2. Study results.
| Study ID | Inclusion criteria | Intervention/comparator | Result |
| Barozzi 2006 | Unilateral peripheral vestibular deficit, 1 to 6 months after the acute phase, diagnosed by clinical examination, CDP, videonystagmography, rotatory chair and caloric tests demonstrating a canal paresis of at least 25% | Intervention groups (n not stated): oculomotor rehabilitation (adaptation) Comparator group (n not stated): vestibular electrical stimulation |
No significant differences between groups |
| Basta 2011 | Experienced balance disorder for more than 12 months due to the following conditions: canal paresis, otolith disorder, removal of an acoustic neuroma, microvascular compression syndrome, Parkinson's disease, presbyvertigo | Intervention group (n = 59): vibrotactile neurofeedback training and vestibular rehabilitation exercises performed daily (15 minutes) over 2 weeks with the Vertiguard system Comparator group (n = 9): sham Vertiguard device and vestibular rehabilitation exercises |
Significant reduction in trunk and ankle sway and improved VSS scores on the Vertiguard group. No changes observed in the sham Vertiguard group |
| Cakrt 2010 | Participants undergoing retrosigmoid microsurgical removal of vestibular schwannoma | Intervention group (n = 9): received visual feedback while performing VR using the BalanceMaster Comparator group (n = 8): control group received VR without feedback |
2‐week intervention post acoustic neuroma removal, significant improvement in 5 out of 7 centre of pressure parameters in quiet stance on foam in the visual feedback group only |
| Chang 2008 | First ever attack of unilateral posterior canal BPPV, diagnosed by neurologist and clinical examination | Intervention group (n = 13): canalith repositioning technique (CRT) and vestibular exercises Comparator group (n = 13): CRT only |
Intervention group demonstrated a significant improvement in single leg stance with eyes closed at the 2‐week assessment, and static balance and DGI at the 4‐week assessment |
| Cohen 2002 | Acoustic neuroma resection ‐ postoperative (1 week ‐ acute) diagnosed by history, audiometry, MRI | Intervention group (n = 16): VR (head exercises) Comparator group (n = 15): control (attention only) |
No significant difference between groups |
| Cohen 2003 | Chronic vestibulopathy (labyrinthitis or neuronitis of more than 2 months) diagnosed by physician using posturography, calorics and oculomotor test battery | Intervention group (n = 13): VR (slow head exercises ‐ habituation) Comparator group 1 (n = 22): VR (rapid head exercises) Comparator group 2 (n = 18): VR (rapid plus attention) |
All groups significantly improved for VI, VF, DHI, VSS VHQ no change |
| Cohen 2005 | Unilateral BPPV (post SC) diagnosed by physician (D‐H test), with dizziness for at least 1 week | Intervention group (n = 25): B‐D exercises Comparator group 1 (n = 25): habituation exercises Comparator group 2 (n = 24): CRM Comparator group 3 (n = 25): LM Comparator group 4 (n = 25): sham manoeuvre |
Manoeuvres (CRM and LM) better results than exercises (B‐D, habituation), both better than sham |
| Foster 2012 | Adults with a history suggestive of BPPV and Dix‐Hallpike manoeuvre consistent with unilateral posterior canal BPPV | Intervention group: (n = 33) half‐somersault manoeuvre was performed twice in the clinic and also given as a home exercise Comparator group: (n = 35) Epley manoeuvre was performed twice in the clinic and also given as a home exercise |
Significantly less nystagmus observed after the initial half‐somersault manoeuvre, but no difference in recurrence over the 6‐month follow‐up period |
| Garcia 2013 | Participants were included if they had Ménière's disease diagnosed by an ENT specialist, and had complaints of dizziness between exacerbations of their disease | Intervention group (n = 23): 12 rehabilitation sessions (twice weekly for 45 minutes) with virtual reality stimuli in a Balance Rehabilitation Unit, plus diet and lifestyle advice and betahistine Intervention group (n = 21): 12 stimulus enriched exercise sessions (twice weekly) on the Balance Rehabilitation Unit, plus diet and lifestyle advice and betahistine |
