788598

research-article2018
CRE0010.1177/0269215518788598Clinical RehabilitationViziano et al.

CLINICAL
Article REHABILITATION

Clinical Rehabilitation

Long-term effects of vestibular 2019, Vol. 33(1) 24­–33

© The Author(s) 2018
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DOI: 10.1177/0269215518788598
https://doi.org/10.1177/0269215518788598

gaming task procedure in unilateral journals.sagepub.com/home/cre

vestibular hypofunction: a 12-month

follow-up of a randomized
controlled trial

Andrea Viziano1 , Alessandro Micarelli1,2, Ivan Augimeri3,

Domenico Micarelli3 and Marco Alessandrini1

Abstract
Objective: To investigate the long-term effects of adding virtual reality–based home exercises to
vestibular rehabilitation in people with unilateral vestibular hypofunction.
Design: Follow-up otoneurological examination in two randomized groups following a previous one-
month trial.
Setting: Tertiary rehabilitation center.
Subjects: A total of 47 patients with unilateral vestibular hypofunction, one group (n = 24) undergoing
conventional vestibular rehabilitation and the other one (n = 23) implementing, in addition, head-mounted
gaming home exercises, 20 minutes per day for one month.
Interventions: One year after completing rehabilitation, patients underwent testing with static
posturography, video head impulse test, self-report questionnaires, and a performance measure.
Main measures: Vestibulo-ocular reflex gain, posturographic parameters such as length, surface, and
fast Fourier transform power spectra, self-report, and gait performance measure scores.
Results: Vestibulo-ocular reflex gain was significantly better with respect to pretreatment in both groups.
The mixed-method group showed significantly higher gain scores: mean (standard deviation (SD)) at
12 months was 0.71 (0.04), versus 0.64 (0.03) for the vestibular rehabilitation–only group (P < 0.001).
Accordingly, some classical posturography scores such as surface with eyes open and length with eyes
closed and low-frequency power spectra were significantly different between groups, with the virtual
reality group showing improvement (P < 0.001). Self-report measures were significantly better in both
groups compared to pretreatment, with significant improvement in the mixed-method group as compared
to conventional rehabilitation alone: Dizziness Handicap Inventory mean total score was 24.34 (2.8)
versus 35.73 (5.88) with a P-value <0.001.

1Department of Clinical Sciences and Translational Medicine, Corresponding author:

