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Review Article
Clinical application of virtual reality for vestibular rehabilitation
Sung Kwang Hongorcid
Research in Vestibular Science 2024;23(4):124-131.
DOI: https://doi.org/10.21790/rvs.2024.019
Published online: December 15, 2024

Department of Otorhinolaryngology-Head and Neck Surgery, Hallym University College of Medicine, Anyang, Korea

Corresponding author: Sung Kwang Hong Department of Otorhinolaryngology-Head and Neck Surgery, Hallym University College of Medicine, 22 Gwanpyeong-ro 170beon-gil, Dongan-gu, Anyang, 14068, Korea. E-mail: skhong96@hallym.ac.kr/ent.skhong96@gmail.com
• Received: October 26, 2024   • Revised: November 18, 2024   • Accepted: November 24, 2024

© 2024 The Korean Balance Society

This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • Virtual reality has emerged as a promising tool in vestibular rehabilitation therapy (VRT), offering immersive and interactive environments that enhance patient engagement and adherence to therapy. Its potential lies in delivering controlled, customizable exercise protocols that simulate real-world challenges in a safe, monitored environment. This allows healthcare providers to tailor exercises based on gaze stabilization, vestibulo-ocular reflex training, and balance training, according to a patient’s specific complaints, symptoms, and progress. While cybersickness is a potential concern with virtual reality interventions, patients with vestibular loss are generally less susceptible to the visual-vestibular mismatch that often causes motion sickness. Studies have shown that side effects, such as nausea or discomfort from cybersickness, are minimal for most patients undergoing virtual reality-based VRT. Despite these promising results, further research is needed to fully validate the effectiveness of virtual reality interventions in VRT. This article will explore the current status and future potential of virtual reality in VRT, including considerations for its clinical application and areas for future research.
  • Keywords: Vertigo; Dizziness; Rehabilitation; Virtual reality; Virtual reality exposure therapy
An immediate loss of vestibular function typically leads to vertigo and severe postural instability. These symptoms improve over time through vestibular compensation, which occurs via substitution or adaptation of the remaining sensory information [1]. Vestibular rehabilitation therapy (VRT) is an exercise-based treatment program designed to promote vestibular compensation through processes such as adaptation and substitution. The program was first developed by Cawthorne [2] and Cooksey [3] for the treatment of peripheral vestibular disorders. Numerous researchers have expanded the indications for VRT by proving its efficacy in patients with dizziness from various pathologies, not limited to peripheral vestibular disorders. As a result, this treatment method is commonly used for patients with dizziness caused by a variety of factors, including central vertigo and psychogenic dizziness, in addition to peripheral vestibular dysfunction [1,4-8].
However, patients with severe postural instability need to perform exercises several times a day over the course of weeks or months to achieve successful clinical outcomes. This can be difficult to maintain, and low adherence to the VRT program often becomes a barrier to success. Given the critical role of regular vestibular rehabilitation exercises in alleviating symptoms, gamified virtual reality has been introduced into clinical settings to enhance patient engagement and adherence. This article will explore how virtual reality has transformed traditional VRT programs for patient care.
Cellular recovery, sensory substitution, habituation, and adaptation are the main mechanisms that contribute to the recovery of function following vestibular deficits [9]. Although anatomical recovery may support vestibular function restoration, it remains unclear whether hair cell regeneration plays a significant role in the recovery of vestibular function in humans while adaptation, habituation, and sensory substitution are key mechanisms for restoring vestibular function, as supported by physiological evidence [2,7,8,10]. Thus, classical VRT is structured around these principles: (1) habituation, achieved through repetitive movements to reduce sensitivity to stimuli, (2) adaptation exercises to recalibrate the vestibulo-ocular reflex (VOR) by correcting retinal slip (blurred vision caused by misalignment of eye and head movements), and (3) sensory substitution exercises that enhance the use of visual and somatosensory systems to compensate for reduced vestibular function. In clinical practice, VRT begins with a comprehensive evaluation, including medical records review, patient history, and assessments of eye movement, gaze stability and balance. Based on these findings, a personalized exercise program is developed and explained to the patient. The most common exercises include gaze stabilization or VOR adaptation exercises (Fig. 1). Active eye and head movements while focusing on a target help promote recovery by recalibrating the VOR, aiding in the restoration of function.
Research indicates that individualized home-based exercise programs are the most effective treatment for patients with vestibular dysfunction [11]. However, performing these programs can sometimes be tedious, and symptoms may initially worsen. As a result, adherence may be low, as seen in other physical therapies, where up to 65% of patients struggle to follow through [12,13]. Poor adherence negatively affects healthcare outcomes, reduces treatment efficacy, and increases costs. Kalderon et al. [14] suggested that certain facilitators could improve adherence, such as providing patients with quantitative and visual feedback (e.g., graphs), effective time management strategies, and more detailed exercise instructions. Thus, if these facilitators are incorporated into the current VRT program, it is expected to improve adherence over time with consistent effort. As a result, patients may find themselves better able to participate in daily life activities.
