Researchers removed 5,519 excess completely identical rows before analysis. They retained non-identical rows recorded for the same patient at the same time and disclosed this decision. American Society of Anesthesiologists physical status was linked only when both the patient and exact encounter or start time matched. The primary cohort comprised 120,680 assessments from 45,177 patients and 15 assessors. Logistic mixed models from M0 through M4 were used to account for repeated patients and to incorporate year, ward and available case-mix information.

Corrected assessor-specific rates ranged from 0.14% to 13.19% for a nausea or vomiting code of at least 1, from 0.10% to 16.43% for a dizziness code of at least 1, and from 0% to 7.78% for a documented sedation score of at least 1. Assessor-only variance partition coefficients were 28.1% for nausea or vomiting, 42.5% for dizziness and 67.6% for sedation. These figures describe variation in the corrected recorded rates, rather than causal effects of assessor behavior or differences in patients’ clinical risk.

The adjusted analysis was incompletely estimable. Of 14 primary-cohort models with numeric result records, nine met the prespecified numerical acceptance criteria and five were not estimable; three accepted fits were singular. For M3, two models produced median odds ratios of 1.00 and 1.02 but were singular, while the third was not estimable. Sedation M4 remained not estimable after the prespecified fallback attempts. A post hoc amendment approved by the corresponding author preceded the remaining restricted-cohort models, but those six models were not run; the restricted cohorts were instead summarized descriptively with Wilson 95% confidence intervals. The authors concluded that prospective validation is required before these routinely recorded fields are used for benchmarking.

Subject of Research: Variability in routinely recorded postoperative symptom fields among nursing assessors

Article Title: Between-assessor and temporal heterogeneity in routinely recorded postoperative symptom fields: a five-year retrospective observational study of 121,755 nursing assessments

Article References: Ge, J., Chen, S., Xie, F., Zhang, Q., Cao, N., Zhang, S., Wang, T., Ding, R., Li, Z., Cao, X., & Kong, Q. (2026). Between-assessor and temporal heterogeneity in routinely recorded postoperative symptom fields: a five-year retrospective observational study of 121,755 nursing assessments. BMC Nursing. https://doi.org/10.1186/s12912-026-05380-7

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05380-7

Keywords: postoperative symptoms, patient-controlled analgesia, nursing assessments, assessor variability, nausea and vomiting, dizziness, sedation, retrospective cohort study, mixed-effects models, benchmarking, Between-assessor, temporal

The cerebellum, tucked beneath the rear of the skull, is best known for fine-tuning movement. But a substantial portion of it, the vestibulocerebellum, is devoted to calibrating the vestibulo-ocular reflex, or VOR, the automatic eye movement that keeps images stable on the retina when the head moves. When this calibration fails, patients experience the world as a blur of motion and feel profoundly unsteady. The Korean team’s report shows that when inflammation strikes this region, the resulting eye-movement abnormalities can be so distinctive that they point directly to cerebellar disinhibition, the loss of the cerebellum’s normal restraining influence on vestibular circuits.

The most striking finding in the case involves what the authors call reversed corrective saccades. During the head impulse test, a bedside maneuver in which the examiner turns the patient’s head rapidly and unexpectedly while the patient fixes their gaze on a target, a healthy vestibular system generates a compensatory eye movement that keeps the eyes locked on the target. If the reflex is weak, the eyes are dragged off target with the head, and the patient makes a quick corrective saccade back to the target. In cerebellar disease, however, the corrective movement can go the wrong way, jumping in the same direction as the head turn rather than back toward the target. This paradoxical sign, previously documented in acute cerebellar dysfunction by Choi and colleagues in a 2014 study, indicates that the inhibitory brake normally applied by the cerebellum has been released, allowing the vestibular response to overshoot rather than undershoot.

Equally revealing was the frequency-dependent behavior of the vestibulo-ocular reflex. The team observed VOR hyperactivity that varied with the frequency of head rotation, a pattern that helps localize the problem to specific cerebellar structures. The nodulus and uvula, midline structures of the vestibulocerebellum, are known from decades of experimental work, including classic studies by Cohen and colleagues published in 2002, to control the spatial orientation of the angular vestibulo-ocular reflex and to regulate the velocity storage mechanism, a central process that prolongs and shapes vestibular signals. The flocculus, by contrast, exerts direct inhibitory control over the VOR gain itself. When the flocculus is damaged, as Yacovino and colleagues described in isolated floccular infarction, the VOR gain rises, producing hyperactive eye responses and oscillopsia, the distressing sensation that the visual world is jumping.

