used to generate head movement.
Chen et al.
[75] conducted a controlled cross-sectional study comparing gaze-shift DVA during standing and walking in 40 patients with UVH and 40 healthy participants. Patients with UVH demonstrated poorer visual acuity during active gaze shifts and walking. These findings support the discriminative validity of gaze-shift DVA as a functional measure of gaze instability. However, because the study did not evaluate change before and after rehabilitation, it does not establish treatment responsiveness or provide a direct measure of vestibular compensation.
In a randomized double-blind study, Herdman et al.
[37] found that specific vestibular exercises significantly improved DVA in patients with UVH, whereas placebo eye-movement exercises did not produce comparable improvement. Changes in DVA were not closely correlated with changes in subjective oscillopsia, and the improvement was considered to reflect, at least in part, centrally programmed compensatory eye movements rather than normalization of peripheral vestibular function. DVA should therefore be interpreted as a functional outcome rather than as a direct surrogate for peripheral VOR recovery.
Clinical DVA is affected by the characteristics of the head movement. Dannenbaum et al.
[76] found that DVA impairment became more apparent as head-movement frequency increased in patients with UVH, while the association between DVA and the magnitude of caloric weakness was low. Serial testing should therefore use standardized head direction, velocity or frequency, movement amplitude, viewing distance, optotype, baseline visual acuity, and testing conditions
[77].
vHIT and bedside head impulse testing provide complementary physiological information. vHIT quantifies high-frequency semicircular-canal VOR gain and identifies overt and covert corrective saccades. The bedside head impulse test can rapidly identify marked unilateral VOR impairment but is less sensitive to mild deficits and covert saccades. Neither test directly measures visual performance during everyday activity.
Wettstein et al.
[78] found that patients with unilateral peripheral vestibular loss who generated a greater proportion of covert saccades had better DVA performance. Riska et al.
[108] similarly reported that covert saccades were associated with better DVA, gait, and balance performance in patients with UVH. These findings support combined interpretation of DVA and vHIT, but they do not establish corrective saccades as an independently validated treatment target.
Assessment findings may inform exercise selection and progression. Patients with impaired DVA or GST performance and clinically relevant movement-induced visual symptoms may benefit from gaze-stabilization and eye–head coordination exercises. vHIT findings can help characterize residual high-frequency VOR function and compensatory saccade patterns, but exercise prescription and treatment response should not be based on VOR gain alone. During rehabilitation, functional visual performance, symptoms, activity limitations, and task-specific goals should be reassessed together.
Patients with persistent visual symptoms despite near-normal conventional VOR findings should be evaluated for visually induced dizziness, excessive visual dependence, motion sensitivity, ocular disorders, migraine, persistent postural-perceptual dizziness, or other factors that may affect visual stability.
In summary, DVA, GST, vHIT, and bedside head impulse testing provide complementary information about functional visual performance and vestibular physiology. Their combined and clinically contextualized interpretation can help identify the predominant impairment, guide gaze-stabilization training, and monitor functional recovery.
Recommendation 10: Assess postural control, dynamic gait, functional mobility, and fall risk in adults with standing or walking instability, difficult turning or stair negotiation, impaired mobility in darkness or on uneven surfaces, or a history of falls or near-falls (Level of evidence: 2b; Recommendation strength: Strong).
Evidence summary
The evidence included a clinical practice guideline, systematic review, and randomized studies using balance and gait outcomes
[8,
14,
69,
70]. Direct evidence that assessment itself improves clinical outcomes is limited. However, postural control, dynamic gait, mobility, and fall risk are central impairments and treatment outcomes in UVH, and their assessment is necessary for individualized exercise prescription and safe rehabilitation. The strong recommendation reflects the clinical importance, low burden, and safety implications of assessment rather than high-certainty comparative evidence.
Rationale
UVH may impair vestibular symmetry, sensory integration, postural control, and gait adaptability. Patients may experience instability while standing, walking, turning, negotiating stairs, or moving under conditions of reduced visual input or unreliable somatosensory information. Deficits may be minimal during sitting or level straight-line walking but become apparent during head movement, changes in support surface, rapid turning, obstacle negotiation, or dual-task activity. Assessment of balance, dynamic gait, and fall risk is therefore important for identifying functional limitations, determining treatment priorities, and ensuring the safety of VRT.
The 2022 APTA clinical practice guideline identifies postural stability, gait, functional mobility, and fall risk as important assessment and outcome domains in peripheral vestibular hypofunction. Vestibular laboratory tests alone do not characterize the patient’s safety during standing and walking and cannot replace assessment of falls, use of mobility aids, or performance in visually and environmentally challenging situations. Assessment should be selected according to the individual clinical presentation rather than through a fixed battery applied to every patient.
The Cochrane review of 39 randomized controlled trials found that VRT improved dizziness, balance, mobility, and functional performance in unilateral peripheral vestibular disorders
[8]. This evidence supports balance and gait as clinically important treatment outcomes, although it does not directly establish that any particular assessment strategy improves prognosis. Establishing baseline functional performance nevertheless provides a reference for exercise selection, treatment progression, and evaluation of response.
Dynamic gait tests assess the ability to adapt walking to changes in speed, head movement, turning, obstacles, and stairs. In a randomized controlled trial of patients with chronic peripheral vestibular hypofunction, Tanaka et al.
[70] used the Functional Gait Assessment (FGA) as the primary outcome and the Dynamic Gait Index (DGI) and Dizziness Handicap Inventory as additional outcomes. A supervised home-based VRT program produced greater improvement in gait and dizziness-related disability than usual physician care. Because the population was not restricted exclusively to UVH, these findings provide indirect evidence supporting the use of standardized gait measures for monitoring rehabilitation.
Lilios et al.
[69] randomized 81 patients with chronic UVH to adaptation, habituation, or combined exercise programs and assessed outcomes at baseline and during the 8-week intervention using measures that included the FGA and Mini-Balance Evaluation Systems Test. All groups improved, while the combined program produced faster or greater improvement in selected measures of static balance, dynamic postural stability, and perceived disability. These findings support serial assessment of different balance and gait domains and adjustment of treatment when recovery is uneven across domains.
Fall-risk assessment should be multifactorial. It should include falls and near-falls, the circumstances in which they occurred, use of mobility aids, visual impairment, peripheral sensory loss, muscle weakness, medication exposure, neurological and musculoskeletal comorbidities, environmental hazards, fear of falling, and the patient’s level of activity. Functional tests such as the FGA, DGI, Timed Up and Go test, gait speed, tandem walking, turning, walking with head movements, and dual-task walking may contribute useful information, but no single test adequately predicts falls in all patients with UVH.