Virtual reality is a computer-generated simulation of an environment that mimics reality and can be interacted with using special electronic equipment. It can include varying levels of immersion, designed to create a sense of presence by intentionally stimulating the user’s senses to simulate real-world experiences [15] (Fig. 2).
Given that VRT promotes vestibular compensation through active eye and head movements, focusing on a target, and balance exercises, it can create an ideal environment for more engaging rehabilitation. This approach may lead to improved compliance with exercise routines, as the active nature of the exercises makes them more interactive and motivating for patients. Indeed, it has been reported that the attractive components of virtual reality may contribute to successful outcomes [16]. This immersive environment enhances patient engagement, potentially leading to more effective rehabilitation, and also enables visual-vestibular interactions through abundant visual stimuli [17]. These factors together can improve the overall effectiveness of the rehabilitation process. Additionally, sensors integrated into virtual reality devices can provide real-time feedback, enhancing the accuracy of exercise performance. This feedback can serve as a facilitator, helping to improve adherence to VRT by making exercises more precise and engaging for patients [18,19]. There are several levels of immersion in virtual reality for VRT, each with distinct characteristics and therapeutic applications (Fig. 2). Non-immersive virtual reality utilizes computers, video game consoles, or smartphone applications, along with input devices such as keyboards, mice, and hand controllers. While it allows users to interact with activities within the software, it does not fully engage the user in the virtual environment, maintaining their awareness and control of the physical surroundings. VRT using the Nintendo Wii Fit Plus with a balance board has demonstrated positive effects on clinical outcomes for patients with dizziness. Despite its limited assistance with gaze stabilization and large-scale movements, studies have shown that it can still be beneficial in improving balance and stability in this patient population [20,21].
Semi-immersive virtual reality provides a partial virtual environment, often through digital images projected in three-dimensional (3D) format. Users can easily reorient themselves to their physical environment by looking away from the virtual display. This level of immersion is typically generated with expensive equipment like 3D projectors, seen in IMAX theaters or specialized research facilities. The Balance NAVE (Multisensory Virtual Reality Center, University of Pittsburgh), featuring three back-projected screens, one front-projected floor, and a surface with rotation and translation capabilities, was first introduced for use in VRT [22]. However, VRT using those cave automatic virtual environments while effective, is less accessible for public or home use due to their high cost and complexity.
Fully immersive virtual reality involves head-mounted displays (HMDs), such as Oculus (Meta), Vive (HTC), and FOVE (FOVE) delivering high-resolution content and a wide field of view that fully immerses the user in a virtual world. This type of virtual reality allows for a sense of presence and interaction with virtual objects, making it the most immersive form of virtual reality. It has been reported that VRT using HMDs with eye and head tracking capabilities provides higher goal-directed attention and increased activation of brain networks during therapy [19]. This enhanced focus and engagement hold promise for more successful outcomes in VRT, improving the effectiveness of the rehabilitation process.
Choosing the appropriate level of immersion for VRT depends on the individual patient’s vestibular function and circumstances. Non-immersive virtual reality is often easier to use at home but may be limited in providing the detailed feedback and specific protocol required for VRT. On the other hand, fully immersive virtual reality can offer more comprehensive protocols by providing a highly engaging environment, but it may not be well-tolerated by all patients. The isolated environment created by fully immersive virtual reality during exercises could increase the risk of falls or other accidents, especially for patients with severe vestibular loss. Therefore, careful consideration and monitoring are necessary to ensure safety during therapy and healthcare providers should determine the most suitable level of immersion for each patient’s treatment plan. Augmented reality (AR) or mixed reality in HMDs could serve as an alternative choice for patients with severe vestibular loss (Fig. 3).
Virtual reality has the potential to enhance patient engagement by making therapy more interactive and enjoyable. Virtual reality systems specifically designed for VRT have been developed to achieve three primary goals, consistent with standard VRT; (1) reduce symptoms, (2) improve gaze stabilization, and (3) improve postural stability. To accomplish these goals, virtual reality can offer several benefits for individuals with dizziness, including (1) better control and monitoring of the VRT dose, (2) customizing the virtual environment to match the patient’s specific complaints [16,23], and (3) facilitating changes in the VOR gain [24,25]. By incorporating those benefits of virtual reality, VRT can become more dynamic and simulate real-world scenarios, potentially improving adherence and outcomes.
Specifically, eye and head tracking sensors integrated with virtual reality devices provide real-time feedback and allow for precise monitoring of the exercises being performed, including the dose and accuracy of eye and head movements. Additionally, virtual environments can be tailored to the patient’s specific complaints. For example, if a patient experiences difficulty in environments like tunnels or bridges, those scenes can be simulated to help with adaptation and desensitization. This level of customization and real-time feedback is not possible with standard treatment techniques, making virtual reality a powerful tool in vestibular rehabilitation.