Acute cerebellitis is an uncommon diagnosis, and its presentation in adults is rarer still. Most of the literature concerns children, in whom the condition frequently follows viral infections or arises with autoimmune antibodies against neural targets. A large Italian multicenter retrospective study published in 2017 by Lancella and colleagues documented the pediatric experience over eleven years, while a 2023 European study by Quack and colleagues systematically examined autoantibody status, neuroradiological findings, and clinical features in children with the condition. In adults, reports are largely confined to individual case descriptions, such as the review by Van Samkar and colleagues published in BMC Research Notes in 2017. The scarcity of adult cases means that each well-documented patient adds meaningful weight to the clinical map of the disease.

What makes this case particularly instructive is the predominance of vestibular symptoms. A patient who complains primarily of dizziness and imbalance is far more likely to be evaluated for benign paroxysmal positional vertigo, vestibular neuritis, or other inner ear disorders than for brain inflammation. Yet the eye-movement examination, performed with modern video head impulse testing, can separate these possibilities with remarkable precision. Video head impulse testing has become a cornerstone of the assessment of central vestibular disorders, as summarized by Choi, Kim, and Kim in a 2018 review in Neurology, because it measures the gain of the vestibulo-ocular reflex across individual semicircular canals and captures the corrective saccades that reveal where in the vestibular pathway the fault lies.

The frequency dependence of the VOR abnormality carries specific mechanistic significance. The vestibulo-ocular reflex operates across a range of head movement frequencies, from slow postural sway to rapid voluntary head turns. Different cerebellar regions modulate the reflex at different points along this spectrum. Studies of patients with chronic degeneration of the vestibulocerebellum by Bertolini and colleagues suggested that vestibular self-motion perception is shaped by the velocity storage mechanism, and work by Lee and colleagues on spinocerebellar ataxia type 6 traced how vestibular function evolves during head impulses in a degenerative disease. Against this background, the acute, frequency-dependent hyperactivity seen in the present case of cerebellitis stands out as a signature of sudden disinhibition rather than gradual degeneration, offering a dynamic window into cerebellar physiology that chronic conditions cannot provide.

The concept of cerebellar disinhibition unifies the two key signs in the case. Under normal conditions, the vestibulocerebellum continuously calibrates the vestibulo-ocular reflex, comparing the expected sensory consequences of a head movement with the actual signals arriving from the labyrinth and adjusting the reflex gain accordingly. This internal model computation, as Cullen described in a 2023 review in Trends in Neurosciences, is one of the cerebellum’s central contributions to the perception of self-motion. When inflammation disables this computation, the inhibitory control is lost, the reflex gain climbs above normal, and corrective saccades reverse direction because the eyes have overshot rather than undershot the target. The same logic explains other cerebellar eye signs, such as vibration-induced downbeat nystagmus, which Kim and colleagues reported in 2023 as a new cerebellar sign observed in a paraneoplastic syndrome.

For clinicians, the practical lesson is that a predominantly vestibular presentation does not exclude cerebellar inflammation. The authors emphasize that reversed corrective saccades during head impulse testing and frequency-dependent VOR hyperactivity should be recognized as clues to cerebellar disinhibition, prompting appropriate neuroimaging and further workup rather than discharge with a diagnosis of uncomplicated inner ear disease. The case was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of Keimyung University Dongsan Hospital, with written informed consent obtained from the patient’s parent for publication of the report and accompanying images. The authors report no conflicts of interest, and the work received no dedicated funding.

Beyond its immediate clinical message, the report illustrates how a single carefully examined patient can sharpen our understanding of a brain region that remains incompletely mapped. The cerebellum’s role in vestibular processing has been built up over decades through lesion studies, animal experiments, and increasingly sophisticated bedside testing, and acute, reversible insults such as cerebellitis offer some of the cleanest natural experiments available. As video head impulse testing and related technologies spread through emergency departments and vestibular clinics, signs that were once obscure, such as reversed corrective saccades, are likely to be recognized more often, turning a rare case report into a practical diagnostic lesson for the many patients who arrive complaining simply that the room will not stop spinning.

