ORIGINAL RESEARCH ARTICLE
Efficacy of Vestibular Rehabilitation in Vestibular Neuritis
A Systematic Review and Meta-analysis
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Hsiao-Han Huang, MD, Chih-Chung Chen, MD, PhD, Hsun-Hua Lee, MD, Hung-Chou Chen, MD, Ting-Yi Lee, MD,
Ka-Wai Tam, MD, PhD, and Yi-Chun Kuan, MD
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Objective: This study aimed to evaluate the efficacy of vestibular re-
habilitation in vestibular neuritis.
Design: A randomized controlled trial was collected from MEDLINE,
Embase, Cochrane Library, PEDro, LILACS, and Google Scholar be-
fore May 2023.
Results: This study included 12 randomized controlled trials involving
536 patients with vestibular neuritis. Vestibular rehabilitation was com-
parable with steroids in dizziness handicap inventory score at the first,
sixth, and 12th months (pooled mean differences: −4.00, −0.21, and
−0.31, respectively); caloric lateralization at the third, sixth, and 12th
months (pooled mean difference: 1.10, 4.76, and −0.31, respectively);
and abnormal numbers of vestibular-evoked myogenic potentials at
the first, sixth, and 12th months. Patients receiving a combination of re-
habilitation and steroid exhibited significant improvement in dizziness
handicap inventory score at the first, third, and 12th months (mean dif-
ference: −14.86, pooled mean difference: −4.63, mean difference:
−9.50, respectively); caloric lateralization at the first and third months
(pooled mean difference: −10.28, pooled mean difference: −8.12, re-
spectively); and numbers of vestibular-evoked myogenic potentials at
the first and third months (risk ratios: 0.66 and 0.60, respectively) than
did those receiving steroids alone.
Conclusions: Vestibular rehabilitation is recommended for patients
with vestibular neuritis. A combination of vestibular rehabilitation
and steroids is more effective than steroids alone in the treatment of
patients with vestibular neuritis.
Key Words: Meta-analysis, Vestibular Neuritis,
Randomized Controlled Trial, Rehabilitation
(Am J Phys Med Rehabil 2024;103:38–46)
estibular neuritis (VN) is the second most common cause
V of peripheral vestibular vertigo with annual incidence reaching
to 3.5 per 100,000. It is a disorder characterized by acute or
From the School of Medicine, Taipei Medical University, Taipei, Taiwan (H-HH); Dizzi-
ness and Balance Disorder Center, Shuang Ho Hospital, Taipei Medical University,
New Taipei City, Taiwan (C-CC, H-HL, T-YL); Department of Neurology, Shuang
Ho Hospital, Taipei Medical University, New Taipei City, Taiwan (C-CC, H-HL,
T-YL, Y-CK); Taipei Neuroscience Institute, Taipei Medical University, Taipei,
Taiwan (C-CC, H-HL, T-YL, Y-CK); Department of Neurology, School of Medicine,
College of Medicine, Taipei Medical University, Taipei, Taiwan (C-CC, H-HL, T-YL,
Y-CK); Department of Neurology, Taipei Medical University Hospital, Taipei Medical
University, Taipei, Taiwan (H-HL); Department of Physical Medicine and Rehabilita-
tion, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan (H-CC);
Center for Evidence-Based Health Care, Taipei Medical University–Shuang Ho Hos-
pital, New Taipei City, Taiwan (H-CC, Y-CK); Department of Physical Medicine and
Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University,
Taipei, Taiwan (H-CC); Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan
(K-WT); Department of Surgery, School of Medicine, College of Medicine, Taipei
Medical University, Taipei, Taiwan (K-WT); Division of General Surgery, Depart-
ment of Surgery, Shuang-Ho Hospital, Taipei Medical University, New Taipei City,
Taiwan (K-WT); and Institute of Epidemiology and Preventive Medicine, College
of Public Health, National Taiwan University, Taipei, Taiwan (Y-CK).
38 www.ajpmr.com American Journal of Physical Medicine & Rehabilitation • Volume 103, Number 1, January 2024
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
What Is Known
• The management of vestibular neuritis (VN) includes
steroids and rehabilitation. There was insufficient evi-
dence to support corticosteroids in managing acute
VN in adults. Vestibular rehabilitation effectively im-
proves dizziness with peripheral vestibular disorders.
What Is New
• The efficacy of vestibular rehabilitation, as evaluated
using dizziness handicap inventory (DHI) scores, ab-
normal vestibular-evoked myogenic potentials (VEMPs),
and caloric lateralization tests (at the third, sixth, and
12th months), was comparable with that of steroid
monotherapy. A combination of vestibular rehabilita-
tion and steroids resulted in significantly greater re-
ductions in DHI scores, caloric lateralization tests (at
the first and third months), and numbers of abnormal
VEMPs than did steroids alone.
subacute, isolated, spontaneous prolonged vertigo due to a sud-
den unilateral loss of vestibular function. Patients with VN typ-
ically experience an acute onset of rotatory vertigo and postural
imbalance with a tendency to fall. Auditory symptoms (deafness
or tinnitus) or other neurological symptoms (particular diplopia
or dysarthria) are usually absent. Typical clinical signs of VN
include horizontal nystagmus toward the healthy side with a ro-
tational component associated with oscillopsia, a positive head
impulse test for the involved semicircular canal, a positive
Romberg test, obvious horizontal saccadic persistence, an ab-
normal subjective vertical visual test during eccentric rotation,
decreased responses of cervical or ocular vestibular evoked
myogenic potentials (VEMPs) during stimulation of the af-
fected ear, and ipsilateral caloric weakness.1
All correspondence should be addressed to: Yi-Chun Kuan, MD, Department of
Neurology, Shuang-Ho Hospital, Taipei Medical University, No. 291
Zhongzheng Rd, Zhonghe District, New Taipei City, Taiwan, 23561.
The datasets generated during and/or analyzed during the current study are not
publicly available, but are available from the corresponding author on
reasonable request.
H-HH, Y-CK, and K-WT did the study concept and design. H-HH, Y-CK, and C-CC
did the acquisition of data. H-HH, Y-CK, C-CC, and K-WT did the analysis and
interpretation of data. H-HH, C-CC, H-HL, H-CC, T-YL, K-WT, and Y-CK did
the preparation of manuscript.
Financial disclosure statements have been obtained, and no conflicts of interest have
been reported by the authors or by any individuals in control of the content of
this article.
Supplemental digital content is available for this article. Direct URL citations appear
in the printed text and are provided in the HTML and PDF versions of this article
on the journal’s Web site (www.ajpmr.com).
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0894-9115
DOI: 10.1097/PHM.0000000000002301
 Volume 103, Number 1, January 2024
The management of VN includes symptomatic treatment,
etiological treatment, and physical rehabilitation. Symptomatic
treatment includes vestibular suppressants, antiemetics, and in-