Cybersickness can be a barrier to the general use of virtual reality, as nausea, vomiting or various discomforts may arise, especially in patients with hypersensitivity. However, research suggests that the vestibular system’s involvement in motion sickness, particularly through sensory conflict, is a key factor. Thus, patients with vestibular loss are typically less susceptible to motion sickness because they typically lack significant vestibular function, which would otherwise trigger visual-vestibular conflicts [26,27]. The absence of visual-vestibular mismatch in patients with vestibular loss reduces their susceptibility to motion sickness. Since cybersickness arises through a similar mechanism as motion sickness, this may explain why cybersickness is less of an issue for these patients. As a result, cybersickness is less likely to be a concern during VRT using virtual reality, making it a more viable and effective treatment option for individuals with vestibular dysfunction. In fact, two studies have shown significant decreases in Simulator Sickness Questionnaire scores after VRT using virtual reality [24,28], indicating its potential safety and effectiveness in this context.
Several studies have reported that VRT using virtual reality has led to significant improvements in VOR gain in patients with unilateral vestibular loss. Patients who underwent a combination of virtual reality-based VRT and conventional rehabilitation revealed better outcomes in the Dizziness Handicap Inventory (DHI) score [29] and Dynamic Gait Index compared to those who received only conventional rehabilitation [24,25]. Additionally, improvements have been observed in individuals with symptoms of visual discomfort [30]. There is also evidence that virtual reality can enhance balance in people with mild head injuries [31], older adults at risk of falls [25], and individuals with Ménière’s disease [32]. Interestingly, regardless of the type of device used, virtual reality has been shown to improve balance in people with peripheral vestibular disorders [16,23,24,32].
A published systematic review on the effectiveness of virtual reality for VRT demonstrated the promising potential of virtual reality intervention in this area. The review concluded that the duration of time spent in virtual reality-based training contributed more to its effectiveness than the number of sessions. As a result, longer virtual reality sessions over a shorter period of time may be both effective and convenient for patients undergoing vestibular rehabilitation [33]. However, the review also noted significant limitations due to the considerable differences in protocols used and outcome evaluations among the selected studies. Additionally, the methodological quality of the studies was not ideal, as only four of the seven studies included had a control group. These limitations make it challenging to generalize the findings and emphasize the need for more standardized, high-quality research in this field.
Other systematic reviews concluded that virtual reality interventions effectively achieved the primary objectives of vestibular rehabilitation, as evidenced by improvements in DHI scores [29,34]. Additionally, a meta-analysis demonstrated that virtual reality intervention, as a vestibular rehabilitation tool, offers potential clinical benefits. It was found to improve both objective parameters, such as posturography, and subjective symptom scales, including the DHI, Vertigo Symptom Scale, and Visual Analogue Scale, in patients with peripheral vestibular disorders, showing greater effectiveness than conventional rehabilitation methods [35].
Regarding the side effects of virtual reality interventions, Micarelli et al. investigated changes in Simulator Sickness Questionnaire scores after VRT using virtual reality [24]. They found that symptoms decreased over time, with significant reductions in nausea, oculomotor stress, and disorientation scores from the first to the fourth week of the virtual reality-based exercise program. The study concluded that patients were safely habituating to the virtual reality stimuli. Similarly, Pavlou et al. [30] reported consistent findings, showing no major side effects following virtual reality exposure. Additionally, no significant side effects, including major cybersickness, incidents, or falls, were reported in any of the studies.
As of September 6, 2024, the U.S Food and Drug Administration (FDA) has authorized 69 medical devices incorporating AR and virtual reality technologies (source: FDA Digital Health Center of Excellence). Although the REAL System (Penumbra Inc.) and MindMotion PRO/GO (MindMaze) have received FDA clearance for neurorehabilitation, no digital content specifically intended for VRT has been FDA-approved at the time of writing. However, a wide range of virtual and AR hardware and software is potentially available for VRT. NeuroEars Inc. recently completed an exploratory clinical trial, approved by the Ministry of Food and Drug Safety of Korea, to evaluate the efficacy of digital therapeutics for VRT. As a result, digital therapeutics using virtual reality for VRT could play a significant role in augmenting or even replacing traditional VRT options.
In summary, numerous studies have demonstrated that virtual reality can enhance the effectiveness of vestibular rehabilitation by making it more engaging and potentially improving patient compliance with exercises. Systemic reviews suggest that VRT using virtual reality may improve subjective symptoms more effectively than standard VRT. Additionally, side effects like cybersickness have not been significant. However, further research is necessary to validate the effectiveness of virtual reality in treating vestibular conditions, identify the most suitable hardware and software, and determine the appropriate balance between virtual reality intervention and traditional vestibular therapy. For now, it remains best practice to use virtual reality for vestibular rehabilitation under the supervision of a healthcare professional.