Intervention participants improved significantly on the DHI, dizziness analogue scale and had greater stability on posturography compared to control participants |
| Giray 2009 | Participants were diagnosed by a neuro‐otologist or neurologist with chronic decompensated unilateral peripheral vestibular deficit, secondary to peripheral vestibular dysfunction. Diagnosed by ENG, bithermal caloric test, ocular motor testing and positional testing | Intervention group (n = 20): VR incorporating adaptation, substitution, visual desensitisation and balance exercises Comparator group (n = 21): control, no input |
Significant improvements were seen in all parameters for the intervention group while there were no changes in the control group |
| Herdman 1995 | Participants post removal of acoustic neuroma. Diagnosed by MRI and surgically resected ‐ study performed in acute post period | Intervention group (n = 11): VR (adaptation to increase gain) plus ambulation exercises Comparator group (n = 8): smooth pursuit exercises (no head movement) plus ambulation exercises |
Intervention group significant improvements for dysequilibrium VAS, VOR to slow head movements, gait and posturography on day 6 compared to control group |
| Herdman 2003 | Unilateral vestibular hypofunction with abnormal DVA, diagnosed by caloric, rotary chair, positive head thrust | Intervention group (n = 13): VR (adaptation to enhance VOR) Comparator group (n = 8): placebo exercises designed to be "vestibular neutral" |
12/13 improved DVA in intervention group
1/8 improved DVA in comparator group Both improved VAS |
| Horak 1992 | Peripheral vestibular dysfunction diagnosed by neuro‐otologist for BPPV, inner ear concussion syndrome, reduced unilateral vestibular function, 18 to 60 years of age | Intervention group (n = 14): VR Comparator group 1 (n = 4): general conditioning exercises Comparator group 2 (n = 8): medication (meclizine or Valium) |
VR ‐ superior reduction in sway and increased SOOL DI decreased for both VR and medication 92% improvement rate with VR (75% with comparator group 1, 75% with comparator group 2) |
| Kammerlind 2005 | Acute unilateral vestibular loss confirmed by ENG with calorics | Intervention group (n = 28): VR (home exercises plus extra PT (habituation, adaptation, balance and gait) (extra PT included individualised instruction and further exercises) Comparator group (n = 26): VR (home exercises only) |
No significant difference between groups ‐ intensity not supported |
| Karanjai 2010 | Diagnosed with posterior canal BPPV through history and clinical examination (Dix‐Hallpike manoeuvre) | Intervention group: Brandt‐Daroff exercises 3 times a day for 2 weeks, n = 16 Comparator group 1: single Epley manoeuvre followed by post‐treatment instructions, n = 16 Comparator group 2: single Semont manoeuvre followed by post‐treatment instructions (sleep upright for 2 nights, then on the unaffected side for the next 5 nights), n = 16 |
Statistical analysis of the differences between groups not performed; 73% of participants overall reported resolution of symptoms with no recurrence at 3 months follow‐up |
| Krebs 2003 | Mixed diagnoses ‐ unilateral and bilateral peripheral vestibular dysfunction. Diagnosed by VOR gain, calorics etc. | Intervention group (n = 42): VR (adaptation, balance) Comparator group (n = 44): control (strength exercises) |
VR group significantly improved for gait speed and base of support measures UPVD and BVD groups improved equally though BVD were less functional at baseline |
| Kulcu 2008 | Diagnosed with BPPV and has undergone repositioning techniques by their otorhinolaryngologists but were still complaining of vertigo and dysequilibrium | Intervention group (n = 19): VR (Cawthorne‐Cooksey exercises) Comparator group (n = 19): medication (betahistine) |
The intervention group demonstrated significant improvements in the VSS and VDI at the end of the study (8 weeks) |