Subject of Research: Acute cerebellitis presenting with vestibular symptoms and distinctive eye-movement signs of cerebellar disinhibition

Article Title: Acute cerebellitis presenting predominantly with vestibular symptoms: reversed corrective saccades and frequency-dependent VOR hyperactivity as clues to cerebellar disinhibition

Article References: Kwon, H., Kim, H. W., & Kim, H. A. (2026). Acute cerebellitis presenting predominantly with vestibular symptoms: reversed corrective saccades and frequency-dependent VOR hyperactivity as clues to cerebellar disinhibition. Journal of Neurology, 273(11), Article 660. https://doi.org/10.1007/s00415-026-14204-2

Image Credits: AI Generated

DOI: 10.1007/s00415-026-14204-2

Keywords: acute cerebellitis, vestibular symptoms, vestibulo-ocular reflex, reversed corrective saccades, head impulse test, cerebellar disinhibition, vestibulocerebellum, flocculus, nodulus, dizziness, neuro-otology, Journal of Neurology

The review is organized around how patients actually present: acute, episodic, or persistent symptoms. In the acute category, the authors highlight a newly characterized entity called the acute imbalance syndrome, or AIS, defined as an acute vestibular syndrome without nystagmus. Among emergency department consultations for vertigo or dizziness, roughly ten percent meet criteria for the acute vestibular syndrome, and about one fifth of those patients ultimately turn out to have suffered a stroke. Crucially, nearly half of central cases present as AIS rather than the classic nystagmus-associated form. Lesion-symptom mapping in stroke patients shows that AIS lesions cluster in the anterior cerebellar lobe, disrupting networks for posture and gait control, while the classic syndrome with nystagmus involves the posterior cerebellar and flocculonodular lobes and their vestibulo-ocular reflex circuits. This anatomical split means clinicians must choose their bedside tests carefully: when no nystagmus is present, algorithms such as STANDING are the appropriate choice.

For acute unilateral vestibulopathy, often called vestibular neuritis, the epidemiological picture has shifted. A Japanese nationwide survey estimated the annual incidence at about 7.1 per 100,000, double the figure recorded in 1993, likely reflecting better recognition of dizziness as the presenting symptom. About twenty percent of patients experience prodromal dizziness hours to days before the full syndrome, and involvement of both divisions of the vestibular nerve predicts more intense, longer-lasting symptoms and a higher risk of secondary functional dizziness. Delayed post-contrast 3D-FLAIR MRI now visualizes inflammatory enhancement of the labyrinth in roughly half of patients, offering an objective window into the disease process. The video head-impulse test remains the first instrumental examination, with a vestibulo-ocular reflex gain below 0.7 on the affected side serving as the recommended cut-off to separate peripheral from central lesions.

Treatment of vestibular neuritis still rests on three pillars, but each has been refined. Symptomatic drugs such as dimenhydrinate should be limited to one to three days. Steroids remain guideline-endorsed, although a recent placebo-controlled trial showed no effect on peripheral vestibular recovery, a result the authors attribute to a total steroid dose only a quarter of that used in the landmark 2004 randomized trial, leaving the question genuinely open. Physiotherapy has emerged as the strongest evidence-based intervention: a recent randomized trial found that an individualized program including rapid head rotations, performed three times daily for eight weeks, was probably the most effective approach, while isolated eye movements in a static head position show no benefit. In animal work, betahistine enhanced central compensation in a dose-dependent fashion, an effect amplified by combination with the MAO-B inhibitor selegiline, setting the stage for human trials.

Perhaps the most consequential advances concern the emergency department, where the stakes are highest. Vertical or torsional spontaneous nystagmus, though present in only about fifteen percent of acute vestibular syndrome patients, is highly predictive of a central cause, with specificity approaching 98 percent. Adding new-onset hearing loss to the HINTS battery mainly helps detect strokes of the anterior inferior cerebellar artery, raising stroke sensitivity by nearly eighteen percentage points in that subgroup. The four-step STANDING algorithm has now been validated repeatedly: after a single training session, interns achieved a sensitivity of about 85 percent and specificity of about 90 percent for dangerous central causes, and in a multicenter Italian study of isolated acute vertigo, trained emergency physicians using STANDING substantially outperformed standard care, while also reducing unnecessary head CT scans. A meta-analysis further showed that moderately trained non-specialists reach sensitivity comparable to subspecialists, though with somewhat lower specificity, and that as little as six hours of structured training suffices for successful implementation.