Funding/Support

This work was supported by the Basic Science Research Program through the National Research Foundation of Korea, funded by the Ministry of Education (NRF-2023R1A2C1005171) and grants of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute, funded by the Ministry of Health and Welfare (HR18C0016060024).

Conflicts of Interest

No potential conflict of interest relevant to this article was reported.

Availability of Data and Materials

All data generated or analyzed during this study are included in this published article. For other data, these may be requested through the corresponding author.

Fig. 1.
Vestibulo-ocular reflex (VOR) exercise (A, x1 exercise; B, x2 exercise). (A) The patient focuses on a stationary target (like a dot or letter on a wall) while moving their head side to side or up and down. (B) This is a more advanced version of the VOR x1 exercise. Both the target and the head move in opposite directions (e.g., the patient moves their head left while moving the target to the right). These exercises are aimed at recalibrating the VOR to improve balance and reduce dizziness or blurred vision (retinal slip). Adapted from the beta-version of “Recommendations for evaluation and treatment of customized vestibular exercise” (Task Force Team for Vestibular Rehabilitation Treatment of The Korean Balance Society; 2017. Unpublished data).
rvs-2024-019f1.jpg
Fig. 2.
The current virtual reality is achieved through the use of head-mounted displays, which isolate the user from the real-world environment and present a virtual environment via lightweight, high-resolution screens and lenses. In the past, virtual reality simulations were sometimes created using a system known as a CAVE (Cave Automatic Virtual Environment), where projectors or large screens displayed the virtual environment on the walls of a room, surrounding the user.
rvs-2024-019f2.jpg
Fig. 3.

Technical distinctions: the basics of virtual reality and the two kinds of augmented reality.

Augmented reality, particularly the immersive kind, is typically achieved in two main ways. The first is pass-through augmented reality, where one or two cameras are mounted on the front of a virtual reality head-mounted display (HMD), allowing real-world video footage to be overlaid onto the virtual scene displayed by the HMD. In this method, the user doesn’t view the real world directly but through the camera feed. The second method is see-through augmented reality, where the user views the real world directly through clear goggles or glasses, while virtual elements are displayed on transparent lenses.
rvs-2024-019f3.jpg
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      Clinical application of virtual reality for vestibular rehabilitation
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      Fig. 1. Vestibulo-ocular reflex (VOR) exercise (A, x1 exercise; B, x2 exercise). (A) The patient focuses on a stationary target (like a dot or letter on a wall) while moving their head side to side or up and down. (B) This is a more advanced version of the VOR x1 exercise. Both the target and the head move in opposite directions (e.g., the patient moves their head left while moving the target to the right). These exercises are aimed at recalibrating the VOR to improve balance and reduce dizziness or blurred vision (retinal slip). Adapted from the beta-version of “Recommendations for evaluation and treatment of customized vestibular exercise” (Task Force Team for Vestibular Rehabilitation Treatment of The Korean Balance Society; 2017. Unpublished data).
      Fig. 2. The current virtual reality is achieved through the use of head-mounted displays, which isolate the user from the real-world environment and present a virtual environment via lightweight, high-resolution screens and lenses. In the past, virtual reality simulations were sometimes created using a system known as a CAVE (Cave Automatic Virtual Environment), where projectors or large screens displayed the virtual environment on the walls of a room, surrounding the user.
      Fig. 3. Technical distinctions: the basics of virtual reality and the two kinds of augmented reality.Augmented reality, particularly the immersive kind, is typically achieved in two main ways. The first is pass-through augmented reality, where one or two cameras are mounted on the front of a virtual reality head-mounted display (HMD), allowing real-world video footage to be overlaid onto the virtual scene displayed by the HMD. In this method, the user doesn’t view the real world directly but through the camera feed. The second method is see-through augmented reality, where the user views the real world directly through clear goggles or glasses, while virtual elements are displayed on transparent lenses.

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      Clinical application of virtual reality for vestibular rehabilitation
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