When routine testing does not reflect the patient’s reported difficulties, assessment may be extended to conditions involving reduced visual input, compliant or uneven surfaces, head movement, rapid turning, obstacle negotiation, or dual-task performance. Such testing should be undertaken with appropriate guarding and safety precautions.
Balance, gait, and fall risk should be reassessed during rehabilitation. Early reassessment can identify poor exercise tolerance or emerging safety concerns. Interim reassessment can guide progression of balance and gait tasks, whereas assessment at discharge should address residual fall risk, attainment of functional goals, community mobility, and the ability to exercise safely and independently. New falls, a marked deterioration in balance, or neurological findings inconsistent with the expected course of UVH should prompt temporary suspension of routine exercise and medical reassessment.
In summary, assessment of postural control, dynamic gait, and fall risk is essential in adults with UVH who report instability, mobility limitations, or falls. Findings should be used to prioritize treatment, determine the required level of supervision, select safety strategies and mobility aids, and evaluate the functional effects of VRT.
Recommendation 11: Assess patient-reported disability and psychological or behavioral factors relevant to rehabilitation, including activity and participation limitations, balance confidence, fear of falling, anxiety, depression, avoidance behavior, and quality of life (Level of evidence: 2b; Recommendation strength: Moderate).
Evidence summary
The evidence included guidelines, consensus evidence, systematic and qualitative research, cohort and cross-sectional studies, and intervention studies
[35,
74,
79–
84].
Rationale
The burden of UVH is not determined solely by the magnitude of peripheral vestibular loss. Patients may experience dizziness-related disability, reduced balance confidence, fear of falling, restricted activity and participation, anxiety, depression, and avoidance of symptom-provoking activities. These factors may influence daily functioning, exercise tolerance, adherence, and the perceived effect of treatment and should therefore be included in a comprehensive rehabilitation assessment.
A qualitative study of adults with chronic UVH identified a broad range of physical, cognitive, emotional, and participation-related consequences, including difficulty driving, disturbed sleep, intolerance of crowded or visually complex environments, fear of falling, and reduced social activity
[80]. Commonly used patient-reported outcome measures (PROMs), including DHI, hospital anxiety and depression scale (HADS), and EQ-5D-5L, captured only part of the patients’ experiences. Assessment should therefore combine validated questionnaires with direct enquiry about the activities and life roles that matter most to the individual.
Clinically relevant anxiety or depressive symptoms may occur in a subset of patients with chronic UVH. Their presence does not imply that vestibular symptoms lack an organic basis. Psychological distress, fear of falling, and activity avoidance may coexist with persistent peripheral vestibular impairment and may amplify disability or restrict participation. The purpose of screening is to identify potentially modifiable barriers to recovery and rehabilitation, rather than to attribute the patient’s symptoms solely to psychological causes.
PPPD should be considered when dizziness, unsteadiness, or non-spinning vertigo persists on most days for at least 3 months and is exacerbated by upright posture, movement, or complex visual stimuli
[35]. Duration alone is insufficient for diagnosis, and all Bárány Society criteria must be fulfilled. PPPD may be precipitated by a peripheral vestibular disorder and may coexist with residual UVH; the two conditions should not be regarded as mutually exclusive.
Psychological and behavioral factors may also modify treatment response. In a real-world observational study, Kim et al.
[81] found that individualized VRT improved DHI and Vestibular Disorders Activities of Daily Living scores, whereas higher baseline HADS scores were associated with less favorable outcomes. This association does not establish causality but supports assessment of psychological distress as a potential prognostic and treatment-modifying factor.
Prospective evidence after vestibular neuritis further indicates that acute visual dependence and autonomic arousal may predict subsequent dizziness-related disability
[74]. These findings suggest that persistent symptoms may reflect interactions among residual vestibular impairment, visual dependence, perceptual processing, psychological distress, and behavioral responses rather than peripheral vestibular function alone.
Evidence from chronic dizziness and PPPD populations suggests that patient education, graded exposure, psychologically informed rehabilitation, or cognitive behavioral interventions may provide additional benefit in selected patients
[82,
83]. Because these studies were not restricted to UVH, they should be regarded as indirect evidence. Patients with marked, persistent, or worsening psychological symptoms, substantial avoidance, or major impairment in daily function should be considered for multidisciplinary assessment.
Adherence to home exercise may be affected by motivation, symptom provocation, competing time demands, associated impairments, inadequate understanding of the exercises, lack of professional feedback, and psychosocial factors
[84]. Observational evidence also suggests that greater exercise participation and adherence are associated with better functional outcomes
[79], although such associations do not prove a causal effect. Assessment of treatment expectations, confidence, practical barriers, and available support can therefore help determine the appropriate exercise dose, educational approach, and frequency of supervision.
Patient-reported and psychological measures should be selected according to the clinical concern and should not be applied as a fixed battery to every patient. Suitable measures may include the DHI or Vestibular Disorders Activities of Daily Living Scale for perceived disability, the Activities-specific Balance Confidence Scale or Falls Efficacy Scale–International for confidence and fear of falling, HADS, Generalized Anxiety Disorder-7, or Patient Health Questionnaire-9 for psychological screening, and an appropriate generic or disease-specific quality-of-life measure. Screening scores should not be interpreted as psychiatric diagnoses and should be followed by clinical assessment when abnormal.
In summary, patient-reported outcomes and psychological and behavioral assessment complement vestibular laboratory, balance, and gait testing by capturing the lived burden of UVH and barriers to rehabilitation. The findings should be used to establish patient-centered goals, tailor exercise and supervision, support graded return to meaningful activities, and identify patients who may benefit from education, psychologically informed treatment, or specialist referral.
3.4 How should VRT be formulated and delivered?
Recommendation 12: VRT should combine professional supervision with regular home exercise. Patients should receive clear written instructions, supplemented by video demonstrations when appropriate (Level of evidence: 1b; Recommendation strength: Strong).
Evidence summary
The evidence included a guideline, diagnostic consensus, randomized trials, and evidence summaries supporting supervised and individualized home-based VRT
[10,
14,
70,
85–
88].
Rationale
The effectiveness of VRT depends not only on the exercises selected but also on appropriate clinical assessment, individualization of the program, timely progression, and sustained adherence. Most vestibular exercises require frequent and repeated practice in daily life; treatment limited to brief clinic-based sessions is unlikely to provide an adequate training dose. Conversely, an entirely self-directed home program may result in inappropriate exercise selection, insufficient or excessive loading, poorly controlled symptom provocation, incorrect technique, or delayed progression.