University of Rome “Tor Vergata,” Rome, Italy
2Department of Systems Medicine, Neuroscience Unit,
University of Rome “Tor Vergata,” Rome, Italy
3ITER Center for Rehabilitation, Rome, Italy
Andrea Viziano, Department of Clinical Sciences and
Translational Medicine, University of Rome “Tor Vergata,” Via
Montpellier, 1, E sud Tower, 00133 Rome, Italy.
Email: andrea.viziano@gmail.com
Viziano et al. 25
Conclusion: Results suggest that head-mounted gaming home exercises are a viable, effective, additional
measure to improve long-term vestibular rehabilitation outcomes.
Keywords
Vestibular rehabilitation, virtual reality, head-mounted devices, posturography, video Head Impulse Test
Date received: 3 December 2017; accepted: 21 June 2018
Introduction
Vestibular rehabilitation has been proven effective
in improving balance and gait in people with ves-
tibular disorders, whose daily life may be impaired
by dizziness and falls, as well as by concomitant
depression and anxiety. Central neuroplasticity
mechanisms like adaptation, habituation, and sub-
stitution underline the effectiveness of this inter-
vention, which can be provided through a variety
of methods lasting different periods of time.1,2
Although the short-term efficacy of conventional
vestibular rehabilitation has been widely ascer-
tained, there is no consensus or long-term data
about patient satisfaction and the absence of symp-
toms, with studies evaluating improvement reten-
tion after the suspension of vestibular rehabilitation
exercises ranging from a one- to six-month follow-
up.3–5 Due to the recent explosion of virtual reality
in the field of rehabilitation, the use of head-
mounted devices has been proposed in addition to
conventional vestibular rehabilitation therapy in
unilateral vestibular hypofunction patients.6 This
approach has been proved to be useful in maximiz-
ing vestibular rehabilitation outcomes, with mini-
mum simulator-related side effects.6 Virtual
reality-based devices have been tested in vestibular
rehabilitation by many clinicians, due to the possi-
bility of achieving habituation, substitution and
adaptation, effectiveness in people presenting vis-
ual vertigo, and positive effects on anxiety.4,7–9
In our previous study,6 the possible advantages
of the integration of head-mounted devices into a
vestibular rehabilitation protocol were demon-
strated, by comparing otoneurological and daily
life outcomes in a cohort of patients with vestibular
hypofunction randomized into two groups (one
treated with vestibular rehabilitation alone, the
other one undergoing a mixed-method protocol
including vestibular rehabilitation and head-
mounted device treatment over the same period of
time) immediately after completing a rehabilitation
cycle. This study is a 12-month follow-up evalua-
tion of the same study group. Long-term results
have been compared with both pretreatment and
posttreatment values to investigate possible differ-
ences in the outcomes related to additional virtual
reality–based rehabilitation.
Methods
Selection of patients
In line with previous studies demonstrating func-
tional correlations between vestibular dominance
and side of vestibular lesion,10,11 right chronic ves-
tibular hypofunction right-handed patients were
enrolled consecutively in the study at “Tor Vergata”
University Hospital of Rome. According to
accepted criteria,1 the diagnosis of chronic unilat-
eral vestibular hypofunction was achieved by
responses to bithermal water caloric irrigations,
with at least 25% reduced vestibular response on
one side when calculated by means of Jongkees’
formula.12,13 The study adhered to the principles of
the Declaration of Helsinki, and all participants
provided written informed consent.
Selection of patients—exclusion criteria
All study participants who met the following cri-
teria were excluded from the study: subjects with
diabetes; a history of cancer; HIV; neurological,
psychiatric or mood disorders; surgery; radiation;
or brain trauma. None of the subjects showed
liver or renal abnormalities, or were pregnant or
26 Clinical Rehabilitation 33(1)
breastfeeding. Moreover, patients with neuro-psy-
chiatric disorders (Parkinson’s disease,
Alzheimer’s disease, schizophrenia, multiple
sclerosis, and depression), lower respiratory tract
and/or lung diseases, active hepatitis, cirrhosis,
chronic renal failure, Vitamin B12 deficiency,
alcohol or drug abuse, cerebral vascular acci-
dents, insulin-dependent diabetes mellitus, hypo-
thyroidism, or Cushing syndrome were not
included in the study. We also excluded all sub-
jects taking drugs that could affect auditory and
visuo-vestibular functions.
None of the patients enrolled in the study under-
went previous vestibular rehabilitation treatment,
and they were all naïve to virtual reality–based
procedures.
Trial registration and random allocation
The study population consists of participants
belonging to a previous randomized controlled
pilot trial6 registered in the clinicaltrials.gov web-
site with identification number NCT03553264.
Patients had previously been allocated to two
matched groups—in terms of age, sex, body mass
index (BMI), pathology, and cause of vertigo—by
means of a computer-generated randomization
schedule.
Patient enrollment for the follow-up visit
Patients belonging to both groups, tested in the pre-
vious study, one undergoing only the conventional
vestibular rehabilitation therapy, and the other one
with the mixed protocol including head-mounted
device treatment in addition to the vestibular reha-
bilitation treatment, were called back 12 months
after the conclusion of the intervention. Patients
were contacted by means of a phone interview and
written consent was obtained for a follow-up
examination, if not already scheduled. These visits
were performed in a time frame not exceeding
10 days before or after exactly one year from
the last visit of the rehabilitation program.
Examinations were all carried out on the same
occasion, by one clinical researcher (A.V., who
was blinded to the treatment allocation), with a fur-
ther otoneurological examination and self-report
and performance measures evaluation (carried out
one week before and one week after the respective
rehabilitation protocol) which included a variety of
otoneurological tests.
Otoneurological testing
Video Head Impulse Test.  The EyeSeeCam System
(Interacoustics, Middelfart, Denmark) and the
technique proposed in previous studies14,15 were