travenous hydration if necessary. Although the etiology of VN
is not completely understood, the predominant hypothesis in-
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volves the reactivation of herpes simplex virus infection and
the inflammation of the vestibular nerve.1 However, valacyclovir
does not positively affect the disease course of VN, as a mono-
therapy nor in combination with methylprednisolone.2 Some
studies have reported that etiological treatment, which refers
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to steroid therapy, using prednisone, prednisolone, methyl-
prednisolone, or dexamethasone, can improve the degree and
rate of VN recovery.1 However, previous systematic reviews
and meta-analyses uncovered insufficient evidence to support
the use of corticosteroids in managing acute VN in adults ex-
cept for some benefits on the short-term recovery in patients
with canal paresis.3 Moreover, some adverse effects—namely,
hyperglycemia, bleeding stomach ulcers, and mood changes—
have been commonly observed during short-term treatment for
VN.3 Steroids may also have life-threatening effects such as vul-
nerability to infection and adrenal crisis, and many contraindica-
tions for steroid use, such as peptic ulcer disease, osteoporosis,
pregnancy, and breastfeeding women, have been identified.2,4,5
A systematic review and meta-analysis published in 2021 stated
that there was insufficient evidence to support the use of cortico-
steroids in managing acute vestibular neuritis in adults. Cortico-
steroids seemed to help short-term recovery in canal paresis but
not benefit long-term canal paresis and symptomatic recovery.3
Considering the adverse effects and limited curative ef-
fects of steroids, vestibular rehabilitation might be an alterna-
tive therapy for VN. Vestibular rehabilitation programs use
exercise-based techniques, which are widely used to relieve
patients’ symptoms and improve their gaze stabilization, pos-
tural control, functional activities, and quality of life. Vestib-
ular rehabilitation can attenuate peripheral vestibular loss through
three major mechanisms: vestibulo-ocular reflex (VOR) ad-
aptation, vestibular habituation, and vestibular substitution.
Vestibulo-ocular reflex adaptation may enhance the adapta-
tion of the vestibular system, thereby improving balance
and reducing dizziness. Vestibular habituation is a central
process of learning used to address problems with motion
sensitivity. Vestibular substitution uses other sensory stimuli
to improve postural control and prevent falls. Therefore, ves-
tibular rehabilitation mainly consists of gaze stabilization
(for vestibulo-ocular reflex adaptation), balance retraining,
habituation, and substitution interventions.6
A previous systematic review and meta-analysis published
in 2015 suggested that vestibular rehabilitation effectively re-
duces the frequency of dizziness in adults with various uni-
lateral peripheral vestibular disorders such as peripheral ves-
tibular hypofunction, VN, acoustic neuroma/schwannoma,
perilymphatic fistula, Ménière disease, benign paroxysmal po-
sitional vertigo, or a combination of these.6 However, only two
trials regarding VN were enrolled: Strupp et al.7 reported that
postural control improved more in the vestibular rehabilitation
group than in the nonspecific exercise group; Teggi et al.8 dis-
covered that the vestibular rehabilitation group exhibited sig-
nificantly lower anxiety than did the control group. Therefore,
to elucidate the effect of vestibular rehabilitation on patients
with VN, this study was an updated comprehensive systematic
© 2023 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
Vestibular Exercise for Vestibular Neuritis
review and meta-analysis to evaluate the efficacy of vestibular
rehabilitation and compare it with that of steroids in the treat-
ment of patients with VN.
MATERIALS AND METHODS
This systematic review was in accordance with the 2020 Pre-
ferred Reporting Items for Systematic Reviews and Meta-Analysis
guidelines (see Supplementary Checklist, Appendix 1, Supple-
mental Digital Content 1, http://links.lww.com/PHM/C89).9 The
systematic review protocol described here was registered on
PROSPERO, the online international prospective register of sys-
tematic reviews of the National Institute for Health Research
(CRD42020201143). The systematic review and meta-analysis
are exempt from ethics approval because these collected and
synthesized data from previous clinical trials in which informed
consent had already been obtained by the trial investigators.
Selection Criteria
The inclusion criteria of this study included randomized
controlled trials (RCTs), which evaluated the efficacy of ves-
tibular rehabilitations in patients with VN and described the in-
clusion and exclusion criteria for patient selection and detailed
information about the intervention, with no age or sex restric-
tions. This study excluded trials that involved participants with
conditions other than VN or with symptoms indicating central
lesions such as brainstem or cerebellar disorders and those in
which the participants experienced associated hearing loss.
Search Strategy and Study Selection
A literature search was conducted on MEDLINE, Embase,
Cochrane Library, PEDro, LILACS, and Google Scholar for
studies on VN published before May 15, 2023. The following
Medical Subject Headings terms and Boolean operators were
used: vestibular exercise/rehabilitation/training AND (vestibular
neuritis/neuronitis) OR (acute vestibular hypofunction/acute
peripheral vestibular hypofunction/acute unilateral peripheral
vestibulopathy). The details of search strategy in each database
were presented in Appendix 2 (Supplemental Digital Content 2,
http://links.lww.com/PHM/C90). The “Related Articles” option
in MEDLINE was used to broaden the search. No language or
publication period restrictions were applied. Studies meeting
the selection criteria regardless of the field were included.
Data Extraction
Two of the present article’s authors (H-HH and Y-CK) in-
dependently selected RCTs and extracted the relevant details:
the number, age, and sex of participants; inclusion and exclu-
sion criteria; strategies of intervention; and related outcome pa-
rameters. The individually recorded information of both re-
viewers was compared, and a third reviewer (K-WT) resolved
any discrepancies.
Methodological Quality Appraisal
The two abovementioned reviewers (H-HH and Y-CK) in-
dependently evaluated the methodological quality of the RCTs
according to the Cochrane risk-for-bias method 2.0,10 which
accounts for bias from (1) the randomization process, (2) devi-
ations from intended interventions, (3) missing outcome data,
(4) measurement of the outcomes, (5) selection of the reported
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 Huang et al. Volume 103, Number 1, January 2024