The 2022 APTA clinical practice guideline strongly recommends supervised vestibular physical therapy for individuals with unilateral or bilateral peripheral vestibular hypofunction. Supervision should be understood as professional assessment, prescription, monitoring, and modification of treatment rather than a requirement that every exercise session be completed in the clinic. The Bárány Society consensus on acute unilateral vestibulopathy or vestibular neuritis is principally a diagnostic consensus and should be regarded as contextual rather than direct evidence for a specific model of VRT delivery
[10]. Evidence summaries also support the involvement of appropriately trained health professionals in assessment, exercise prescription, progression, and safety monitoring
[85].
Evidence regarding the superiority of supervised over unsupervised rehabilitation is not entirely uniform. A systematic review of randomized trials found that most studies favored supervised VRT for dizziness, balance, or emotional outcomes, although methodological limitations prevented a definitive conclusion that supervision was consistently superior to all unsupervised approaches. These findings support access to professional supervision while allowing the frequency and mode of contact to be adapted to the patient’s needs, risks, preferences, and available resources.
Lilios et al.
[86] compared two individualized 6-week home-based programs in patients with chronic UVH. Both groups underwent weekly review and modification of their exercises, while one group received additional structured telephone support twice weekly. Additional remote support was associated with better clinical outcomes and greater adherence. The study therefore supports the value of regular professional contact and feedback rather than implying that all home exercise without frequent contact is ineffective.
Wang et al.
[87] compared a fixed VRT program with a short-term, professionally supervised, individualized program in patients with decompensated recurrent peripheral vertigo. Both interventions improved clinical outcomes, but the individualized program produced earlier improvements in dizziness-related disability, anxiety, postural control, and balance confidence. Because the population was not restricted to UVH, the study provides indirect evidence that matching exercise content and progression to the patient’s current impairments may be more important than simply extending treatment duration.
Structured written materials can improve the consistency and reproducibility of home training. In a randomized trial involving patients with chronic peripheral vestibular hypofunction, Tanaka et al.
[70] found that a booklet-based home program combined with weekly professional review improved gait and dizziness-related disability compared with usual medical care. Kellerer et al.
[88] similarly found that patients who received individualized expert instructions in addition to a home-exercise booklet achieved greater improvement in dizziness-related disability than patients who used the booklet without specific professional guidance. These findings indicate that educational materials are most useful when they are linked to an individualized prescription rather than provided as a generic list of exercises.
More recent randomized evidence suggests that customized video demonstrations may further facilitate home exercise. Compared with booklet-based instructions, customized web video-based VRT produced greater improvement in dynamic gait, although both delivery formats improved dizziness-related disability. Video materials may be particularly useful when an exercise is difficult to describe using static images, but they should complement rather than replace professional assessment and individualized progression.
Written or video instructions should clearly describe exercise technique, frequency and duration, progression criteria, the expected range and duration of symptom provocation, safety precautions, and circumstances in which training should be reduced or stopped. Materials should correspond to the individual prescription and should not consist solely of a standardized exercise list without guidance on selection or progression.
Supervision may be delivered through face-to-face appointments, telephone calls, video consultations, or other telerehabilitation methods. The principal purposes are to verify exercise performance, review symptoms and adherence, adjust dosage and difficulty, manage safety risks, and identify clinical changes requiring diagnostic reassessment. The frequency and intensity of supervision should be individualized according to disease stage, fall risk, cognitive and physical capacity, symptom variability, treatment adherence, and the patient’s ability to perform the exercises correctly and safely.
In summary, combining professionally prescribed and periodically supervised VRT with regular home exercise balances individualization, safety, treatment dose, accessibility, and long-term feasibility. Clear written instructions, supplemented by video demonstrations where appropriate, can improve the consistency of home practice and facilitate adherence, but do not replace clinical reassessment and individualized treatment progression. A practical framework for the formulation and delivery of VRT in adults with UVH is summarized in Table 4.
Recommendation 13: For adults with UVH and clinically relevant gaze instability, gaze-stabilization exercises involving active head movement should be prescribed. Voluntary saccadic or smooth-pursuit eye exercises performed with the head stationary should not be prescribed in isolation as gaze-stabilization treatment (Level of evidence: 1b; Recommendation strength: Strong).
Evidence summary
Evidence was derived primarily from the 2022 APTA clinical practice guideline and randomized controlled trials comparing gaze-stabilization exercises involving head movement with eye-movement-only control. The evidence directly supports the use of active head movement and indicates that isolated voluntary saccadic or smooth-pursuit exercises do not improve gaze stability to the same extent
[14,
86,
89,
90]. Direct comparative evidence for selecting among VOR adaptation, substitution, and combined strategies remains limited.
Rationale
Gaze-stabilization exercises address visual instability during head movement through VOR adaptation and compensatory substitution. Adaptation exercises, most commonly VOR×1 (VOR adaptation exercises with one target) and, when appropriate, VOR×2 (VOR adaptation exercises with two target) tasks, use active head movement and retinal slip to promote changes in gaze-stabilizing responses. Substitution exercises use predictive or compensatory, including gaze shifts between targets and remembered-target exercises, to compensate for deficient VOR function.
Randomized trials have shown that gaze-stabilization exercises involving active head movement improve dynamic visual acuity and functional outcomes, whereas voluntary saccadic or smooth-pursuit exercises performed with the head stationary do not provide comparable benefits
[89]. The latter exercises should therefore not be prescribed in isolation for the purpose of restoring gaze stability, nor should they be applied when saccadic or pursuit exercises are used for a separate, specifically identified oculomotor indication.
Adaptation and substitution strategies may be used alone or in combination. Selection should be guided by movement-induced visual symptoms, functional gaze-stability testing, residual vestibular function, task-specific limitations, exercise tolerance, and patient goals rather than by vHIT gain alone. The relative contribution of adaptation and substitution may also change during rehabilitation.
Exercise difficulty may be progressed by modifying head velocity and direction, target distance, body position, visual background, balance demands, and task complexity. However, evidence defining the optimal sequence or rate of progression remains limited. Progression should therefore be individualized according to visual clarity, symptom response, movement quality, and safety
[86,
90].
Recommendation 14: Provide individualized, progressive, and task-specific balance and gait training based on postural control, sensory integration, dynamic gait, functional mobility, and fall-risk findings (Level of evidence: 2b; Recommendation strength: Strong).
Evidence summary
This recommendation was informed by one clinical practice guideline, three randomized controlled trials, one systematic review, and two observational studies
[14,
70,
74,
86,
91]. Evidence supports the inclusion of static and dynamic balance and gait exercises within multimodal vestibular rehabilitation therapy. However, direct evidence comparing individual exercise components or validating a training-selection algorithm based on vestibulospinal reflex measurements remains limited.