Technology is now entering the acute workflow. Machine learning models applied to video head-impulse data from all six semicircular canals distinguished stroke from vestibular neuritis with an accuracy of 87.8 percent, matching blinded expert clinicians and clearly beating simple gain cut-offs. A meta-analysis of horizontal canal data across 905 patients reported sensitivity of 85 percent and specificity of 84 percent for stroke detection, with a negative likelihood ratio useful for ruling out the disease. A separate retrospective model combining saccade gains, pursuit asymmetries, age and hypertension differentiated posterior circulation stroke from peripheral disease with sensitivity and specificity above 82 percent. The authors caution, however, that radiographic conjugate gaze deviation on CT or MRI cannot by itself separate peripheral from central causes and does not replace bedside examination.

In episodic vertigo, the review champions a provocative renaming: benign paroxysmal positional vertigo should become peripheral paroxysmal positional vertigo, because the condition is often not benign at all. Delayed diagnoses, atypical presentations in the elderly, high recurrence rates, fear of falling and residual dizziness in up to seventy percent of successfully treated patients all argue against the label. When the supine roll test is performed correctly, with the head raised twenty-five degrees and the whole body turned, horizontal canal variants account for nearly forty percent of cases, far more than previously appreciated. On the therapy side, the Semont Plus maneuver, which moves the head at least 150 degrees to the affected side based on biophysical modeling, halved the mean time to symptom freedom compared with the classic Semont maneuver and outperformed the Epley maneuver in randomized trials. For Menière’s disease, six 2023 Cochrane analyses rated the evidence for most established treatments as low or very low, but a phase 1 study showed that combining betahistine with selegiline increases the drug’s bioavailability a hundredfold, and a properly powered placebo-controlled trial is planned.

Vestibular migraine, the most common cause of recurrent spontaneous vertigo, is being reconceived as a broad spectrum rather than a narrow diagnosis. In a 2025 cross-sectional study of 2,801 newly diagnosed migraine patients, 68.4 percent reported vestibular symptoms, yet only 15.2 percent met formal diagnostic criteria. Therapeutically, the first adequately designed acute trial found rizatriptan ineffective against vertigo, but the INVESTMENT study, the first placebo-controlled trial of a CGRP monoclonal antibody in vestibular migraine, showed that galcanezumab improved disease-specific handicap and reduced dizzy days without serious adverse events, and a 2025 network meta-analysis ranked it as the current best preventive option. Meanwhile, delayed gadolinium-enhanced MRI revealed that endolymphatic hydrops occurs in vestibular migraine too, though typically bilateral, low-grade and vestibular-predominant, helping distinguish it from the pronounced, lateralized hydrops of Menière’s disease.

Genetics has transformed the understanding of chronic vestibular disorders. In bilateral vestibulopathy, biallelic RFC1 repeat expansions were found in eight percent of isolated cases, making RFC1 the most common monogenic cause, while FGF14 GAA expansions define the new spinocerebellar ataxia 27b. Quantitative vestibulo-ocular reflex testing now separates these entities at the bedside: a horizontal gain cut-off of 0.50 distinguished RFC1-related ataxia from SCA 27b with 91 percent specificity, and vHIT gains correlate with repeat size and disease duration, offering a progression biomarker. In so-called idiopathic downbeat nystagmus, FGF14 expansions were detected in roughly half of patients, and carriers showed an 80 percent response rate to 4-aminopyridine, compared with under five percent in RFC1 carriers whose disease involves neurodegeneration rather than reduced Purkinje cell excitability, a striking closure of the loop between genotype, mechanism and therapy.