results; and finally, the overall risk of bias. All RCTs we in- RESULTS
cluded were assessed as having low, some concerns, or high
risk of bias in each domain. Any disagreements were discussed Study Selection and Characteristics of
by the two abovementioned reviewers and resolved by a third Included Studies
reviewer (K-WT).
Figure 1 presents a flowchart of the study selection pro-
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cess. This study initially involved 17,620 potential trials but

Outcome Assessment 525 duplicates and 16,563 ineligible articles were excluded af-
In this study, subjective outcomes, such as the dizziness ter screening their titles and abstracts. Subsequently, 520 re-
handicap inventory (DHI), and objective outcomes, such as ca- ports were excluded; of these, 327 were on irrelevant topics,
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loric lateralization and VEMPs were evaluated. The patients’
DHI scores were collected from a self-administered question-
naire to evaluate their functional, emotional, and physical
handicaps.11 Caloric tests with water at 30°C and 44°C were
calculated using Jongkee’s formula.12 A caloric test results
was considered abnormal if the patient’s caloric lateralization
was 25% or higher4 or 20% or higher.5 Cervical VEMPs were
recorded by surface electrodes placed over the unilateral ster-
nocleidomastoid muscle, a reference electrode on the unilateral
clavicle, and a ground electrode on the forehead.4,5 The VEMPs
were considered abnormal if they were absent or if the amplitude
asymmetry ratio of the affected side to the unaffected side was
25% or higher.4,5
Statistical Analysis
The Review Manager (version 5.3; Cochrane Collabo-
ration, Oxford, United Kingdom) was applied to conduct
the meta-analysis of the RCTs. The mean difference (MD)
was computed as the effect size for continuous outcomes.
The results for all outcomes are expressed as MDs with
95% confidence intervals, calculated from patients’ end-
of-treatment values. When necessary, the means and SDs
of pretreatment-posttreatment changes were calculated accord-
ing to the reported pretreatment and posttreatment data.13 The
risk ratio (RR) was computed as the effect size for dichotomous
outcomes. A P value less than 0.05 was considered statistically
significant. A DerSimonian and Laird random-effects model
was used to calculate a pooled estimate of the MD and RR.14
An I2 test was used to assess the heterogeneity of the outcomes
among these trials.
68 used different interventions, 42 were narrative reviews, 15
were systematic reviews, 19 were protocols, 35 were observa-
tional studies, and 14 were clinical answers. The 12 remaining
RCTs were included in the study, and six of the RCTs were in-
cluded in the meta-analysis.
The characteristics of the 12 eligible RCTs are summa-
rized in Table 1.4,5,7,8,17–24 All of the studies were published
between 1998 and 2022 and employed sample sizes of 21–71
patients. The mean participant age was 40–60 yrs in all the
studies, except for the study conducted by Wang et al.,21 which
did not provide information on the participants’ ages. All the
patients had been diagnosed with VN. During the acute phase
of VN, patients received an antiemetic agent (dimenhydrinate)
for less than 5 days in three RCTs,4,5,23 vestibular suppressants
for less than 2 days in two RCTs,21,22 and Ginkgo biloba ex-
tract twice a day for 4 wks in one RCT.24
Among the studies evaluating the effects of rehabilitation,
three compared vestibular rehabilitation with placebo7,8,17; one com-
pared conventional vestibular rehabilitation with three-dimensional
standardized training conducted using an aerotrim18; one RCT