Rationale
UVH may impair postural control, sensory integration, and gait adaptability. Deficits may be minimal during quiet standing or level walking but become evident when visual input is reduced, somatosensory information is unreliable, the head is moving, or the task involves turning, obstacle negotiation, stair use, or divided attention. Balance and gait performance reflects the combined contribution of vestibular, visual, somatosensory, musculoskeletal, and cognitive systems; therefore, training should be based on functional assessment rather than on vestibulospinal reflex (VSR) findings alone.
The 2022 APTA clinical practice guideline supports static and dynamic balance exercises as important components of VRT for peripheral vestibular hypofunction. Relevant training domains include control of the center of mass, anticipatory and reactive postural control, multisensory balance training, and task-specific gait practice. Training should target the patient’s predominant impairments and functional limitations rather than follow an identical exercise sequence for all patients.
Randomized studies support the benefits of multimodal rehabilitation. Lilios et al.
[86] reported improvements in balance, gait, and patient-reported outcomes in patients with chronic UVH receiving adaptation, habituation, or combined exercise programs. The combined program produced faster or greater improvement in selected measures of functional gait and dynamic postural control. However, the study did not establish the independent effectiveness of each individual balance or gait exercise.
Tanaka et al.
[70] found that supervised home-based VRT improved the Functional Gait Assessment, Dynamic Gait Index, and dizziness-related disability in patients with chronic peripheral vestibular hypofunction. Because the study population was not restricted exclusively to UVH and the intervention included multiple exercise components, the findings provide indirect support for structured balance and gait training in UVH.
Training should progress from relatively simple and stable tasks to more complex, dynamic, and task-specific activities. Depending on the identified impairment, progression may involve narrowing the base of support, changing the support surface, reducing or conflicting visual input, adding weight shifting or head movements, and advancing to changes in gait speed, turning, stair negotiation, obstacle avoidance, and dual-task walking. Exercise selection and progression should be individualized according to performance, symptom response, fall risk, and functional goals.
Visual-motion exposure may be incorporated when visually induced dizziness or excessive visual dependence is a prominent impairment
[91]. It should be regarded as an impairment-specific component rather than a routine element of every balance program. Observational evidence linking visual dependence with persistent symptoms after vestibular neuritis supports assessment of this factor but does not establish the superiority of a specific sensory-reweighting protocol
[74].
Patients at increased risk of falling should train with appropriate supervision, guarding, assistive devices, and environmental precautions. New falls, marked deterioration in balance, or neurological findings inconsistent with the expected course of UVH should prompt treatment modification and clinical reassessment.
In summary, individualized static and dynamic balance and gait training is an important component of VRT for patients with UVH and functional postural or mobility deficits. Training should address the predominant impairment, progress according to performance and safety, and remain aligned with the patient’s fall risk and meaningful activity goals.
Recommendation 15: For patients with reproducible motion-provoked or visually induced dizziness, individualized habituation exercises or graded visual-motion exposure should be considered according to the specific provoking stimuli. Exercises should induce only mild-to-moderate, transient, and tolerable symptoms, with dosage adjusted according to symptom recovery and the response later that day or on the following day (Level of evidence: 2b; Recommendation strength: Moderate).
Evidence summary
This recommendation was informed by the APTA guideline, systematic and symptom evidence, randomized and intervention studies
[21,
69,
86,
92].
Rationale
Some patients with UVH experience reproducible dizziness, nausea, or unsteadiness during repeated head or body movements or during exposure to moving or visually complex environments. Habituation is a form of symptom-specific exercise in which repeated, controlled exposure to a provoking stimulus is intended to reduce the symptomatic response over time. Visual-motion exposure applies the same general principle using moving visual scenes, optokinetic stimuli, or progressively more complex visual environments.
The 2022 APTA clinical practice guideline describes habituation exercises as repeated exposure to body movements or visual-motion stimuli that provoke mild-to-moderate symptoms. Exercise selection should be based on the individual’s reproducible provoking stimuli, functional limitations, and participation goals. A generic sequence of movements unrelated to the patient’s symptoms is unlikely to provide an appropriately targeted intervention.
Positionally triggered symptoms require appropriate diagnostic evaluation before habituation is prescribed. In particular, brief vertigo provoked by lying down, rolling in bed, looking upward, or other gravity-dependent head positions may indicate benign paroxysmal positional vertigo and should be assessed with appropriate positional testing. Confirmed BPPV should be treated with a canalith-repositioning procedure rather than with habituation exercises as the primary intervention.
In a small randomized preliminary study, Clendaniel
[94] compared habituation with gaze-stabilization exercises in 7 patients with UVH. Both groups showed improvements in self-reported disability, motion sensitivity, and dynamic visual acuity; however, the sample was too small to permit meaningful between-group comparisons. These findings support habituation as a potentially useful component of VRT for patients with motion-provoked symptoms, but do not establish its superiority over, or equivalence to, other vestibular exercise approaches.
Lilios et al.
[69] randomized 81 patients with chronic UVH to adaptation, habituation, or combined adaptation–habituation exercise programs. Most balance and functional outcomes improved across groups, while the combined program produced faster or greater improvement in selected measures of functional gait, dynamic postural control, and perceived disability. These findings support combining exercise components when gaze instability, motion sensitivity, and postural dysfunction coexist, but they do not establish that habituation is required for every patient with UVH.
In a subsequent randomized study, Lilios et al.
[86] prescribed individualized habituation exercises according to head or body movements that provoked symptoms during motion-sensitivity assessment. Exercise difficulty was progressed by changing posture, movement range, duration, and velocity. However, both study groups received a multimodal program comprising adaptation, habituation, balance, and gait exercises, and the primary comparison concerned additional remote supervision. The study therefore supports individualized prescription and progression but does not isolate the specific efficacy of habituation training.
A systematic review of chronic UVH found that symptoms provoked or exacerbated by head movement, visually induced dizziness, worsening in darkness, and postural instability were common clinical features
[92]. These findings provide symptom-based support for identifying patients who may require habituation or graded visual-motion exposure. However, the review did not evaluate the effectiveness of habituation training and should therefore be regarded as indirect evidence for treatment selection.
Visual-motion exposure may be considered when moving scenes, crowds, traffic, scrolling displays, supermarkets, or other visually complex environments provoke clinically relevant symptoms. Randomized studies in unilateral or mixed peripheral vestibular populations suggest that optokinetic or virtual-reality exposure may reduce visually induced dizziness and improve selected functional outcomes. Because these studies were not consistently restricted to well-defined UVH populations, the evidence should be regarded as indirect.
Visual dependence alone should not automatically determine treatment. The clinical relevance of visual dependence should be established by the presence of visually induced symptoms, impaired function in complex visual environments, or findings from appropriate visual-motion or sensory-integration assessment. Persistent visually induced dizziness may also coexist with persistent postural-perceptual dizziness (PPPD). PPPD should be considered when all Bárány Society diagnostic criteria are fulfilled and should not be diagnosed solely from the presence of visual-motion sensitivity or symptoms. Vestibular UVH may coexist.