The review closes with candid gaps. Functional dizziness, including persistent postural-perceptual dizziness, develops in roughly one in four patients after acute or episodic vestibular disorders, and new work on gaze behavior, maladaptive multisensory integration and illness-related cognitive appraisals is clarifying its mechanisms. Yet acute vestibular migraine episodes still evade emergency algorithms, evidence for thrombolysis and thrombectomy in posterior circulation stroke presenting as dizziness remains too thin for firm recommendations, and the authors emphasize that the field’s greatest unmet need is not new ideas but rigorous, placebo-controlled clinical trials with meaningful endpoints, together with systematic training so that the remarkable diagnostic knowledge of the last three years actually reaches the bedside.

Subject of Research: Recent advances in the diagnosis and treatment of vestibular and ocular motor disorders, including acute vestibular syndrome, positional vertigo, vestibular migraine and bilateral vestibulopathy

Article Title: An update on neuro-otology and neuro-ophthalmology – focusing on new developments in the last three years

Article References: Tarnutzer, A. A., Strupp, M. L., & Lehner, L. (2026). An update on neuro-otology and neuro-ophthalmology – focusing on new developments in the last three years. Journal of Neurology, 273(11), Article 657. https://doi.org/10.1007/s00415-026-14153-w

Image Credits: AI Generated

DOI: 10.1007/s00415-026-14153-w

Keywords: vertigo, dizziness, vestibular disorders, stroke, HINTS, STANDING algorithm, vestibular migraine, Meniere's disease, bilateral vestibulopathy, vestibular neuritis, video head-impulse test, machine learning

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

The research, published in the Journal of Neurology, comes from the MobilE-TRA 2 cohort, a prospective observational study run at the German Center for Vertigo and Balance Disorders in Munich, a tertiary referral centre that sees more than 3,000 patients a year. The team, led by Sophia P. Schulze and Ralf Strobl of Ludwig-Maximilians-Universität München, followed 337 adults aged 60 and over who had been newly assessed for a vertigo, dizziness, or balance disorder. Just over half were women, and the average age was 71. Each participant underwent a full interdisciplinary work-up—structured medical history, neurological, ocular-motor, and neuro-otological examinations, and where clinically indicated, caloric testing, video head impulse testing, vestibular-evoked myogenic potentials, posturography, and audiometry. Then, at three and twelve months after receiving their individualised treatment recommendations, patients filled in postal questionnaires reporting how often they had actually implemented what had been prescribed. Follow-up rates were impressively high: 88.7 percent at three months and 87.2 percent at twelve.

The researchers drew a deliberate distinction between two categories of non-pharmacological recommendation. The first was specific exercises—balance, gait, or habituation exercises prescribed as part of vestibular rehabilitation, the standard therapy for many vestibular disorders. The second was lifestyle-related recommendations, a composite covering physical activity, general everyday movement, and weight control. This distinction matters because the two types demand different patterns of behaviour. Specific exercises need not be performed daily to be effective, whereas lifestyle changes depend on frequent, near-continuous implementation. Accordingly, the team applied different cut-offs on a five-point self-reported frequency scale, defining adherence to exercises as a score of two or higher and adherence to lifestyle recommendations as three or higher. The framework guiding the analysis was the World Health Organization’s multidimensional model of adherence, which sees the phenomenon as shaped by interacting social and economic, health system-related, condition-related, therapy-related, and patient-related factors.

The headline numbers look reassuring at first glance. Around 80 percent of participants were classified as adherent to each recommendation type at least once during follow-up—79.6 percent for specific exercises among the 216 who reported receiving them, and 80.4 percent for lifestyle recommendations among the 270 who received those. But the longitudinal analysis, using logistic generalised linear mixed-effects models with random intercepts to account for repeated measurements within each person, told a more nuanced story. Adherence to specific exercises dropped markedly between the three-month and twelve-month assessments, with an odds ratio of 0.28 (95 percent confidence interval 0.12 to 0.67). In plain terms, the odds of a patient still performing their prescribed vestibular exercises a year after their initial assessment were less than a third of the odds at three months. Adherence to lifestyle recommendations, by contrast, remained statistically stable over the same period.

Why do the exercises fall away while the lifestyle changes persist? The authors are careful not to interpret the decline as simple failure. In vestibular rehabilitation, symptoms often improve or resolve with treatment, and a patient whose dizziness has faded may genuinely need less practice. Previous research has also documented persistent barriers: symptom provocation during the exercises themselves—which can temporarily make people feel worse—along with time constraints, coexisting impairments, and insufficient guidance or feedback. People with vestibular disorders also report higher fear-avoidance beliefs and lower confidence during balance activities than healthy adults, which can make unsupervised home exercise feel risky. The decline may therefore reflect a mixture of successful recovery, waning motivation, and the well-known difficulty of sustaining self-managed home exercise that has been observed across physiotherapy and chronic disease populations more broadly.