Assessment of Certainty of the Evidence

(GRADE)
The GRADE approach, as outlined in the handbook for
Grading the Quality of Evidence and the Strength of Recom-
mendations using the GRADE approach, was applied,15 to
assess the overall certainty of the evidence supporting the
primary outcomes (caloric lateralization and DHI) and secondary
outcomes (VEMPs). The two abovementioned reviewers
(H-HH and Y-CK) independently used the GRADEpro GDT
software (Evidence Prime, McMaster University, Ontario,
Canada),16 which imported data from Review Manager 5
and finally created a “Summary of findings” table, and a third
reviewer (K-WT) resolved any discrepancies. The overall ev-
idence was graded as high, moderate, low, or very low cer-
tainty. While the data were from RCT, the overall evidence be-
gun as high certainty. However, it could be disparaged based
on the following criteria: risk of bias, indirectness, inconsis-
tency (unexplained heterogeneity), imprecision (sparse data),
and publication bias. FIGURE 1. Flowchart of the study selection process.

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TABLE 1. Characteristics of included studies

Author (Year) Inclusion Criteria No. Patients Age, Year, Mean ± SD Caloric Test, Mean ± SD (%) Intervention
7
Strupp (1998) VN diagnosis; E: 19 E: 51.7 ± 11.1 NA E: VR
MSPV during caloric test <2–3 C: 20 C: 52.4 ± 9.9 C: Usual daily activities
Herdman17 (2003) VN diagnosis E: 13 (31) E: 65.2 ± 16.5 NA E: VR
C1: 8 (38) C1: 64.9 ± 16.2 C1: Usual daily activities  4 wks, then switch to VR
Teggi8 (2009) VN diagnosis; age 18–75 E: 20 (40) E: 53.5 ± 9.8 NA E: VR
C: 20 (45) C: 51.4 ± 9.1 C: Usual daily activities
Lauenroth18 (2008) VN diagnosis E1: 34 (71) E1: 50.9 ± 15.8 NA E1: VR + 3D training
Volume 103, Number 1, January 2024

E2: 34 (65) E2: 53.3 ± 15 E2: VR

Ismail5a (2018) VN diagnosis ES: 20 (50) ES: 49.1 ± 12.8 ES: 69.50 ± 21.60 ES: VR + methylprednisolone PO 20 mg TID  7 d,
S: 20 (60) S: 47.9 ± 13.7 S: 70.90 ± 19.10 then tapered down
E: 20 (45) E: 49.3 ± 11.6 E: 69.20 ± 20.70 S: Methylprednisolone PO 20 mg TID  7 d, then

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tapered down
E: VR
Goudakos4a (2014) VN diagnosis E: 20 (65) E: 53.95 (29–79)b E: 78.75 ± 16.11 E: VR
S: 20 (55) S: 51.75 (35–79)b S: 67.64 ± 22.00 S: Dexamethasone 24 mg IV tapering down  7 d, then
2 mg PO tapering down  14 d
Sparrer19a (2013) VN diagnosis; age 18–85; ES: 37 (43) ES: 40 ± 3 NA ES: VR + cortisone 250 mg IV tapering down to
BW < 150 kg S: 34 (32) S: 47 ± 4 25 mg  10 d
S: Cortisone 250 mg IV tapering down to 25 mg  10 d
Tokle20a (2020) VN diagnosis ES: 31 (64) ES: 49.5 ± 14 NA ES: VR BIW  10 wks, OAW  3 m,
S: 30 (77) S: 53.6 ± 14 OAM  6 m + home rehabilitations + prednisolone
60 mg tapering down to 10 mg  10 d
S: Prednisolone 60 mg tapering down to 10 mg  10 d
Wang21a (2019) Acute VN diagnosis ES: 26 (54) NA ES: 65.34 ± 18.63 ES: VR  1 m + methylprednisolone 80 mg IV
S: 24 (42) S: 70.64 ± 20.81 tapering down to 20 mg  9 d
S: Methylprednisolone 80 mg IV tapering down to
20 mg  9 d
Xi22 (2022) Acute VN diagnosis; ES1: 11 (64) ES1: 43.27 ± 15.07 ES1: 68.82 ± 6.75 ES1: VR started within 1 wk after VN onset + steroid
age ≤70 ES2: 10 (50) ES2: 47.2 ± 10.15 ES2: 52.20 ± 15.76 and betahistine
S: 10 (40) S: 44.2 ± 15.51 S: 55.20 ± 17.26 ES2: VR started 1–2 wks after VN onset + steroid and