The initial stimulus should be sufficiently provocative to generate a therapeutic response but should not cause severe or prolonged deterioration. Exercise dosage may be adjusted by changing the number of repetitions, movement velocity, range, body position, duration of exposure, or visual complexity. Mild-to-moderate symptoms that are transient and return toward baseline after exercise may be acceptable. Persistent worsening, prolonged interference with daily activity, or deterioration on the following day indicates that the stimulus or dose should be reduced and the program reassessed.
In summary, individualized habituation or graded visual-motion exposure may be incorporated into VRT when a patient with UVH has reproducible motion-provoked or visually induced symptoms. The provoking stimulus, symptom intensity, recovery pattern, functional relevance, and coexistence of other vestibular disorders should guide exercise selection and progression. Habituation should complement, rather than replace, gaze-stabilization, balance, gait, or other interventions required for the patient’s remaining impairments.
Recommendation 16: As a general minimum reference, prescribe gaze-stabilization exercises at least 3 times daily for a total of at least 12 minutes/day in acute or subacute UVH and at least 20 minutes/day for 4–6 weeks in chronic UVH. Adjust dose and progression according to symptoms, head speed, task difficulty, recovery, adherence, and reassessment findings (Level of evidence: 2b; Recommendation strength: Weak).
Evidence summary
This recommendation was informed by one clinical practice guideline and three original studies
[14,
86,
90,
94]. The recommended dose should be interpreted as a minimum reference dose derived from clinical practice guideline synthesis and feasible dosing schedules used in intervention studies. Direct evidence comparing different frequencies, session durations, or total daily doses of gaze-stabilization exercise is limited. Therefore, this recommendation should not be interpreted as indicating that the stated dose is superior to all other dosing regimens.
Rationale
Gaze-stabilization exercises require repeated practice to provide sufficient stimuli for vestibulo-ocular reflex adaptation, substitution, and other compensatory eye–head strategies. However, most clinical studies have evaluated the overall effectiveness of gaze-stabilization exercises rather than directly comparing alternative exercise frequencies, session durations, or cumulative daily training times. Specific dosage recommendations are therefore based mainly on guideline synthesis of existing intervention protocols and expert interpretation of clinical feasibility.
The 2022 APTA clinical practice guideline recommends that individuals with acute or subacute UVH perform gaze-stabilization exercises at least 3 times daily for a total of at least 12 minutes per day. For individuals with chronic UVH, the guideline recommends gaze-stabilization exercises 3–5 times daily for a total of at least 20 minutes per day for 4–6 weeks
[14]. These values should be regarded as minimum reference doses rather than the only effective or optimal prescription.
Previous interventional research has shown that gaze-stabilization exercises can improve dynamic visual acuity and VOR-related functional performance in patients with UVH
[94]. This supports the need for regular and repeated practice but does not establish that 12 or 20 minutes per day is superior to other training doses.
Recent individualized VRT studies commonly used home programs divided into several short sessions each day. Lilios et al.
[86] used a 6-week individualized home-based program that included VOR × 1, VOR × 2, habituation, balance, and gait exercises. This supports the feasibility of frequent, short, and regular home practice, but because the reported training time reflected a multimodal VRT program, it cannot be used to define the independent dose of gaze-stabilization exercise.
Lee et al.
[90] studied adults with acute unilateral peripheral vestibular dysfunction using exercise programs performed multiple times daily and observed improvement in symptoms and balance-related outcomes across different VRT approaches. This provides feasibility evidence for repeated daily training in the acute stage, but it does not directly compare different total durations of gaze-stabilization exercise.
Exercise dose should be adjusted according to symptom tolerance, residual vestibular function, movement quality, head velocity, body position, visual background, and functional goals. The same number of minutes may represent different training loads depending on head speed, range of motion, stance condition, visual complexity, and task demands. As the patient improves, progression should usually emphasize increasing head velocity, changing target distance, altering posture or gait conditions, and increasing visual or task complexity rather than simply extending exercise duration.
If training causes severe or prolonged symptom exacerbation, the exercise intensity, duration, or environmental complexity should be reduced while maintaining regular practice within a tolerable range. Conversely, if symptoms are minimal and performance is stable, the task should be progressed to maintain an adequate training stimulus.
In summary, a total daily duration of at least 12 minutes for acute or subacute UVH and at least 20 minutes for chronic UVH over 4–6 weeks may be used as a minimum reference dose for gaze-stabilization exercises. Because direct dose-comparison evidence is limited, the actual prescription should be individualized and modified according to symptom response, functional progress, and serial reassessment.
Recommendation 17: For acute or subacute UVH, individualize low-intensity, progressive static and dynamic balance and safe-walking practice according to symptom tolerance, activity limitation, and fall risk; no fixed minimum daily dose is established. For chronic UVH, approximately 20 minutes/day for at least 4–6 weeks is a reasonable minimum reference when tolerated (Level of evidence: 2b; Recommendation strength: Weak).
Evidence summary
The evidence included a clinical practice guideline, randomized and intervention studies, and observational evidence
[8,
36,
39,
40,
64–
66,
86,
95]. Balance-training efficacy is supported, but direct dose-comparison evidence is sparse.
Rationale
Balance and gait training are important components of VRT for improving postural stability, mobility, and activity safety in adults with UVH. However, few studies have directly compared alternative exercise frequencies, daily durations, or treatment periods. Dosage should therefore be determined according to disease stage, functional impairment, task difficulty, exercise tolerance, and safety rather than by time alone.
The 2022 APTA clinical practice guideline states that adults with chronic UVH may perform static and dynamic balance exercises for a minimum of 20 minutes daily for at least 4–6 weeks. This recommendation represents a minimum reference dose derived from the intervention protocols available to the guideline panel and should not be interpreted as evidence that the same dose is optimal for every patient. The guideline does not establish a corresponding minimum dose for gait training.
For acute or subacute UVH, the APTA guideline supports the use of static and dynamic balance exercises but concludes that the available evidence is insufficient to recommend a specific dose. Evidence from early-rehabilitation studies suggests that sitting, standing, balance activity, and safe ambulation can be introduced once urgent central causes have been excluded, severe autonomic symptoms are controlled, and the patient is medically stable enough to participate
[8,
36,
39,
40,
64–
66]. However, differences in symptom severity, physical capacity, and fall risk preclude a uniform daily duration.
Initial training in the acute or subacute stage should therefore consist of short, manageable tasks performed with appropriate guarding or assistance. Duration, repetition, and task demands may be increased as symptoms become more tolerable and postural control improves. The aim is to restore safe movement and mobility without producing excessive or prolonged symptom exacerbation.