One of the study’s most intriguing findings concerns who stuck with the exercises. Patients with greater perceived dizziness-related handicap at baseline—measured with the validated 25-item Dizziness Handicap Inventory, which scores the functional, physical, and emotional impact of dizziness from 0 to 100—were more likely to adhere to specific exercises, with an odds ratio of 1.03 per point (95 percent CI 1.00 to 1.06). This seems counterintuitive until one considers the psychology of symptom-driven motivation. People whose dizziness seriously disrupts their lives have a powerful, immediate reason to work at their rehabilitation. Those with mild or rapidly improving symptoms, on the other hand, may simply lose the incentive to continue. The same symptom burden can cut both ways, however: in other vestibulopathy subgroups, symptoms provoked by the exercises have been identified as a barrier to adherence. Symptom burden, the authors conclude, appears to influence adherence in ways that are highly context-specific.

The lifestyle recommendations obeyed a different logic altogether. Here, the strongest predictor was self-efficacy—a person’s belief in their own ability to perform specific behaviours, assessed with a three-item General Self-Efficacy Short Scale. Higher self-efficacy was associated with higher adherence (OR 1.65; 95 percent CI 1.02 to 2.66), while male gender was associated with lower adherence (OR 0.37; 95 percent CI 0.16 to 0.88). The self-efficacy finding aligns neatly with systematic reviews in physiotherapy, where low self-efficacy is consistently described as a barrier to home exercise, and with broader behavioural evidence linking confidence to health behaviour change. It also echoes earlier results from the same cohort, in which self-efficacy predicted functioning after specialised care. In a condition where patients must manage dizziness and unsteadiness while simultaneously changing daily habits, the belief that one can cope with difficult situations may be precisely the resource that sustains behaviour over time.

Perhaps the most methodologically interesting part of the study is what did not predict adherence. Drawing on behavioural economics, the team measured two further patient-related traits: time preferences, meaning how much people value future benefits relative to immediate rewards, and health-related risk attitudes, meaning willingness to take risks in health contexts. Both have been linked to health behaviours such as smoking, alcohol consumption, exercise, and diabetes self-management in previous research. Yet in this cohort, neither showed a statistically significant association with adherence to either recommendation type. The finding suggests that the psychological machinery behind keeping up vestibular exercises or lifestyle changes may differ from that behind other preventive health behaviours—or simply that the single-item measures used here lacked the sensitivity to detect weaker effects. Either way, it tempers the assumption that present-oriented, risk-tolerant patients are inevitably the ones who drift away from their treatment plans.

The study has honest limitations that shape how its results should be read. Adherence was self-reported and therefore vulnerable to recall and social desirability bias; the authors emphasise that the figures represent perceived implementation rather than objectively measured behaviour. Adherence measurement in VDB has never been standardised, and the category of specific exercises may have encompassed different exercise types across diagnostic subtypes, which ranged from benign paroxysmal positional vertigo and persistent postural-perceptual dizziness to Menière’s disease, vestibular migraine, and bilateral vestibulopathy. Diagnostic subtype could not be included in the multivariable models because several groups were too small, leaving open the possibility of residual confounding. Sensitivity analyses with alternative cut-offs shifted some estimates—for instance, under a stricter exercise cut-off, multimorbidity emerged as a barrier and self-efficacy as a stronger facilitator—so individual effect estimates warrant caution. Recruitment during the SARS-CoV-2 pandemic, when healthcare access was disrupted, may also have selected a more severely affected population, limiting transferability to primary care.