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betahistine
S: Steroid and betahistine
Kim23 (2015) VN diagnosis; age >18 ES: 15 (53) ES: 51 ± 9 ES: 58.5 ± 29.4 ES: Dexamethasone 5 mg IV  2 d + VR
E: 11 (64) E: 52 ± 15 E: 39.7 ± 28.0 E: VR
Yoo24 (2017) VN diagnosis; ES: 15 (53) ES: 54.1 ± 12.5 ES: 67.09 ± 24.99 ES: VR > 1 m + Ginkgo biloba + methylprednisolone
age 19–80 E: 14 (71) E: 59.6 ± 11.8 E: 64.41 ± 25.38 48 mg tapering down to 8 mg  5 d
E: VR > 1 m + Ginkgo biloba
a
RCTs included in meta-analysis.
b
Mean (range), number of patients (% male).
3D, three-dimensional; BIW, twice a week; BW, body weight; C, control; E, vestibular rehabilitation; ES, vestibular rehabilitation + steroid; IV, intravenously; MSPV, maximum slow-phase velocity; OAM, once a

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month; OAW, once a week; PO, per os; S, steroid; TID, three times daily; VN, vestibular neuritis; VR, vestibular rehabilitation; x, for.

41
Vestibular Exercise for Vestibular Neuritis
 Huang et al. Volume 103, Number 1, January 2024

compared vestibular rehabilitation with both vestibular reha-
bilitation plus steroids and steroids alone5; one compared ves-
tibular rehabilitation with steroids4; four studies compared ves-
tibular rehabilitation plus steroids with steroids alone19–22; and
two compared vestibular rehabilitation plus steroids with ves-
tibular rehabilitation alone.23,24 The included RCTs, which
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Comparison of Vestibular Rehabilitation and
Placebo (Usual Daily Activities)
Strupp et al.7 reported that total sway path values on the
30th day after symptom onset differed significantly between
the physiotherapy group (3.2 ± 1.9 m/min) and the control

group (16.9 ± 6.1 m/min; analysis of variance, P < 0.001).

evaluated various vestibular rehabilitation methods, are sum-
marized in Table 1. The details of vestibular rehabilitation are
listed in Appendix 3 (Supplemental Digital Content 3, http://
links.lww.com/PHM/C91). The follow-up period of these eight
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However, no significant differences in ocular torsion for the
vestibulo-ocular system and the subjective visual vertical for
perception were identified between the groups.7 Teggi et al.8

reported that the rehabilitation group exhibited significant im-

RCTs ranged from 5 days19 to 12 mos.4,5,20
Study Quality
The methodological quality of the 12 studies was summa-
rized in Table 2. All trials reported adequate randomization;
however, five of them did not mention whether with allocation
concealment or not.7,8,19,21,22 That may result in some bias
arising from the randomization process needed to be con-
cerned. Besides, double blind of the vestibular rehabilitation
is not feasible and three RCTs did not report the participants’
compliance, which may lead to some bias due to deviations
from intended interventions.7,21,22 Most of the RCTs analyzed
the outcomes of more than 95% participants. However, one
study reported an unexplained loss to follow-up of more than
20% of patients’ VEMP measurements,21 and one study ex-
cluded 52% patients for analysis due to their labyrinthine func-
tion recovery,7 which may cause some bias due to missing data.
Furthermore, the outcome assessor was not blinded in one trial,
which may lead to some bias in subjective outcome measure-
ment (DHI score).20 All the RCTs exhibited a low risk of
reporting bias. Therefore, seven of the RCTs exhibited a low
overall risk of bias4,5,17,18,20,23,24 and five exhibited some con-
cerns of overall risk of bias.7,8,19,21,22
provement in DHI score and reduction in anxiety comparing
with the control group. Herdman et al.17 evaluated dynamic vi-
sual acuity (DVA) during head movements, and the DVA sig-
nificantly improved in the vestibular rehabilitation group but
not in the control group.
Comparison of Vestibular Rehabilitation and
Steroid Therapy
Subjective Outcome (DHI)
Two RCTs evaluating DHI4,5 showed no significant dif-
ferences in DHI scores between the rehabilitation group and
the steroid group at the first, sixth, and 12th months (pooled
MD = −4.00, 95% CI = −8.31 to 0.31; pooled MD = −0.21,
95% CI = −2.10 to 1.67; pooled MD = −0.31, 95% CI = −0.80
to 0.17, respectively; Fig. 2A).
Objective Outcomes (Caloric Lateralization
and VEMPs)
Two RCTs assessed the efficacy of rehabilitation with ste-
roid treatment by patients’ caloric lateralization and VEMPs.4,5
Although the patients’ caloric lateralization improved gradu-
ally in both groups, significantly less improvement was noted