Tanaka et al.
[95] compared different frequencies of professionally supervised rehabilitation in patients with chronic UVH. Patients receiving repeated intervention demonstrated improvement in the Timed Up and Go test, Dynamic Gait Index, and Functional Gait Assessment, whereas the Activities-specific Balance Confidence Scale did not change significantly. As this was a case-control study primarily examining supervision frequency, it supports continued treatment and reassessment but does not establish a specific daily exercise dose.
Lilios et al.
[86] evaluated a 6-week individualized home-based program comprising adaptation, habituation, balance, and gait exercises, with additional remote supervision provided to one group. Improvements in balance, gait, and patient-reported outcomes support the feasibility of sustained multimodal rehabilitation over approximately 6 weeks. However, because the intervention combined several exercise components, the study cannot determine the independent daily dose required for balance or gait training.
Training load is determined not only by duration but also by task difficulty. Prolonged practice of a task that no longer challenges postural control may provide limited additional benefit. Progression may involve modifying the base or surface of support, visual input, head movement, movement speed, turning, obstacle negotiation, stair use, or dual-task demands. These variables should be adjusted according to performance, symptom response, fall risk, and functional goals.
For patients at high risk of falling, exercise dosage and progression may need to be more conservative, with closer supervision, environmental safeguards, or assistive devices. Conversely, patients who perform the prescribed tasks safely and without sufficient postural challenge may require progression of task complexity rather than a simple increase in training time.
In summary, at least 20 minutes of static and dynamic balance exercise per day for at least 4–6 weeks may be used as a minimum reference dose for chronic UVH. No uniform balance or walking-training dose can currently be recommended for acute or subacute UVH. Exercise prescription should remain individualized according to disease stage, functional performance, symptom tolerance, and safety.
3.5 When should VRT be modified, suspended, or discontinued?
Recommendation 18: Transition from active supervised rehabilitation to maintenance or discharge when patient-centered functional goals have been achieved, symptoms and function have stabilized, the patient can exercise safely and independently, or progress has plateaued despite an adequate, appropriately progressed, and sufficiently adhered-to program. Temporarily suspend treatment and arrange medical reassessment when new red flags, marked or prolonged deterioration, or increased falls occur. Assess and address modifiable barriers before terminating treatment for nonadherence (Level of evidence: 5; Recommendation strength: Moderate).
Evidence summary
This recommendation was informed by one updated clinical practice guideline and its 2016 predecessor, together with one systematic review
[8,
14,
67]. The 2022 APTA guideline rated the evidence supporting decisions to stop VRT as level II and issued a moderate recommendation, based largely on extrapolation from the methods and findings of intervention studies rather than on trials directly comparing alternative stopping criteria
[14]. Because no study has directly validated a specific stopping rule or discharge threshold, the present guideline development group assigned level 5 evidence under the OCEBM 2009 framework.
Rationale
The duration of VRT should not be determined solely by a predetermined number of weeks or treatment sessions. Etiology, disease stage, residual vestibular function, comorbidities, rehabilitation goals, and functional demands vary substantially among patients with UVH. Decisions regarding discharge should therefore be based primarily on whether clinically relevant, modifiable impairments remain and whether continued skilled treatment is likely to provide meaningful additional benefit.
The 2022 APTA clinical practice guideline identifies achievement of primary goals, resolution or substantial improvement of symptoms, normalization or meaningful recovery of balance and vestibular-related function, and a plateau in progress as possible reasons for stopping VRT
[14]. Similar principles were included in the 2016 guideline
[67]. These criteria should be interpreted in relation to functional recovery rather than complete normalization of every vestibular laboratory measure.
Some patients may continue to demonstrate abnormal physiological vestibular findings despite having regained safe mobility, work capacity, independence in daily activities, and participation in personally meaningful tasks. In such circumstances, supervised treatment may be discontinued and the patient may transition to an independent maintenance program when further skilled supervision is no longer required.
A plateau should not be concluded from a brief period without improvement. Before determining that further treatment is unlikely to provide meaningful benefit, the clinician should confirm that the patient has received an adequate trial of exercises matched to the predominant impairments, has achieved reasonable adherence, and has undergone serial reassessment and appropriate modification of exercise content, dose, progression, and supervision.
When repeated assessment shows no clinically meaningful change despite these measures, the diagnosis, etiology, exercise prescription, adherence, comorbidities, and psychological or behavioral factors should be reconsidered. If no remediable factor is identified and further benefit from the current program is unlikely, supervised treatment may be discontinued, transitioned to maintenance exercise, or replaced by another management strategy.
The Cochrane systematic review demonstrated that VRT can improve dizziness, balance, mobility, and activities of daily living in unilateral peripheral vestibular disorders
[8]. Although the review did not evaluate stopping criteria, it supports the use of symptom and functional outcomes rather than treatment duration alone when determining whether rehabilitation should continue.
Nonadherence should not automatically result in discharge when first identified. Clinicians should assess whether the patient has difficulty understanding or performing the exercises, excessive symptom provocation, competing work or family demands, inadequate feedback, low confidence or motivation, psychological distress, or insufficient social support. Exercise simplification, dose adjustment, additional education, alternative delivery methods, or closer supervision should be considered before treatment is discontinued.
The patient may choose to stop VRT after receiving appropriate information about the potential benefits and consequences of continuing or discontinuing treatment. Treatment may also need to end when an acute illness, serious comorbidity, or other health condition prevents safe participation. The reason for discontinuation should be documented, together with any advice regarding self-management, follow-up, or re-entry into rehabilitation.
Clinical deterioration should be distinguished from the mild, transient, and recoverable symptom provocation that may occur during appropriately dosed vestibular exercises. New neurological findings, sudden or fluctuating auditory symptoms, recurrent falls, marked deterioration in balance, or other features inconsistent with the expected course of UVH should prompt temporary suspension of the exercise program and medical reassessment rather than routine discharge.
In summary, discharge from supervised VRT should be based on goal attainment, the continuing need for skilled intervention, and serial evidence of treatment response. A persistent plateau after adequate and appropriately modified rehabilitation may justify transition to maintenance exercise or another management strategy. Patient choice and inability to participate are legitimate reasons for terminating the current episode of care, whereas clinical deterioration or new warning signs require suspension and diagnostic reassessment.
3.6 What is the role of adjunctive and emerging technologies?
Recommendation 19: (a) Where appropriate technology, professional guidance, and safety provisions are available, virtual reality may be used selectively as an adjunct to conventional VRT; (b) For clinically stable adults with UVH who can perform home exercises safely, telerehabilitation and mobile applications may be used to support VRT delivery, monitoring, and feedback. In-person or hybrid care should be used when direct examination or closer safety supervision is required; (c) Sensory-augmentation biofeedback may be considered as an adjunct to balance training in selected patients with persistent postural-control impairment despite appropriately prescribed conventional VRT (Level of evidence: 2b; Recommendation strength: Weak).