used for the video Head Impulse Test measure-
ments. As per the instructions of the software man-
ufacturer (OtoAccess, Interacoustics), the
vestibulo-ocular reflex median gain values of both
sides recorded at 60 ms were extracted on an .xls
file for raw analysis. According to previous proce-
dures,14,15 a diagnosis of unilateral vestibular hypo-
function was re-confirmed in case of gain below
0.83, calculated as the lower cut-off value of the
gain–reference range (meannormal ± 2(standard devi-
ation; SD) equal to 0.91 ± 2 (0.04) = 0.83–0.99),
incorporating 95% of healthy population, age and
gender matched with the current population of
patients14 and regarding 87 normal volunteers in
our laboratory.6
Static posturography testing. Each patient was
instructed to maintain an upright position on a
standardized platform for static posturography
(EDM Euroclinic, MEDI-CARE Solutions, Bolo-
gna, Italy). The recording period was 60 seconds
for each test, with eyes closed or open while
standing on the stiff platform and the sampling
frequency was 25 Hz.16 The posturography param-
eters considered in our study were the trace length,
the surface of the ellipse of confidence, and the
fast Fourier transform elaboration of oscillations
on both the X (right–left) and Y (forward–back-
wards) planes. As in previous experiences,17,18
spectral values (power spectra) of body oscilla-
tions were subdivided into three groups: 0.01–
0.70 Hz (low-frequency interval); 0.70–1.00 Hz
(middle-frequency interval); and 1.00–5.00  Hz
(high-frequency interval).
Viziano et al. 27
Self-report and performance measures
1. The Italian Dizziness Handicap Inventory
consists of 25 questions designed to assess a
patient’s functional (nine questions), emo-
tional (nine questions), and physical (seven
questions) limitations;19 scores range from 0 to
100, with moderate and severe disability usu-
ally associated with scores above 30 and 60,
respectively.20
2. The Activities-specific Balance Confidence
scale was used to record the patient’s per-
ceived level of balance confidence during 16
everyday activities ranging from 0% to
100%.21
3. The Dynamic Gait Index examined the
patient’s ability to perform various gait activi-
ties on an eight-item scale;22 range is from 0 to
24, with scores of less than 19 indicating
increased risk of falls.
Vestibular rehabilitation and head-
mounted device protocol
The vestibular rehabilitation protocol, which was
administered to both study groups in the exact
same way, and the head-mounted device-based
home exercise program are described in the
Appendix.
Statistical analysis
The chi-square test was carried out to define associ-
ations between categorical factors in both groups.
Mean and SDs of otoneurological and self-report
and performance measures scores were calculated in
both vestibular rehabilitation and head-mounted
device groups before and after a four-week period of
treatment as well as during the follow-up visit after
12 months. In order to assess that data that were of
Gaussian distribution, the D’Agostino K-squared
normality test was applied (where the null hypothe-
sis is that the data are normally distributed).
A mixed analysis of variance (ANOVA) was
performed with group as the between-factor and
otoneurological and self-report and performance
measurement variables recorded before and after
four weeks of treatment as well as during the fol-
low-up visit after 12 months as the within subject
factors. Age, disease duration (in months), and
gender were treated as continuous and categorical
predictors. The significant cut-off level (α) was set
at a P-value of 0.05. In order to avoid family-wise
error, Bonferroni correction for multiple compari-
sons was used post hoc to test significant main
effects. The STATISTICA 7 package for Windows
was used for the statistical analysis.
Results
Patients
Among the 51 enrolled patients, two were using
antidepressant drugs, one did not report vestibulo-
ocular reflex gain below the calculated reference
range when undergoing video Head Impulse Test,
and one reported a history of diabetes. Therefore,
these patients were excluded. Among the remain-
ing 47 patients (vestibular rehabilitation–only
group: n = 24, head-mounted device group: n = 23)
who completed the randomized trial with no com-
pliance differences, all were re-tested at the pro-
grammed follow-up meeting (Figure 1) with the
following results:
Otoneurological testing
Vestibulo-ocular reflex gain.  When comparing long-
term vestibulo-ocular reflex gain values at the fol-
low-up visit, the head-mounted device group
patients showed significantly higher scores com-
pared to the vestibular rehabilitation-only group
(P = 0.003; Table 1, Supplementary Figure 1).
However, the vestibulo-ocular reflex gain in the
ipsilesional side, as measured 12 months after ves-
tibular rehabilitation with the video Head Impulse
Test, showed a significant increase compared to
pretreatment values in both the head-mounted
device (P = 0.0021) and the vestibular rehabilita-
tion–only group (P = 0.0025; Table 1, Supplemen-
tary Figure 1). When comparing the vestibulo-ocular
reflex gain to values measured immediately after
treatment, a non-significant reduction in mean
scores was found.
28 Clinical Rehabilitation 33(1)
Figure 1.  Flow-diagram of participants in the study.
Static posturography testing. Significant reduc-
tions were found in surface values during closed-
eyes condition (P = 0.0029), trace length values
during open-eyes condition (P = 0.0022) as well
as low-frequency interval power spectra out-
comes (closed eyes on X plane, P = 0.0028;
closed eyes on Y plane, P = 0.0026; eyes open on
X plane, P = 0.0024; eyes open on Y plane,
P = 0.0025) in the head-mounted device group
compared to the vestibular rehabilitation-only
group (Table 1, Supplementary Figure 2). These
findings reflect the within-subjects behavior,
which only demonstrated a significant reduction
of the abovementioned pretreatment and post-
treatment conditions in the head-mounted device
group (for details see Micarelli et al.6).
No significant within-subjects differences in
values measured one week and 12 months after
treatment were found in either group. Between-
groups and within-subject analyses showed no
significant difference in middle- and high-
frequency power spectra or in the surface during
open eyes and trace length in closed-eyes
condition.
 Viziano et al.