| Marioni 2013 | Adults aged 18 to 65 with acute unilateral peripheral vestibular disorder occurring within 2 weeks of entry into the study, with at least 50% weakness on videonystagmography with caloric testing | Intervention group (n = 15): posturography‐assisted VR Comparator group 1 (n = 15): group awaiting spontaneous compensation, no VR Comparator group 2 (controls, n = 10): healthy adults without a vestibular disorder |
Both groups of participants with vestibular dysfunction improved over the 6‐week intervention but only the posturography‐assisted VR improved postural control, which approximated the healthy controls |
| Morozetti 2011 | Adults with a chronic vestibular disorder diagnosed by otorhinolaryngologists | Intervention group (n = 10): home exercises based on vertical and horizontal vestibulo‐ocular reflex stimulation (VRS) Comparator group (n = 10): personalised VR home exercise programme |
Both groups improved over time but the personalised VR group reported less dizziness on VAS and greater gains on the DHI |
| Mruzek 1995 | Participants had been reviewed by a physician for acoustic neuroma or Ménière's disease and were referred for ablative surgery | Intervention group (n = 8): VR plus social reinforcement, 15 minutes, 2 x day plus a daily walk Comparator group 1 (n = 8): VR no social reinforcement Comparator group 2 (n = 8): general range of motion exercises plus social reinforcement |
All the same at 4 weeks Intervention group and comparator group 1 significant improvement for MSQ at 7 weeks Intervention group significant improvement for DHI at 8 weeks CDP no difference between groups |
| Pavlou 2004 | Peripheral vestibular disorder diagnosed by full vestibular examination | Intervention group (n = 20): VR (customised exercises, including gaze control and stability, balance training) Comparator group (n = 20): simulator (optokinetic disc to produce visual‐vestibular conflict plus above) |
Both groups improved significantly on posturography: intervention group more than comparator group Subjective symptom reports reduced for both (? any difference) Visual‐vertigo symptoms improved for intervention comparator group Depression reduced significantly for both groups: intervention group more than comparator group Anxiety reduced for both BBS not sensitive |
| Pavlou 2012 | Participants with a history of acute onset of vertigo and had a confirmed peripheral vestibular deficit on the basis of the caloric tests and/or rotational tests on ENG | Intervention group (n = 5): dynamic virtual reality, performed for 45 minutes twice weekly for 4 weeks plus home exercises and general conditioning programme (walking) Comparator group 1 (n = 11): static virtual reality image rehabilitation, performed for 45 minutes twice weekly for 4 weeks plus home exercises and general conditioning programme (walking) Comparator group 1 (n = 5): cross‐over of 5 group 1 participants who then received dynamic virtual reality (not included in our analysis) |
After 4 weeks the dynamic groups reported significantly less visual vertigo, but depression improved in the static virtual reality VR group only |
| Resende 2003 | Participants with BPPV diagnosed by ENT using history, ENT examination, ENG | Intervention group: VR (compensation, adaptation, sensory substitution, balance: C‐C) Comparator group: control (nil) |
Intervention group significantly improved Comparator group no change |
| Rossi‐Izquierdo 2011 | Participants with instability due to chronic unilateral peripheral vestibular disorders, which had not spontaneously resolved after a month. Hypofunction was defined with caloric tests, at least 25% labyrinthic preponderance according to defined criteria | Intervention group (n = 12): computerised dynamic posturography (CDP), 5 sessions of approximately 15 to 20 minutes on consecutive days Comparator group (n = 12): optokinetic stimulation (OKN), 5 sessions lasting 5 to 15 minutes on consecutive days |
Outcomes assessed 3 weeks after treatment. Both groups improved, with the CDP group showing greater gains in the visual and vestibular input and limits of stability, while the OKN group showed greater improvement in visual preference |