Evidence summary
This recommendation was informed by one clinical practice guideline, two systematic reviews, five randomized controlled trials, two cohort studies, one cross-sectional study, one intervention study, and one narrative review
[86,
96–
106]. The evidence suggests that virtual reality, telerehabilitation, mobile technologies, and sensory-augmentation systems are feasible and may improve selected short-term outcomes. However, the studies are heterogeneous in patient population, technology, comparator, treatment content, and outcome measurement. Evidence that these technologies provide clinically important benefits beyond well-delivered, individualized conventional VRT remains inconsistent.
Rationale
Virtual reality, telerehabilitation, mobile applications, and sensory-augmentation biofeedback may facilitate graded exposure, contextual balance practice, home-exercise monitoring, remote feedback, and access to specialist care. These technologies should be regarded as methods of delivering or augmenting established VRT principles rather than as independent replacements for gaze-stabilization, habituation, balance, and gait training.
(a) Virtual reality
Virtual reality (VR) can provide controlled and repeatable visual-motion and postural environments with adjustable task complexity. It may be particularly relevant for patients with visually induced dizziness, intolerance of complex visual environments, or difficulty maintaining balance during multisensory tasks.
A meta-analysis by Chu et al.
[97] included 20 studies involving 968 participants and found additional improvement in several DHI outcomes with VR-assisted therapy. However, balance-confidence outcomes were not consistently superior, and substantial heterogeneity existed across diagnoses, devices, exercise protocols, and treatment doses. The findings therefore support possible additional benefit but do not establish universal superiority over conventional VRT.
In a randomized trial involving patients with acute unilateral vestibulopathy, both head-mounted VR and conventional VRT improved dizziness-related disability and balance confidence
[98]. Changes in total DHI, symptom severity, and adherence did not differ significantly between groups, although selected DHI and balance-confidence outcomes improved more rapidly with VR. VR should therefore be considered broadly comparable to conventional delivery, with possible advantages in selected outcomes rather than as a generally superior intervention.
Studies in older adults with chronic dizziness have also reported improvements in dizziness, balance, and mobility with VR-assisted rehabilitation
[99]. Because these populations were not restricted to objectively confirmed UVH, their findings provide indirect evidence.
Meldrum et al.
[100] found that VR-based balance exercises were not superior to conventional balance exercises in adults with unilateral peripheral vestibular loss. Both approaches improved clinical outcomes, while participants rated virtual reality as more enjoyable and less difficult or tiring. These findings support virtual reality as an acceptable and potentially engaging delivery method, but not as a replacement for conventional VRT.
VR may provoke visual discomfort, nausea, excessive symptom exacerbation, or postural instability. Device selection, visual-motion intensity, exposure duration, supervision, and fall precautions should therefore be individualized, particularly in patients with severe visual-motion sensitivity or elevated fall risk.
(b) Telerehabilitation and mobile applications
Telerehabilitation and mobile applications can support exercise instruction, adherence monitoring, symptom recording, professional feedback, and timely modification of home programs. They do not replace the need for appropriate diagnosis, baseline assessment, individualized prescription, and safety screening.
A systematic review by Grillo et al.
[101] included seven studies of telerehabilitation for dizziness and reported improvement in dizziness severity, disability, anxiety, and selected functional outcomes. However, diagnoses, intervention formats, levels of supervision, and outcome measures varied substantially, limiting direct application to all patients with UVH.
Lilios et al.
[86] compared two individualized 6-week home-based programs in patients with chronic UVH. Both groups underwent weekly review and exercise modification, while one group received additional structured telephone support twice weekly. The additional-support group demonstrated better adherence and greater improvement in the Mini-BESTest, Functional Gait Assessment, and DHI. The study supports structured remote contact as an adjunct to periodic clinical reassessment rather than as a complete substitute for professional evaluation.
A multi-institutional retrospective study found improvements in DHI scores after in-clinic, telehealth, and hybrid VRT, without a significant difference in the pattern of change among delivery modes
[102]. Other small intervention and cohort studies reported improvements in balance, dizziness-related disability, balance confidence, and anxiety following remotely delivered gaze-stabilization and balance exercises
[103,
104]. These findings primarily support feasibility; they do not establish equivalence or superiority.
Mobile applications may improve the consistency of instructions, facilitate exercise recording, and provide clinicians with performance or symptom data. However, evidence supporting the independent clinical efficacy of a particular application remains limited. App-based tools should therefore support an individualized VRT prescription rather than provide an unsupervised generic exercise program.
Telerehabilitation is most appropriate for patients who are clinically stable, can understand and perform the prescribed exercises, have adequate technology access, and can exercise safely at home. Patients with uncertain diagnosis, marked fall risk, cognitive or sensory limitations, inadequate support, or new or worsening symptoms should receive in-person assessment or a hybrid model.
(c) Sensory-augmentation biofeedback
Sensory-augmentation systems provide additional information about trunk tilt, center-of-mass position, or postural error through vibrotactile, electrotactile, auditory, or visual feedback. Their purpose is to supplement information available during balance training rather than to restore vestibular function or replace multisensory balance practice.
The 2022 APTA guideline identifies augmented sensory feedback as a possible technique for addressing specific activity limitations. Nevertheless, the available studies are generally small and use heterogeneous devices, feedback parameters, and treatment protocols.
In a randomized preliminary study of eight participants with unilateral vestibular disorders, Bao et al.
[105] found that vibrotactile sensory augmentation was associated with greater improvement in balance confidence and selected standing-balance tasks. Several other balance and gait outcomes showed numerically greater but non-significant improvement. The findings are hypothesis-generating and require confirmation in adequately powered trials.
An RCT evaluating an electronic balance-assistance device in patients with acute peripheral vestibular injury reported greater short-term improvement in DHI and Sensory Organization Test outcomes when device-based training was added to medication
[106]. However, the population included different acute peripheral disorders, and the control group did not receive an equivalent dose of conventional VRT. The study therefore does not establish superiority over standard rehabilitation.
Available reviews indicate that wearable sensors and sensory-feedback systems have potential for real-time postural feedback and individualized training but that optimal patient selection, device parameters, dosage, carry-over, long-term effectiveness, attentional demands, and cost-effectiveness remain uncertain
[96]. Sensory augmentation should therefore be used selectively, preferably in experienced centers and in patients with persistent balance impairment who may benefit from additional external feedback.
