How Much Vestibular Rehabilitation Is Enough After Concussion?

Vestibular rehabilitation after concussion is often prescribed using broad principles, but clinicians still face a practical question: how hard and how often should a patient train?

The 2026 Targeted Rehabilitation Exercises for Vestibular impairments, or T-REV, randomised clinical trial examined different exercise doses after mild traumatic brain injury. It compared programmes performed once or twice daily and at lower or higher symptom-related intensity.

What did the trial find?

The study included 120 participants. The prespecified comparisons between approximately 30 per cent and 70 per cent exercise intensity, and between once-daily and twice-daily practice, were equivocal. In other words, the trial did not establish a clearly superior dose combination.

Across the study groups, participants improved by an average of about 16 points on the Dizziness Handicap Inventory at four weeks. This is meaningful as a group-level change, but without a non-exercise control group it cannot all be attributed to the exercise programme. Natural recovery, clinical contact and other care may also have contributed.

Why a neutral dose result is still useful

A trial does not fail simply because one dose is not clearly superior. The result suggests that more frequent or more provocative exercise is not automatically better. It also reinforces the need to consider adherence, symptom recovery, exercise quality and the patient's wider clinical presentation.

About 20 per cent of participants experienced adverse events. This does not mean vestibular exercise is unsafe, but it highlights the importance of monitoring and adjusting the programme rather than using a rigid dose for everyone.

Important limitations

The trial recruited 120 participants against an intended sample of 252, reducing statistical power. The dose contrasts may therefore have been too small, or the study too underpowered, to identify modest differences. The programme also sits within the complexity of mild traumatic brain injury, where cervical, autonomic, migraine, visual and psychological factors may alter exercise tolerance.

A practical dosing framework

Instead of assuming that the highest dose is best, clinicians can progress exercise using four questions:

• Does the task target the impairment identified during assessment?
• Is the symptom response mild, expected and short lived?
• Can the patient perform the movement accurately without substituting?
• Is performance improving across sessions and transferring to daily activity?

Useful variables include head speed, target size, visual background, stance, walking, duration, repetitions and cognitive load. Change one or two variables at a time so that the reason for a symptom response remains interpretable.

Where HeadX Kross and Duo may fit

HeadX Kross can support graded gaze stability, head movement and cervical target tasks. HeadX Duo can add objective information about movement amplitude, direction and consistency. These tools may make a home or clinic programme more measurable, but they do not prescribe the correct dose automatically.

The clinician still needs to decide whether symptoms reflect an acceptable training response or a sign that the task, diagnosis or progression should be reconsidered.

For practical task examples and wider context, see the HeadX exercise programme and our guide to vestibular disorders and dizziness rehabilitation.

Clinical takeaway

The T-REV trial does not identify one universally optimal vestibular exercise dose after concussion. It supports a more useful principle: choose a targeted starting dose, monitor response and progress according to performance and recovery rather than assuming that more is always better.

Source: Sparto et al. Effect of Dose of Targeted Rehabilitation Exercises for Vestibular Impairments following mTBI on Dizziness Handicap: A Randomized Clinical Trial, 2026.

This article is for professional education and does not replace individual clinical assessment.