Clinical bottom line
Vestibular rehabilitation shows promise as a targeted intervention to improve dizziness and balance impairments in patients with mild traumatic brain injury (mTBI). Current evidence suggests that individualized vestibular therapy can reduce symptoms and enhance functional mobility, although variability in protocols and patient response warrants cautious interpretation. Clinicians should consider vestibular rehabilitation as part of a multidisciplinary approach for mTBI patients presenting with persistent vestibular symptoms, while recognizing the need for further high-quality trials to optimize treatment parameters.
What the evidence shows
Dizziness and balance dysfunction are common sequelae following mTBI, often resulting from vestibular system involvement (Gottshall et al., 2019; Szczupak et al., 2019). Vestibular rehabilitation therapy (VRT) aims to promote central compensation through exercises targeting gaze stabilization, habituation, and balance retraining.
Gottshall et al. (2019) provide a comprehensive overview of vestibular rehabilitation in mTBI, highlighting that structured VRT protocols can significantly reduce dizziness severity and improve postural control. Their synthesis emphasizes that early initiation of vestibular therapy may enhance recovery trajectories, although individual variability in symptom presentation necessitates tailored interventions.
Recent clinical observations by Akin et al. (2022) in veterans with chronic dizziness post-mTBI and blast exposure reinforce the utility of vestibular and balance function assessments to guide rehabilitation. Their findings suggest that vestibular dysfunction contributes substantially to persistent symptoms and that targeted VRT can yield functional improvements even in chronic stages.
Herman et al. (2026) and Elovic et al. (2021) discuss the multifactorial nature of dizziness and balance impairment post-mTBI, underscoring the importance of integrating vestibular rehabilitation with management of comorbid somatic symptoms such as fatigue. They advocate for comprehensive assessment protocols to identify vestibular deficits amenable to rehabilitation.
Szczupak et al. (2019) also note that vestibular rehabilitation may improve neuroplasticity and sensorimotor integration, which are often disrupted following mTBI. However, they caution that heterogeneity in injury mechanisms and patient characteristics can influence outcomes.
Caveats and uncertainty
Despite encouraging findings, the evidence base for vestibular rehabilitation in mTBI remains limited by several factors. Most available data derive from observational studies, case series, or expert consensus rather than large randomized controlled trials (Gottshall et al., 2019; Szczupak et al., 2019). This limits the ability to draw definitive conclusions about efficacy and optimal treatment protocols.
There is considerable heterogeneity in vestibular rehabilitation approaches, including differences in exercise types, intensity, duration, and timing relative to injury. Standardized protocols and dose-response relationships are not well established, complicating clinical decision-making (Herman et al., 2026).
Patient factors such as age, comorbidities, psychological status, and severity of vestibular impairment may modulate response to therapy but are insufficiently characterized in the literature. Additionally, the overlap of vestibular symptoms with other post-mTBI sequelae (e.g., migraine, cervical spine injury) can confound assessment and treatment outcomes (Elovic et al., 2021).
Long-term follow-up data on functional outcomes and quality of life improvements after vestibular rehabilitation in mTBI are sparse. The durability of treatment effects and the potential need for maintenance therapy remain unclear.
How this may change practice
Physical medicine and rehabilitation clinicians managing mTBI patients with persistent dizziness and balance deficits should consider vestibular rehabilitation as a valuable component of comprehensive care. Early referral to vestibular therapy specialists for detailed assessment and individualized exercise prescription may enhance symptom resolution and functional recovery.
Clinicians should adopt a multidisciplinary approach, integrating vestibular rehabilitation with management of coexisting symptoms such as fatigue and cognitive dysfunction. Careful patient selection and monitoring for treatment response are essential, given the variability in outcomes.
Awareness of the current evidence limitations should temper expectations and guide shared decision-making with patients. Documentation of vestibular function before and after therapy can support clinical evaluation and research efforts.
Future practice may benefit from emerging standardized vestibular rehabilitation protocols and incorporation of objective vestibular function testing to personalize interventions. Clinicians are encouraged to stay abreast of ongoing research to refine treatment strategies.