VR, telerehabilitation, mobile applications, and sensory-augmentation biofeedback may extend the delivery and adaptability of VRT, but current evidence primarily supports feasibility, acceptability, and selected short-term benefits. Their use should be guided by the patient’s predominant impairment, ability to use the technology, safety risk, access, preferences, and cost, while preserving professional assessment, individualized exercise prescription, and periodic reassessment.
4 Limitations and Future Directions
4.1 Limitations
This guideline was developed on the basis of the best available evidence, expert judgment, and input from patients and caregivers to provide practical guidance on the assessment and VRT of adults with UVH. Nevertheless, limitations in both the evidence base and the guideline-development process should be considered when applying the recommendations to individual patients and clinical settings.
First, high-quality evidence primarily supports the overall effectiveness of VRT, whereas direct comparisons of specific exercise components, sequencing strategies, dosages, progression criteria, supervision models, and stopping rules remain limited. Several dosage recommendations are derived from guideline synthesis of previously studied protocols rather than formal dose–response trials. Many available studies have small samples, heterogeneous interventions and comparators, inconsistent outcome measures, and relatively short follow-up periods. These limitations restrict quantitative synthesis and the assessment of long-term effectiveness. Consequently, some recommendations—particularly those concerning dosage, combinations of exercise modules, and duration of care—necessarily incorporate indirect evidence and expert judgment. The APTA guideline similarly identified exercise dosage, treatment progression, patient subgroups, and technology-assisted delivery as important priorities for further research.
Second, UVH is etiologically, temporally, and functionally heterogeneous. Acute unilateral vestibulopathy, stable unilateral Ménière disease with persistent hypofunction, vestibular schwannoma (VS) and its treatment, labyrinthectomy, and temporal-bone trauma may all result in unilateral vestibular loss. However, the affected vestibular end organs, residual function, potential for peripheral recovery, capacity for central compensation, comorbidities, and rehabilitation needs may differ substantially. Some supporting studies included mixed peripheral vestibular populations rather than patients meeting uniform UVH criteria, and few studies adequately stratified participants according to etiology, disease stage, or predominant functional impairment. The recommendations are therefore primarily applicable to the broader UVH population and require adaptation for specific etiologies, active disease states, and complex comorbidities.
Third, no widely accepted and validated core outcome set is currently available for UVH rehabilitation. Existing studies use diverse measures, including the DHI, Activities-specific Balance Confidence Scale, Vestibular Disorders Activities of Daily Living Scale, FGA, DGI, Mini-Balance Evaluation Systems Test, dynamic visual acuity, video head impulse testing, and caloric testing. These measures represent different levels of functioning and should not be regarded as interchangeable. Patient-reported improvement, functional performance, and physiological vestibular recovery may not occur in parallel. Future evaluations should therefore avoid reliance on a single symptom scale or laboratory measure and should encompass symptoms, functional gaze stability, postural and gait performance, falls, activity and participation, quality of life, and individualized patient goals.
Fourth, although patients and caregivers contributed to the development of this guideline, the breadth and representativeness of their participation were necessarily limited. Outcomes that matter to patients extend beyond reduction in dizziness and include driving, return to work or education, mobility in darkness, tolerance of complex visual environments, sleep, fear of falling, and social participation. Commonly used PROMs capture only part of this lived experience. In addition, access to vestibular testing, appropriately trained rehabilitation professionals, telerehabilitation infrastructure, and assistive technologies varies across regions and levels of care. Evidence concerning implementation, cost-effectiveness, resource use, and health equity remains insufficient.
Finally, VR, telerehabilitation, mobile applications, wearable sensors, and sensory-augmentation or biofeedback technologies show promise for improving access, engagement, and real-time feedback. However, existing studies are heterogeneous in patient populations, equipment, intervention content, and outcomes, and evidence concerning durability, adverse effects, cost-effectiveness, and real-world scalability remains limited. These approaches should currently be regarded as adjuncts to conventional VRT rather than substitutes for etiological evaluation, in-person safety assessment when required, individualized prescription, and appropriate professional supervision.
4.2 Future directions
Future research should prioritize adequately powered multicenter randomized controlled trials and pragmatic effectiveness studies using standardized definitions of UVH, disease stage, and functional phenotype. Studies should directly compare exercise components, sequencing, dosage, progression strategies, supervision frequency, and treatment duration. In addition to short-term symptom and balance outcomes, trials should evaluate falls, driving and work-related function, participation, adherence, adverse events, maintenance of benefit, and recurrence or re-entry into rehabilitation.
Etiology-, stage-, and phenotype-informed rehabilitation models should be developed and prospectively validated. Potential predictors and modifiers of response include residual semicircular-canal and otolith function, visual dependence, motion sensitivity, age, cognitive and musculoskeletal comorbidities, anxiety, depression, fear of falling, activity avoidance, and coexisting conditions such as persistent postural-perceptual dizziness. Future research should move beyond asking whether VRT is effective and determine which intervention, dose, and delivery model is most appropriate for a particular patient at a particular stage of recovery.
A core outcome set for UVH should be developed through collaboration among patients, clinicians, researchers, and methodological experts. This work should define core domains, preferred measurement instruments, assessment time points, minimal clinically important differences, and long-term follow-up standards. The core set should include vestibular physiology, functional gaze stability, balance and gait, falls, activity and participation, psychological and behavioral factors, quality of life, and patient-prioritized life roles.
Implementation-science and health-economic studies are also required. Outpatient, home-based, remote, and hybrid models should be compared across different resource settings with respect to effectiveness, safety, adherence, cost-effectiveness, and acceptability. Particular attention should be given to older adults, patients living in rural or underserved areas, individuals with limited digital literacy, and those with cognitive, visual, auditory, or mobility limitations, so that technology-assisted rehabilitation does not widen existing disparities in care.
Artificial intelligence, VR, and wearable technologies may facilitate movement-quality monitoring, dose recording, adherence feedback, fall-risk detection, and adaptive progression of exercise difficulty. These applications require prospective external validation and systematic evaluation of data security, privacy, algorithmic transparency, explainability, usability, interoperability, and the need for clinical oversight. Digital tools should support, rather than replace, professional judgment and shared decision-making.
In conclusion, this guideline reflects the best evidence currently available for vestibular rehabilitation in adults with UVH, while several recommendations remain constrained by indirect evidence and methodological heterogeneity. The guideline should be revised according to its predefined updating schedule and considered for earlier updating when new evidence emerges that could materially change an important recommendation.
5 Supplementary files
Supplementary material is available in the online version of this article at
https://doi.org/10.15302/ENTD.2026.090005 and is accessible for authorized users.
The Author(s). This article is published by Higher Education Press at journal.hep.com.cn.
This is an open access article distributed under the Creative Commons Attribution License 4.0 (CC BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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