Vestibular Rehabilitation in Multiple Sclerosis: What Does the Evidence Show?
Richard Wheatley
Balance impairment and dizziness are common in multiple sclerosis, but the underlying contributors vary. Sensory integration, central vestibular processing, vision, weakness, fatigue, spasticity and confidence may all influence function. This makes targeted rehabilitation attractive, but also difficult to standardise.
A 2026 systematic review and meta-analysis by Piatti and colleagues examined the effectiveness of vestibular physical therapy for balance and dizziness in people with multiple sclerosis. Sixteen studies were included.
What did the review find?
For the Dizziness Handicap Inventory, the pooled effect favoured vestibular physical therapy, with a Hedges' g of 1.451. The confidence interval ranged from 0.190 to 2.713.
That headline effect appears large, but heterogeneity was also very high, with an I-squared value of 92.6 per cent. This means the included study results differed substantially. Differences in participants, disease severity, interventions, comparators, dose and outcome timing may all have contributed.
The pooled result for the Activities-specific Balance Confidence scale was not statistically significant. This distinction matters because a reduction in dizziness-related handicap does not guarantee a corresponding improvement in balance confidence.
How should clinicians interpret this?
The review supports vestibular rehabilitation as a reasonable consideration for selected people with multiple sclerosis and dizziness or balance impairment. It does not support a single protocol for everyone with the condition.
Assessment should identify the dominant limitations. A programme focused on gaze stability may be appropriate for one person, while another may need sensory integration, dynamic balance, walking with head movement, cervical sensorimotor work or fatigue-aware strength and conditioning.
What high heterogeneity means in practice
High heterogeneity is not simply a statistical footnote. It warns us that the average result may not represent every patient or every programme. Clinicians should expect different responses and should define what success will look like before starting treatment.
Useful measures may include:
- dizziness-related handicap;
- balance confidence;
- gaze stability or dynamic visual acuity;
- standing and walking balance;
- head movement tolerance;
- falls or near falls; and
- fatigue and participation in meaningful activities.
Where HeadX may fit
HeadX Kross can support structured head-eye and target-based tasks, including graded head movement during stance or gait when safe. HeadX Duo may help quantify cervical movement and repositioning when cervical sensorimotor impairment is part of the assessment.
The devices should be used to support a defined rehabilitation objective, not simply because dizziness is present. They were not evaluated directly in the studies included in this review.
Clinical takeaway
Vestibular physical therapy appears capable of improving dizziness-related outcomes in some people with multiple sclerosis. The evidence is encouraging, but the marked variation between studies favours individual assessment, measured progression and outcome tracking over a fixed protocol.
Source: Piatti et al. Effectiveness of vestibular physical therapy on balance and dizziness in people with multiple sclerosis: A systematic review and meta-analysis. Journal of Vestibular Research, 2026.
This article is for professional education and does not replace individual clinical assessment.