Table 1.  Significant follow-up between-group effects of otoneurological variables and self-report and performance measures in head-mounted device and
vestibular rehabilitation.
HMD pre HMD post HMD 12 months VRT pre VRT post VRT 12 months Between-group effect at
12 months
  Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Significance
Ipsilesional 0.38 (0.04) 0.51 (0.05) 0.71 (0.04) 0.37 (0.04) 0.43 (0.04) 0.64 (0.03) F(2, 90) = 21,531; P < 0.001
VOR gain
Low-frequency interval PS
CE X 8.53 (1.9) 6.5 (1.44) 6.61 (1.45) 8.41 (1.43) 7.6 (1.58) 8.3 (1.42) F(2, 90) = 47,457; P < 0.001
CE Y 8.36 (1.75) 6.05 (1.51) 6.21 (1.54) 8.19 (1.82) 7.29 (1.86) 8 (1.75) F(2, 90) = 97,318; P < 0.001
OE X 5.55 (0.49) 4.73 (0.55) 4.82 (0.54) 5.66 (0.46) 5.38 (0.46) 5.45 (0.46) F(2, 90) = 34,710; P < 0.001
OE Y 4.79 (0.36) 3.97 (0.41) 4.07 (0.39) 4.66 (0.39) 4.44 (0.34) 4.5 (0.35) F(2, 90) = 55,893; P < 0.001
Surface
CE 1696.07 (446.38) 1077.59 (341.48) 1108.42 (345.23) 1701.3 (505.33) 1364.96 (452.45) 1436.61 (449.46) F(2, 90) = 64,053; P < 0.001
Length
OE 644.65 (112.48) 395.63 (98.28) 431.49 (99.21) 639.77 (119.88) 568.52 (112.98) 604.14 (112.75) F(2, 90) = 226,66; P < 0.001
Self-report and performance measures
DHI— 16.26 (4.48) 7.13 (2.54) 6.52 (2.01) 15.73 (4.83) 9.73 (3.87) 9.73 (3.87) F(2, 90) = 15,335; P < 0.001
physical
DHI— 20.69 (3.49) 10.08 (2.13) 9.47 (2.1) 20.26 (3.48) 13.56 (3.07) 13.56 (3.07) F(2, 90) = 41,738; P < 0.001
emotional
DHI— 18.66 (5.41) 8.86 (2.61) 8.34 (2.14) 19.91 (4.61) 12.43 (3.9) 12.43 (3.9) F(2, 90) = 15,013; P < 0.001
functional
DHI—total 56.6 (5.13) 26.08 (2.92) 24.34 (2.8) 55.91 (5.3) 35.73 (5.88) 35.73 (5.88) F(2, 90) = 58,566; P < 0.001
DGI 14.39 (2.03) 24.69 (1.76) 24.69 (1.76) 13.91 (1.8) 20.65 (1.64) 19.87 (1.8) F(2, 90) = 11,510; P < 0.001
ABC 64.78 (5.44) 78.56 (4.61) 80.04 (4.65) 65.08 (5.75) 73.21 (6.01) 74.33 (5.86) F(2, 90) = 31,049; P < 0.001