Even with those caveats, the practical message is clear and potentially actionable. Adherence in older adults with vertigo, dizziness, and balance disorders is not a single behaviour but at least two, with different time courses and different drivers. Exercises decay over the year after prescription, particularly among those whose symptoms were mild to begin with, while lifestyle changes persist—especially in patients with high self-efficacy, and less so in men. For clinicians, that argues against a one-size-fits-all follow-up schedule: patients with low self-efficacy, mild symptoms, or a recent exercise prescription may benefit most from booster contacts, feedback, and structured support in the months after their initial assessment, precisely when the data show adherence beginning to slip. For researchers, the study opens a direct question that it could not answer: why do patients stop? Larger cohorts, objective adherence measures, and primary-care replication will be needed to turn these observational patterns into interventions that keep older people steady on their feet.

Subject of Research: Adherence to non-pharmacological treatment recommendations in older adults with vertigo, dizziness, and balance disorders

Article Title: Adherence to treatment recommendations in older adults with vertigo, dizziness, and balance disorders: the MobilE-TRA 2 cohort study

Article References: Schulze, S. P., Katzenberger, B., Koller, D., Huppert, D., Grill, E., & Strobl, R. (2026). Adherence to treatment recommendations in older adults with vertigo, dizziness, and balance disorders: the MobilE-TRA 2 cohort study. Journal of Neurology, 273(10), Article 649. https://doi.org/10.1007/s00415-026-14195-0

Image Credits: AI Generated

DOI: 10.1007/s00415-026-14195-0

Keywords: vertigo, dizziness, balance disorders, vestibular rehabilitation, treatment adherence, older adults, self-efficacy, geriatrics, cohort study, lifestyle modification, Dizziness Handicap Inventory, neurology

The study, led by Huseyin Nezih Ozdemir, Iryna Klopotovska and Diego Kaski of the SENSE Research Unit in UCL’s Department of Clinical and Movement Neurosciences, was conducted at the National Hospital for Neurology and Neurosurgery in London between April 2025 and April 2026. Consecutive patients aged 18 and over arriving at the dizziness clinic underwent a structured ten-question interview before their clinical consultation. Crucially, the interviewer recorded answers about symptom timing, triggers, avoidance behaviours and behavioural responses before any diagnosis had been established. The final diagnoses were then made independently by a vestibular neurologist who was blinded to the interview responses, using established criteria from the Bárány Society and the International Classification of Headache Disorders. This design ensured that the behavioural data could not be contaminated by knowledge of the diagnosis.

The cohort of 109 patients had a mean age of 55.3 years, and 71.5 percent were female. Thirty-three patients were diagnosed with vestibular migraine, thirty-three with persistent postural-perceptual dizziness, fourteen with benign paroxysmal positional vertigo and fifteen with orthostatic dizziness. Smaller groups included patients with central structural disorders such as posterior circulation stroke and other peripheral vestibular conditions including bilateral vestibular loss. When the researchers applied logistic regression to the interview data, four clear behavioural profiles emerged, each mapping closely onto the known biology of the underlying disorder.

The strongest single predictor belonged to vestibular migraine. Patients who reported that reading while travelling as a passenger in a vehicle brought on their dizziness were more than twenty times more likely to have vestibular migraine than any other diagnosis, with an odds ratio of 20.99. This finding fits with the idea that vestibular migraine reflects a heightened vulnerability to sensory conflict, the discordance between visual motion signals and vestibular input that occurs when the eyes track a page while the inner ear registers the movement of a car. It also builds on earlier work from the same group showing that motion sickness while reading in a moving car is highly predictive of the condition. For patients with persistent postural-perceptual dizziness, visually stimulating environments such as crowded, busy or visually complex settings were the strongest precipitating factor, carrying an odds ratio of 12.45, consistent with the disorder’s characteristic over-reliance on visual cues for spatial orientation.

The two remaining diagnoses produced equally distinctive patterns. For benign paroxysmal positional vertigo, head movements and positional changes were the dominant trigger, with an odds ratio of 11.51, exactly what would be expected from the abnormal movement of displaced calcium carbonate crystals, or otoconia, within the semicircular canals. Patients with orthostatic dizziness, by contrast, pointed to standing up quickly as their principal trigger, reflecting the transient drop in cerebral blood flow that occurs during orthostatic stress. In each case, the reported precipitant was not an arbitrary preference but a direct behavioural echo of the underlying mechanism: sensory conflict in vestibular migraine, visual dependence in persistent postural-perceptual dizziness, otoconial displacement in positional vertigo and cerebral hypoperfusion in orthostatic dizziness.

