Vestibular Rehabilitation Shows Promise for Balance and Fatigue in Multiple Sclerosis, Review Finds

People living with multiple sclerosis often describe a frustrating combination of symptoms that no single drug seems to touch: unsteady balance, dizziness that turns a walk across the room into a calculated risk, and a bone-deep fatigue that no amount of rest relieves. A new systematic review and meta-analysis published in the Journal of Neurology suggests that a non-drug therapy long used for inner-ear disorders may help with several of these problems at once. The analysis, led by Hui-Hui Peng of Taipei Medical University Hospital together with Nguyen Thanh Nhu and Wen-Hsuan Hou, pooled data from thirteen randomized controlled trials involving 454 patients with multiple sclerosis and found that vestibular rehabilitation produced measurable improvements in balance, walking speed, walking endurance, dizziness, fatigue, and depression compared with conventional physiotherapy, usual care, or no intervention at all.

Vestibular rehabilitation is a structured exercise-based therapy designed to retrain the brain’s balance system. The vestibular organs of the inner ear, together with the visual system and proprioceptive feedback from muscles and joints, provide the sensory inputs the central nervous system integrates to keep us upright and oriented. In multiple sclerosis, demyelinating lesions can disrupt this integration at multiple points, damaging not only the peripheral vestibular pathways but also the cerebellar and brainstem circuits that calibrate the vestibulo-ocular reflex, the mechanism that stabilizes gaze during head movement, and the vestibulo-spinal pathways that stabilize posture. The therapy works by deliberately provoking these systems with head and eye movements, gaze-stabilization drills, balance exercises on progressively challenging surfaces, and habituation training, forcing the nervous system to recalibrate through compensatory neuroplastic adaptation.

Because multiple sclerosis is fundamentally a disease of the central nervous system, there has long been a question about whether rehabilitation approaches validated in peripheral vestibular disorders, such as benign paroxysmal positional vertigo or vestibular neuritis, would translate to patients whose balance problems arise from brain and spinal cord lesions. Previous reviews had hinted at benefits, but with limited trial numbers and heterogeneous outcome measures. The new analysis, which searched PubMed, EMBASE, the Cochrane Library, Web of Science, and ClinicalTrials.gov from inception to May 2026, represents the most comprehensive quantitative synthesis to date, applying PRISMA reporting standards and Cochrane methodology, including the RoB 2.0 risk-of-bias tool and GRADE certainty-of-evidence assessment.

The headline results are striking in their breadth. Balance, typically measured with instruments such as the Berg Balance Scale, the Functional Gait Assessment, and computerized dynamic posturography, improved with a standardized mean difference of 1.24, a large effect by conventional benchmarks, with a 95 percent confidence interval of 0.46 to 2.01. Walking speed improved with a mean difference of 0.19, and walking endurance, assessed through tests such as the two-minute and six-minute walk tests, showed a standardized mean difference of 0.43. Dizziness severity, most commonly captured by the Dizziness Handicap Inventory, fell by an average of 10.56 points, a change that approaches the thresholds generally considered clinically meaningful for that instrument.

Perhaps most intriguing for patients and clinicians are the effects on fatigue and mood. Fatigue is one of the most disabling and least well-treated symptoms of multiple sclerosis, and the meta-analysis found a standardized mean difference of minus 1.23, indicating a large reduction in favor of vestibular rehabilitation. Depression scores, measured with tools such as the Beck Depression Inventory, dropped by an average of 4.14 points. The authors’ mechanistic rationale is that by improving gaze stability and postural control, the therapy reduces the constant, exhausting effort of maintaining balance, which in turn may lift the psychological burden of dizziness and fear of falling. Postural control in multiple sclerosis has been shown to be intertwined with cognition and fear of falling, so a therapy that targets the sensory-motor machinery of balance may ripple outward into mental well-being.