CE: closed eyes; OE: open eyes; PS: power spectra; VOR: vestibulo-ocular reflex; DHI: Dizziness Handicap Inventory; DGI: Dynamic Gait Index; ABC: Activities-specific Bal-
ance Confidence scale; VRT: vestibular rehabilitation; HMD: head-mounted device.
Mixed-model ANOVA highlighting significant outcomes in otoneurological variables and self-report and performance measures, recorded before (pre) and after (post) treat-
ment and during the follow-up meeting (12 months) in patients undergoing only vestibular rehabilitation (VRT) or the mixed protocol including head-mounted device (HMD).
Exact P values in the text.
29
30 Clinical Rehabilitation 33(1)
Self-report and performance measures
Significant reductions were found in Dizziness
Handicap Inventory total score and subscales in
head-mounted device group compared to the ves-
tibular rehabilitation–only group at the follow-up
meeting (physical subscale, P = 0.0029; emotional
subscale, P = 0.0023; functional subscale,
P = 0.0027; total score, P = 0.002). Conversely, a
significant increase was found in the same com-
parison in the Dynamic Gait Index (P = 0.0026)
and Activities-specific Balance Confidence
(P = 0.0022) scores (Table 1, Supplementary
Figure 3).
As highlighted in previous experiences,6 the
within-subjects analysis yielded statistically sig-
nificant results of the abovementioned self-report
and performance measures in both groups com-
pared to pretreatment scores. No significant differ-
ences were found when posttreatment scores were
compared with scores evaluated at the follow-up
meeting.
Discussion
A total of 47 patients with unilateral vestibular
hypofunction undergoing vestibular rehabilitation
with or without the addition of a virtual reality–
based protocol with head-mounted devices, were
re-tested 12 months after the end of treatment by
means of the video Head Impulse Test, static pos-
turography, self-report, and performance measures.
To our knowledge, no previous trial involving ves-
tibular rehabilitation has evaluated the retention
outcome as far as 12 months after discontinuation.
Vestibulo-ocular reflex gain values maintained
significant improvement—especially in the head-
mounted device group—compared to pretreatment
values, as shown by the within-subjects analysis
on video Head Impulse Test scores. Although
these values were lower in both groups than those
measured immediately after treatment, these dif-
ferences were not significant. Moreover, the
patients in the head-mounted device group showed
higher vestibulo-ocular reflex gain values than the
vestibular rehabilitation-only subjects at the
12-month follow-up test (Table 1, Supplementary
Figure 1). Another interesting finding of this study
is the significant improvement in static posturog-
raphy scores observed in the head-mounted device
group alone. In particular, between-groups analy-
sis showed head-mounted device patients had sig-
nificantly lower surface and length scores—during
closed- and open-eyes conditions, respectively—
and in low-frequency power spectra (Table 1,
Supplementary Figure 2). This aspect is further
corroborated by the within-subjects analysis which
showed a postural sway improvement—especially
in the head-mounted device subjects—compared
to pretreatment in low-frequency power spectra
scores and in classical posturography parameters
like surface and length, in both open- and closed-
eyes conditions. In turn, it is worth pointing out
that the between-groups analysis showed signifi-
cant differences in self-report and performance
measures, like the Dizziness Handicap Inventory,
Activities-specific Balance Confidence, and
Dynamic Gait Index scores, which demonstrate a
significant improvement in both groups compared
to pretreatment scores. These results suggest a
synergic role, played by stimulation via the head-
mounted devices and the well-known mechanisms
of habituation, substitution, and adaptation pro-
vided by vestibular rehabilitation, in restoring the
balance function.
The significant improvement in vestibulo-ocular
reflex gain was maintained in both groups 12 months
after the end of treatment. This confirms previous
experiences, indicating that patient-tailored vestib-
ular rehabilitation may induce long-lasting adapta-
tions in the central nervous system and that patients
can remain free of symptoms after long periods of
time2,4,5 (Table 1, Supplementary Figure 1). As the
sensory mismatch challenges imposed by vestibular
rehabilitation cease with the end of treatment, it is
to be expected that a “damaged” vestibular system
will undergo deterioration, especially in elderly
subjects.23 However, head movements coupled with
reinforcing altered visual scene motion, which
occur during gameplay with head-mounted device
tasks, may explain why the virtual reality group
encountered reinforcing factors that significantly
improved the vestibulo-ocular reflex even for a
long period of time.6,24,25
Viziano et al. 31
Static posturography findings suggest that head-
mounted device exercises may induce specific,
long-lasting effects in ameliorating static balance
related to the vestibular sensorial inflow. In fact,
body sway within low-frequency intervals is con-
sidered to be mainly under vestibular control,18,26
suggesting a head-mounted device–related mecha-
nism of action on the neural centers integrating
postural control, enhancing vestibular contribution
compared to vestibular rehabilitation therapy
alone. Moreover, this behavior is confirmed by the
significant between-group differences in head-
mounted device and vestibular rehabilitation-only
groups in surface outcomes during closed-eyes
condition (Table 1, Supplementary Figure 2). In
fact, among other parameters, surface has been