TABLE 2. Methodological quality assessment of included studies

RCTs Evaluated Using the Revised Cochrane Risk of Bias (RoB 2.0) Tool
Bias Arising From the Bias Due to Deviations Bias Due Bias in
Randomization From Intended to Missing Outcome Bias in Selection of Overall Risk
Author (Year) Process Interventions Outcome Data Measurement Reported Results of Bias
Strupp7 (1998) Some concernsa Some concernsb Some concernsc Low risk Low risk Some concerns
Herdman17 (2003) Low risk Low risk Low risk Low risk Low risk Low risk
Lauenroth18 (2008) Low risk Low risk Low risk Low risk Low risk Low risk
Teggi8 (2009) Some concernsa Low risk Low risk Low risk Low risk Some concerns
Ismail5 (2018) Low risk Low risk Low risk Low risk Low risk Low risk
Goudakos4 (2014) Low risk Low risk Low risk Low risk Low risk Low risk
Sparrer19 (2013) Some concernsa Low risk Low risk Low risk Low risk Some concerns
Tokle20 (2020) Low risk Low risk Low risk Low riskd Low risk Low riskd
Wang21 (2019) Some concernsa Some concernsb Low riske Low risk Low risk Some concernse
Xi22 (2022) Some concernsa Some concernsb Low risk Low risk Low risk Some concerns
Kim23 (2015) Low risk Low risk Low risk Low risk Low risk Low risk
Yoo24 (2017) Low risk Low risk Low risk Low risk Low risk Low risk
a
Allocation concealment was not mentioned.
b
Participants were not blinded, and the compliance was unknown.
c
Patients with labyrinthine function recovery (50%) were excluded from the analysis.
d
The outcome assessor was not blinded, which may cause bias when evaluating DHI scores but no other objective outcomes.
e
More than 20% of VEMP data were missing without explanation.