Avoidance behaviours proved just as diagnostic as triggers. Patients with vestibular migraine disproportionately avoided bright or noisy environments and sought refuge by resting in dark, quiet rooms, mirroring the visual and auditory hypersensitivity that characterises migraine more broadly. Those with persistent postural-perceptual dizziness avoided visually busy places such as supermarkets, crowded streets or scrolling screens, and notably reported trying to maintain their activity despite the symptoms, an effort to push through the persistent, physically non-disabling dizziness that defines the condition. Patients with benign paroxysmal positional vertigo reported deliberately avoiding quick head movements and staying still during attacks, an understandable strategy to prevent the violent, brief episodes of rotational vertigo that position changes provoke. Orthostatic dizziness patients avoided sudden standing and tended to sit or lie down slowly, a sensible countermeasure against orthostatic intolerance, although this particular association did not reach statistical significance, likely because of the smaller size of that subgroup.

Temporal patterns added a further layer of discrimination. Episodic dizziness was significantly associated with vestibular migraine, while patients with persistent postural-perceptual dizziness were far more likely to report continuous dizziness lasting days or longer, in keeping with the chronic nature of that disorder. Patients with benign paroxysmal positional vertigo characteristically reported brief episodes lasting seconds to minutes, matching its paroxysmal presentation. Although patients with positional vertigo and orthostatic dizziness tended to describe dizziness that comes and goes, these associations did not reach statistical significance, a limitation the authors attribute to the relatively small numbers in those diagnostic groups.

The clinical implications of the work are considerable. Because neuroimaging has limited utility in most cases of dizziness and definitive tests are lacking for many vestibular syndromes, diagnosis rests heavily on history taking, and patients’ descriptions of symptom quality are notoriously imprecise. Structured questions about avoidance and coping could capture dimensions of the patient’s experience that conventional symptom questions miss. Asking simply whether a patient avoids supermarkets, refrains from turning their head quickly, or retreats to a dark room when dizzy may sharpen diagnostic accuracy, shorten the long delays many patients experience before correct treatment, and potentially prevent progression to chronic dizziness. Beyond diagnosis, recognising these behaviours may help clinicians understand how the disorders impair daily and occupational functioning, since triggers such as bright environments or awkward head positions have been shown to interfere with work tasks and contribute to reduced productivity and absenteeism.

Perhaps the most intriguing aspect of the findings is that patients developed these behavioural signatures without any formal knowledge of disease mechanisms. The researchers argue that such adaptations arise intuitively through repeated symptom experience, which is precisely what makes them informative: they represent the body’s own experiment on the disorder, conducted over months or years. The behaviours therefore function as natural biomarkers, reflecting pathophysiology rather than clinical teaching. The authors also caution that avoidance behaviours can themselves contribute to disability, and identifying them may open the door to rehabilitation strategies that prevent deconditioning and fear-driven withdrawal from activity.

The study is not without limitations. The structured interview was not a validated instrument, several diagnostic subgroups were small, limiting statistical power for some response categories, and the single-centre design in a specialised London clinic may constrain generalisability. Larger cohorts will be needed to confirm the diagnostic value of these behavioural markers and to quantify their impact on patients’ functioning. Even so, the message is clear and potentially transformative for routine practice: when a patient says they feel dizzy, the clinician should ask not only what it feels like and when it happens, but what the patient does about it. The answers, this research suggests, may point directly to the diagnosis hiding behind one of medicine’s most vague and common complaints.

Subject of Research: Behavioural signatures as diagnostic clues in common vestibular disorders causing dizziness

Article Title: What patients do when they feel dizzy: behavioural signatures reveal diagnostic clues in common vestibular disorders

Article References: Ozdemir, H. N., Klopotovska, I., & Kaski, D. (2026). What patients do when they feel dizzy: behavioural signatures reveal diagnostic clues in common vestibular disorders. Journal of Neurology, 273(10), Article 587. https://doi.org/10.1007/s00415-026-14133-0

Image Credits: AI Generated

DOI: 10.1007/s00415-026-14133-0

Keywords: dizziness, vestibular disorders, vestibular migraine, PPPD, BPPV, orthostatic dizziness, avoidance behaviour, coping strategies, behavioural adaptation, diagnosis, vertigo, neurology