| Rossi‐Izquierdo 2013 | Participants with instability due to chronic unilateral peripheral vestibular disorders, which had not spontaneously resolved after a month | Intervention group (n = 13): 5 sessions of posturography‐assisted VR over a 2‐week period Comparator group (n = 13): 10 sessions of posturography‐assisted VR over a 2‐week period |
Outcomes assessed 3 weeks after the intervention and both groups improved over time, with the 5‐session group reporting greater gains on the DHI, but some items of posturography improved to a greater extent in the 10‐session group |
| Scott 1994 | Ménière's disease diagnosed by medical and audiological examination (5 were bilateral but had one "worse" ear) | Intervention group (n = 10): applied relaxation Comparator group (n = 10): transcutaneous nerve stimulation to the hand |
No change in either group for relevant measures (dizziness etc.) Intervention group improved on hearing ability more than comparator group Comparator group improved on psychoacoustic tests more than intervention group |
| Strupp 1998 | Vestibular neuritis (acute/sub‐acute). Diagnosed by history, examination ‐ nystagmus, postural imbalance, ENG, calorics, ocular tilt reaction | Intervention group (n = 19): VR (home exercises, based on Cooksey‐Cawthorne, Norre ‐ habituation, gaze exercises, sensory substitution, functional retraining) Comparator group (n = 20): control (nil exercise but encouragement to move) |
For OT and SVV tests, intervention group equal to comparator group For SP, intervention group improved significantly more than comparator group, i.e. balance improved |
| Szturm 1994 | Clinical diagnosis of peripheral vestibular dysfunction, persistent dizziness, disorientation or imbalance for at least 1 year, and abnormal balance performance during CDP at baseline | Intervention group (n = 11): VR Comparator group (n = 12): VR (home, C‐C) |
Intervention group had reduced falls, improved CDP values and reduced VOR asymmetry compared with comparator group |
| Teggi 2009 | Participants were recently hospitalised for an acute episode of rotational vertigo which lasted several days and were diagnosed with vestibular neuritis | Intervention group (n = 20): VR Comparator group (n = 20): control ("perform usual daily activities") |
Significant improvement in DHI between groups and reduction in anxiety. For both groups, there was a significant correlation between change in anxiety and change in DHI/DGI |
| Toledo 2000 | BPPV diagnosed with clinical assessment and electronystagmography | Intervention group (n = 10): VR (PC, head‐eye and habituation) Comparator group 1 (n = 10): Semont manoeuvre Comparator group 2 (n = 20): Semont + VR |
Intervention group 80% cure rate at day 15 versus comparator group 1 45% Intervention group 66% cure rate at 3 months versus comparator group 2 100% |
| Varela 2001 | BPPV, diagnosed by history and D‐H test (nystagmus) | Intervention group (n = 29): VR (B‐D habituation exercises) Comparator group 1 (n = 35): Semont manoeuvre Comparator group 2 (n = 42): Epley manoeuvre |
Comparator groups 1 and 2 had a similar cure rate at 1 week; by 3 months comparator group 2 were superior but comparator group 1 more stable CRM superior to habituation (B‐D) for BPPV |
| Venosa 2007 | Acute episode of rotational vertigo within the last 5 days | Intervention group (n = 45): VOR adaptation exercises (X1 and X2 viewing exercises) Comparator group (n = 42): placebo exercises (sham visual fixation task) |
Intervention group recovered more quickly in all parameters measured and required significantly less medication by the end of the follow‐up period (21 days) |
| Vereeck 2008 | Consecutive patients post removal of an acoustic neuroma | Intervention group (n = 31): customised VR (exercises for balance, head motion, mobility, gaze and treadmill walking) Comparator group (n = 22): general instructions |
Participants were stratified according to age (above and below 50 years). Older participants performed significantly better than the control group for balance, TUG and tandem gait compared to the control group. There was no group effect for the younger participants |