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 Volume 103, Number 1, January 2024
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FIGURE 2. A, Forest plot of changes in DHI scores after vestibular
rehabilitation compared with steroids. B, Forest plot of changes in caloric
lateralization after vestibular rehabilitation compared with steroids. C,
Forest plot of changes in abnormal VEMP numbers after vestibular
rehabilitation compared with steroids.
in the rehabilitation group than in the steroid group at the first
month (pooled MD = 8.31, 95% CI = 0.29 to 16.32; Fig. 2B),
and no significant differences in caloric lateralization between
both groups were identified at the third, sixth, and 12th months
(Fig. 2B). Both caloric irrigation and VEMPs were used to
evaluate the extent of patients’ unilateral vestibular loss. The
numbers of abnormal VEMPs were not significantly different
between the steroid group and the rehabilitation group at the
first month (pooled RR = 1.31, 95% CI = 0.71 to 2.43) and
the sixth month (pooled RR = 3.90, 95% CI = 0.18 to 85.93).
All the patients in both groups recovered with no abnormal
VEMPs after the 12th month (Fig. 2C).
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Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
Vestibular Exercise for Vestibular Neuritis
Other Outcomes
Goudakos et al.4 defined complete disease resolution as
the following: a European Evaluation of Vertigo score of 0,
DHI score of less than 6, caloric lateralization of less than 25%,
and normal VEMPs. In their study, the corticosteroids group
had a higher complete disease resolution rate (P < 0.05) than
did the rehabilitation group at the first month. However, no sig-
nificant differences in complete disease resolution rate or Eval-
uation of Vertigo scores were identified between the groups at
the 12th month.
Comparison of Vestibular Rehabilitation Plus
Steroid and Steroid Therapy
Subjective Outcome (DHI)
Five of the RCTs compared the efficacy of rehabilitation
plus steroid treatment with that of steroid therapy alone,5,19–22
by the DHI scores.5,19,20,22 Significant differences in DHI scores
were identified between the combination treatment and steroid
groups at the first, third, and 12th months (MD = −14.86,
95% CI = −16.57 to −13.15; pooled MD = −4.63, 95% CI =
−7.45 to −1.81; MD = −9.50, 95% CI = −18.58 to −0.42, respec-
tively; Fig. 3A). Although the data from the study of Sparrer
et al.19 were not pooled because of unknown sample size of each
intervention group, it showed significantly more improvement
in DHI score in the rehabilitation plus steroid group on the
fifth day.
Objective Outcomes (Caloric Lateralization
and VEMPs)
Three RCTs evaluated vestibular function by using caloric
irrigation tests,5,21,22 and two evaluated by VEMPs.5,21 The
meta-analysis showed significantly lower caloric lateralization
in rehabilitation plus steroid group compared with steroid
group at the first and third months (pooled MD = −10.28,
95% CI = −17.18 to −3.37; pooled MD = −8.12, 95% CI =
−15.74 to −0.51, respectively; Fig. 3B) but not at the sixth and
12th months (Fig. 3B). Significantly less abnormal VEMPs
were identified in the combination group then in the steroid
groups at the first and third months (RR = 0.69, 95% CI = 0.50
to 0.96; RR = 0.60, 95% CI = 0.39 to 0.92, respectively; Fig. 3C).
All the patients in both groups recovered with no abnormal
VEMPs at the sixth and 12th months.
Other Outcomes
Tokle et al.20 reported that the vestibular rehabilitation
group exhibited significantly greater alleviation of overall per-
ceived dizziness than did the steroid therapy group at the third
and 12th months. In addition, the average scores on the Hospi-
tal Anxiety and Depression Scale and visual analog scale of
feelings of unsteadiness and imbalance while standing or walk-
ing were also significantly lower in the combination treatment
group than in the steroid therapy group at the 12th month.
Sparrer et al.19 reported that the patients in the combination
treatment group had shorter durations of hospitalization; expe-
rienced earlier alleviations of nystagmus; and received more fa-
vorable results on the vertigo symptom scale, sensory organi-
zation test, and Tinneti questionnaire at each time point. Wang
et al.21 discovered that although spontaneous nystagmus did
www.ajpmr.com 43
 Huang et al.
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FIGURE 3. A, Forest plot of changes in DHI scores after vestibular
rehabilitation plus steroid compared with steroids alone. B, Forest plot of
changes in caloric lateralization after vestibular rehabilitation plus steroid
compared with steroids alone. C, Forest plot of changes in abnormal
VEMP numbers after vestibular rehabilitation plus steroid compared with
steroids alone.
not differ significantly between the groups, the rehabilitation
plus steroid group exhibited lower directional preponderance
at the first and third months.
Comparison of Vestibular Rehabilitation Plus
Steroid and Vestibular Rehabilitation
Objective Outcomes (Caloric Lateralization)
Two RCTs evaluated vestibular function by using caloric
irrigation tests.5,24 No significant differences in caloric later-
alization were identified between the vestibular rehabilitation
plus steroid and vestibular rehabilitation groups at the first,
third, sixth, and 12th months (pooled MD = −4.44, 95% CI =
−22.91 to 14.02; MD = −1.4, 95% CI = −8.66 to 5.86; MD = −1.99,
95% CI = −8.55 to 4.58; MD = −1.6, 95% CI = −6.13 to 2.93,
respectively; Fig. 4).
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Volume 103, Number 1, January 2024
Other Outcomes
Kim et al.23 reported that neither the combination treat-
ment group nor the vestibular rehabilitation group exhibited
significant improvements according to the visual analog
scale–based test of nausea and vertigo (both P > 0.05). Yoo
et al.24 compared the two groups (steroids and vestibular reha-
bilitation with Ginkgo biloba vs. vestibular rehabilitation with
Ginkgo biloba) and demonstrated that additional steroids did
not reveal significantly more benefits at the first and sixth
months in patients with VN.
Comparison of Different Vestibular
Rehabilitation
Lauenroth et al.18 revealed that the three-dimensional
training program, which involved exercises by AeroStep (Prien
am Chiemsee, Germany) and SpaceCurl (Wittlich, Germany),
improved patients’ postural stability (P = 0.019) and cerebellar
control mechanisms (P = 0.033) significantly more than did the
traditional vestibular rehabilitation program. The patients’ re-
sponses to the accompanying questionnaire also revealed that
those who completed the aerotrim-based training program exhib-
ited greater improvements in the physical subscore (P = 0.001).18
Adverse Effects
None of the enrolled RCTs reported adverse effect of the
vestibular rehabilitation programs in patients with VN.
Quality of the Evidence (GRADE)
The results of the GRADE analysis are reported in Appen-
dices 4, 5, and 6 (Supplemental Digital Content 4, 5, and 6,
http://links.lww.com/PHM/C92, http://links.lww.com/PHM/
C93, http://links.lww.com/PHM/C94). The level of certainty
of most outcomes were moderate, except for the outcomes of