Not every outcome favored the therapy. The analysis found no statistically significant differences between vestibular rehabilitation and control interventions in transfer ability, such as the five-times sit-to-stand test, in balance self-efficacy as measured by the Activities-specific Balance Confidence Scale, or in overall quality of life. The quality-of-life finding, with a standardized mean difference of 0.51 but a confidence interval spanning from minus 0.45 to 1.48, is particularly notable because it suggests that improvements in specific impairments have not yet demonstrably translated into broader gains in how patients rate their lives. The balance self-efficacy result, with a point estimate of 14.58 but a wide confidence interval, hints at a possible effect that larger studies may or may not confirm.

The authors are candid about the central limitation: the certainty of the evidence is generally low or very low under the GRADE framework. This reflects the realities of rehabilitation research. The thirteen trials varied in the specific exercise protocols used, from customized programs and the BEEMS protocol of balance and eye-movement exercises to Cawthorne-Cooksey-style exercises and booklet-based home programs. Sample sizes were modest, with 454 patients spread across all trials, blinding of participants is inherently difficult in exercise studies, and outcome measures differed from trial to trial, forcing the authors to use standardized mean differences that pool heterogeneous instruments. Random-effects models, as used here with Review Manager 5.4.1, account for between-study variability but cannot eliminate it.

There is also the question of clinical versus statistical significance. A standardized mean difference of 1.24 for balance sounds impressive, but its real-world meaning depends on whether the change exceeds the minimal clinically important difference for the scales involved, values that have been estimated for instruments such as the Berg Balance Scale and the six-minute walk test in multiple sclerosis populations. For some outcomes the pooled changes appear to cross those thresholds; for others the picture is less clear. The wide confidence intervals on several estimates, including transfer ability and balance self-efficacy, mean the true effect could range from negligible to substantial.

Even with these caveats, the review arrives at a moment of growing interest in central vestibular dysfunction. Multiple sclerosis is increasingly recognized as a cause of acute vestibular syndromes, and eye-movement abnormalities are among the most common clinical signs of the disease. As disease-modifying drugs continue to advance for relapsing forms of the illness, progressive forms remain stubbornly resistant to pharmacotherapy, and rehabilitation strategies that address mobility, fatigue, and mood represent some of the few tools available to preserve function. The finding that a relatively low-cost, low-risk exercise therapy may improve six distinct symptom domains is therefore significant, even if the evidence base needs reinforcement.

The authors’ conclusion is measured: vestibular rehabilitation may improve balance, walking speed, walking endurance, dizziness, fatigue, and depression in patients with multiple sclerosis, but larger randomized controlled trials are required before firm clinical recommendations can be made. For now, the analysis gives clinicians a stronger quantitative foundation for considering vestibular rehabilitation as an adjunct to traditional physiotherapy, and it gives trial designers a clear roadmap for the studies still needed, with adequately powered samples, standardized outcome measures, and follow-up long enough to determine whether the gains persist. For the millions of people worldwide living with multiple sclerosis, the message is cautiously hopeful: the brain’s balance circuitry, even when damaged, may retain a remarkable capacity to be retrained.

Subject of Research: Effectiveness of vestibular rehabilitation for balance, gait, dizziness, fatigue, and mood in multiple sclerosis

Article Title: Effectiveness of vestibular rehabilitation in patients with multiple sclerosis: a systematic review and meta-analysis of randomized controlled trials

Article References: Peng, H.-H., Nhu, N. T., & Hou, W.-H. (2026). Effectiveness of vestibular rehabilitation in patients with multiple sclerosis: a systematic review and meta-analysis of randomized controlled trials. Journal of Neurology, 273(9), Article 553. https://doi.org/10.1007/s00415-026-14082-8

Image Credits: AI Generated

DOI: 10.1007/s00415-026-14082-8

Keywords: multiple sclerosis, vestibular rehabilitation, systematic review, meta-analysis, balance, gait, dizziness, fatigue, depression, randomized controlled trials, neurorehabilitation, quality of life