associated with vestibular function27,28 and its
improvement—especially during challenging situ-
ations (i.e. with eyes closed)—may reinforce the
hypothesis of the maximization of vestibular input
in central postural signal integration.
The persistence of improvements in vestibular
function 12 months after discontinuation of the
exercises in the head-mounted device group could
be explained by taking into account the numerous
positive contributions of this modality, which is
widely used in neurorehabilitation,9,29–31 such as
providing task-oriented and graduated learning in a
variable and unpredictable fashion, often in a com-
fortable environment.32 The use of head-mounted
device–based exercises, in particular, has the
advantage of proximity to the eye, offering high-
resolution images33 and follows the user’s move-
ments, which makes them feel as part of the
computer-created environment.34
Another important point is that the between-
group analysis showed significant differences in
the self-report and performance measures, like
the Dizziness Handicap Inventory, Activities-
specific Balance Confidence, and Dynamic Gait
Index scores—while demonstrating a significant
improvement in both groups compared to pretreat-
ment scores. In particular, the Dynamic Gait Index
score results are of great significance, as this test is
a valid tool for gait performance in people with
balance and vestibular dysfunction. Some studies
have associated between-group differences in these
measures with greater differences in cohorts of
patients treated with different interventions for bal-
ance rehabilitation.35,36 This may indicate that a
relevant difference in outcomes, also confirmed by
widely accepted self-report scores such as the
Dizziness Handicap Inventory and Activities-
specific Balance Confidence, could be achieved by
the implementation of virtual reality.35 Such data
tend to confirm that (1) vestibular rehabilitation is
a valuable tool in avoiding significant worsening in
the quality of life following unilateral vestibular
hypofunction1,2,4 and (2) the head-mounted device–
specific contribution to self-report and perfor-
mance measures could be related to greater patient
involvement and adherence to treatment with a
home-based technique, as previously confirmed in
other experiences.3,8
However, this study suffers from some limita-
tions which have to be elucidated in order to ade-
quately interpret its main findings. First of all,
some factors, such as the individual variability in
accepting to undergo the rehabilitation protocol,
may have affected the selection of unilateral ves-
tibular deficit patients and thus reduced the possi-
bility to achieve a larger sample size. This aspect
goes together with the fact that no specific test was
administered apart from weekly monitoring of the
compliance of both groups of patients. Then, there
is the different amount of time spent in rehabilita-
tion in the two groups of patients, which probably
has an effect on the final outcomes and which was
driven by ethical reasons for administering the con-
ventional rehabilitation protocol to all the patients.
Bonferroni multiple correction, which may have
increased the likelihood of type II statistical errors,
was chosen in order to achieve an over-conserva-
tive approach so as not to encourage the possibility
of erroneously accepting the null hypothesis. This
should all be borne in mind when considering the
results. Moreover, the results in the head-mounted
device group may have been biased by patients
receiving additional treatment, with considerable
extra time (although short in absolute terms) spent
on rehabilitation procedures. Motivation and other
psychological factors must be accounted for when
interpreting the results, especially with respect to
the self-report measures.
32 Clinical Rehabilitation 33(1)
Considering these promising findings, we could
advocate the use of head-mounted devices in asso-
ciation with conventional vestibular rehabilitation.
The aim of this would be to maximize the effects,
even in the long term, on patients affected by unilat-
eral vestibular hypofunction. It may also be possible
to achieve these results in routine practice, espe-
cially if the trainer has adequate experience and has
prepared the patients properly. The motivation of
these patients, who spend a lot of their time in both
vestibular and virtual rehabilitation, is another deter-
mining factor. Finally, there should be a suitable bal-
ance between the low cost of head-mounted device
models and the technical features of smartphones, in
order to both ensure accessibility and limit any side
effects, which could affect compliance.
Clinical messages
•• The positive effects of vestibular reha-
bilitation on vestibulo-ocular reflex,
static posture, and performance measures
showed retention at a 12-month follow-
up examination in a group of patients
with unilateral hypofunction.
•• After one year, the use of virtual reality
mixed with vestibular rehabilitation
yielded better otoneurological scores
than vestibular rehabilitation alone.
Acknowledgements
A.M., A.V., and M.A. conceived the study. I.A and D.M.
collected the data. A.V. and M.A. performed data analysis
and interpretation, A.V., A.M., and M.A. wrote the paper.
All authors read and approved the final manuscript.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest
with respect to the research, authorship, and/or publica-
tion of this article.
Funding
The author(s) received no financial support for the
research, authorship, and/or publication of this article.
ORCID iD
Andrea Viziano https://orcid.org/0000-0002-6413-
1785
Supplemental material
Supplemental material for this article is available online.
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