DHI, caloric lateralization at the first and third months, and
number of abnormal VEMPs at the first and third months in
the comparison of combined therapy and steroids alone and
the outcome of caloric lateralization at the first month in the
comparison of combined therapy and rehabilitation. The cer-
tainty of the evidence regarding these outcomes was low be-
cause of the imprecision and some concerns of the overall risk
of bias from one study. The possible cause of high heterogene-
ity was variable rehabilitation methods between each study.
DISCUSSION
Vestibular rehabilitation exhibits greater efficacy in pro-
moting the vestibulospinal compensation, DVA, and gait stabil-
ity and in reducing the DHI scores and anxiety of patients with
VN than do nonspecific usual daily activities. The efficacy of
vestibular rehabilitation, as evaluated using DHI scores, num-
bers of abnormal VEMPs, and caloric lateralization tests (at the
third, sixth, and 12th months), was comparable with that of ste-
roid monotherapy, although the caloric lateralization of the pa-
tients who underwent vestibular rehabilitation had improved
less than who underwent steroid therapy at the first month. A
combination of vestibular rehabilitation and steroids resulted
in significantly greater reductions in DHI scores, caloric later-
alization (the first and third month), and numbers of abnormal
VEMPs than did steroids alone. However, for patients who
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 Volume 103, Number 1, January 2024
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FIGURE 4. Forest plot of changes in caloric lateralization after vestibular rehabilitation plus steroid compared with rehabilitation alone.
received vestibular rehabilitation, additional steroids did not
confer additional benefits.
Vestibular rehabilitation involves the treatment of patients
with vestibular symptoms through central compensation. Sev-
eral types of vestibular rehabilitation are used for such treatment.
Most of the RCTs analyzed herein involved the use of conven-
tional vestibular rehabilitation, except for the studies conducted
by Sparrer et al.19 and Lauenroth et al.18 Three-dimensional sen-
sorimotor training improves the postural stability, subjective
well-being, and daily living skills of patients significantly more
than do traditional rehabilitation programs.18 Compared with
patients treated with steroids alone, patients who underwent a
combination of steroid therapy and a novel method of virtual
reality (VR)–based training using a Wii balance board had a
shorter average duration of hospitalization; experienced earlier
alleviation of nystagmus and received more favorable results
on the vertigo symptom scale, sensory organization test, and
Tinneti questionnaire.19 Another advantage of such systems
is that patients can self-rehabilitate at home, which may mo-
tivate their compliance. A case series comparing patients’
preintervention and postintervention conditions discovered
that home-based computer gaming could significantly improve
the DHI scores, standing balance, DVA, gaze control, and walk-
ing performance of patients with peripheral vestibular dysfunc-
tion.25 An RCT involving patients with unilateral peripheral
vestibular loss demonstrated that the effects of VR-based bal-
ance rehabilitations were comparable with those of conven-
tional balance rehabilitations.26 Another RCT involving pa-
tients with unilateral vestibular hypofunction demonstrated
that undergoing additional home-based rehabilitations using
head-mounted gaming systems resulted in greater improve-
ments in vestibulo-ocular reflex and reductions in DHI scores
than did conventional vestibular rehabilitation.27
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Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
Vestibular Exercise for Vestibular Neuritis
Compliance with vestibular rehabilitation exerts a tremen-
dous effect on patient outcomes. Most of the RCTs analyzed
herein used various methods to encourage compliance. Six of
the RCTs involved vestibular rehabilitation under the supervi-
sion of a therapist,4,8,18–20,23 and all the participants in three of
the RCTs were asked about compliance with their rehabilita-
tion plans at the first month after treatment,5 at the first week
after treatment,24 and on a weekly basis after treatment.17 A
comparative study reported that supervised rehabilitation pro-
grams were more effective than unsupervised home-based re-
habilitation for patients with chronic dizziness.28
In addition to intervention type and compliance, age; mul-
tifocal intraocular lens use; physical activity; certain congenital
disorders; duration of symptoms; musculoskeletal, visual, and
neuromuscular comorbidities; cognition; sleep; and medica-
tions also affect the outcomes of vestibular rehabilitation.29 A
review article reported that psychophysical factors not only af-
fect but also predict the development of long-term dizziness.30
Strupp et al.7 reported that patients exhibited a significantly
greater reduction in anxiety after undergoing vestibular reha-
bilitation than after receiving usual care. Tokle et al.20 also re-
ported that patients in the vestibular rehabilitation plus ste-
roid group received significantly lower Hospital Anxiety
and Depression Scale scores than did those in the steroid
group (P = 0.039). Improvement of psychiatric well-being
may be an additional benefit of vestibular rehabilitation.
The study is an updated systematic review and meta-analysis
to evaluate the efficacy of vestibular rehabilitation in patients
with VN. The certainty of most of the outcomes was moderate.
However, the analysis still has some limitations, such as the
heterogeneity of the characteristics of the patients with VN
and the intervention methods employed in the studies, and
the methodological quality of the selected studies (low or some
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 Huang et al.
concerns of risk of bias). In addition, the sample size of this
systematic review was insufficient.
CONCLUSIONS
According to the available evidence, vestibular rehabilita-
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tion is safe and more effective than control activities in the
treatment of patients with VN. The efficacy of vestibular reha-
bilitation can be said with a moderate level of certainty to be
comparable with that of steroids at short- and long-term fol-
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low-ups. Thus, vestibular rehabilitation may be recommended
as a treatment option for patients with VN with contraindica-
tions for steroids or who experience adverse effects from ste-
roids. In addition, a combination of vestibular rehabilitation
and steroid therapy can reduce the DHI scores, caloric lateral-
ization before the third months, and numbers of abnormal
VEMPs in patients with VN more than steroid therapy alone.
Additional RCTs using larger sample sizes are still required
to evaluate the curative effects and optimal frequency and in-
tensity of vestibular rehabilitation for VN.
ACKNOWLEDGMENTS
The authors thank Wallace Academic Editing for editing
this manuscript.
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