| Winkler 2011 | Participants with chronic dizziness (greater than 6 months duration) who had completed a VR programme, functional range of motion and strength in the lower limbs and trunk, intact sensation in the lower limbs, ability to stand unassisted for 1 minute | Intervention group (n = 10): platform tilt perturbations only Comparator group 1 (n = 7): platform tilt perturbations and VR exercise programme Comparator group 2 (n = 12): VR only |
Outcomes were assessed after the 3‐week intervention and a follow‐up at 2 months later. The VR group only demonstrated significant improvement on the DHI but the platform tilt groups improved activity and participation domain outcomes |
| Yardley 1998 | Dizziness of vestibular origin. Mixed aetiology ‐ diagnosed where possible by medical records (1/3) Possibility of central pathology |
Intervention group (n = 67): VR (education, head and body movements, relaxation, breathing, encouragement to function) Comparator group (n = 76): control |
Intervention group improved significantly on all measures more than comparator group, except VHQ (no difference) Overall intervention group 4 times more likely to report subjective improvement than comparator group |
| Yardley 2004 | Dizziness of vestibular origin diagnosed by case history and MPD | Intervention group (n = 83): VR (primary care: demonstration, booklet and follow‐up) Comparator group (n = 87): control, usual medical care |
All measures improved significantly in VR group compared with control group Clinical improvement 67% VR; 38% control |
| Yardley 2006 | Participants with Ménière's disease (non‐acute phase) who had experienced dizziness of imbalance in the last 12 months, had consulted their GP regarding involvement in the study | Intervention group (n = 120): VR (booklet of exercises) Comparator group 1 (n = 120): SC (booklet for self management) Comparator group 2 (n = 120): waiting list control |
At 3 months intervention group had greater improvement on 5 measures compared with comparator group 1 (2 measures) compared with comparator group 2 (0 measures) At 6 months intervention group and comparator group 1 both reported significant improvement, more than comparator group 2 Correlation between adherence and outcome |
| Yardley 2012 | Chronic dizziness, as diagnosed by their GP | Intervention group (n = 112): VR (self management booklet with phone support from a vestibular therapist) Comparator group 1 (n = 113): SC (self management booklet only) Comparator group 2 (n = 112): routine medical care | At 12 weeks all groups showed some improvement in the VSS, and at 1 year both intervention groups improved significantly compared to usual care |
| Zimbelman 1999 | Unilateral peripheral vestibular dysfunction diagnosed by neuro‐otological tests | Intervention group (n = 6): VR (individual with adaptation and postural control) Comparator group (n = 8): VR (general C‐C) |
Intervention group improved dizziness over time, comparator group did not No change for either on the BBS (insensitive) No between‐group differences ‐ but 100% of intervention group reported improvement compared with 62.5% of comparator group Intervention group had more Ménière's disease |
BBS: Berg Balance Scale B‐D: Brandt‐Daroff BPPV: benign paroxysmal positional vertigo BVD: bilateral vestibular dysfunction C‐C: Cooksey‐Cawthorne CDP: computerised dynamic posturography CRM: canalith repositioning manoeuvre CRT: canalith repositioning technique DGI: Dynamic Gait Index D‐H test: Dix‐Hallpike test DHI: Dizziness Handicap Inventory DI: dizziness intensity DVA: dynamic visual acuity ENG: electronystagmography GP: general practitioner LM: liberatory manoeuvre MPD: motion‐provoked dizziness MRI: magnetic resonance imaging MSQ: motion sensitivity quotient OKN: optokinetic reflex OT: ocular tilt PC: postural control PT: physical therapy SC: symptom control SOOL: standing on one leg SP: sway path SVV: subjective visual vertical TUG: Timed Up and Go VAS: visual analogue scale VDI: Vertigo Dizziness Imbalance questionnaire VF: vertigo frequency VHQ: Vestibular Handicap Questionnaire VI: vertigo intensity VOR: vestibular ocular reflex VSS: Vertigo Symptom Scale VR: vestibular rehabilitation