Efficacy of vestibular rehabilitation in middle-aged people with peripheral vestibular disorders: association with cognitive function

1 Introduction

Historically, research on the function of the vestibular system has focused on the vestibulo-ocular and vestibulo-spinal reflexes (Wilson and Peterson, 1978; Dieterich and Brandt, 1995; Allum et al., 1989; Rinaudo et al., 2019). Only in the last few decades has research activity expanded to other functions of the vestibular system related to cognitive function (Smith, 2017; Li et al., 2024). Current research highlights the close interaction between the vestibular system and cognitive processes, with extensive neural involvement in the hippocampus and cortical areas supporting spatial and executive functions (Zhe et al., 2025; Hitier et al., 2014; Zwergal et al., 2024; Smith et al., 2024). Cognitive dysfunction, primarily affecting executive function, attention, and visuospatial ability (Bigelow and Agrawal, 2015), is often present in individuals with both acute (Ayar et al., 2020) and chronic vestibular symptoms (Dordevic et al., 2021). Additional studies indicate that the disruption of the vestibular-cognitive interaction leads to an erroneous perception of self-motion and body representation, a reallocation of attentional demands, altered multisensory integration, and even social deprivation. Consequently, it is evident that this constitutes a dynamic interconnection between these two functions, which modifies brain function as a whole rather than involving an isolated neural mechanism (Smith et al., 2024).

Vestibular Rehabilitation Treatment (VRT) is an established and effective therapeutic intervention for individuals with chronic peripheral uncompensated vestibular dysfunction (Hall et al., 2022). Its goal is to enhance balance, reduce symptom severity, and improve overall quality of life. A series of randomized controlled trials (Pavlou et al., 2013; Tokle et al., 2020) and systematic reviews (Arnold et al., 2017; Hillier and McDonnell, 2015) have confirmed that VRT reduces vertigo severity, improves balance and enhances functionality.

The clinical guidelines for the rehabilitation of peripheral vestibular hypofunction state that cognitive impairment affects functional recovery during treatment but provide minimal evidence and do not fully specify this relationship (Hall et al., 2022). The guidelines essentially indicate that it may be acceptable to exclude individuals with significantly impaired function due to poor learning transfer, or that additional supervision might be necessary for those with cognitive impairments to achieve benefits from rehabilitation (Hall et al., 2022). Currently, little is known about how cognitive function affects the outcomes of vestibular rehabilitation, as research in this area is quite limited (Micarelli et al., 2019, 2018).

The primary hypothesis of this retrospective study is the investigation of the impact of cognitive function, as assessed by the Montreal Cognitive Assessment (MoCA), on the effectiveness of vestibular rehabilitation in people with vestibular disorders. The secondary hypothesis examines whether improvements in rehabilitation measurements related to dizziness and gait differ across several factors affecting cognitive function, such as age, cognitive domains, and educational level.

2 Methodology

This is a retrospective study based on data retrieved from the medical records of the Neurotology Clinic of the first ENT University Department at Hippokration General Hospital of Athens, between 2021 and 2024. All participants provided informed consent in accordance with the Helsinki Declaration on their first visit to the clinic. Ethical approval was obtained (21179-01/12/2025). Demographic, clinical, and functional data were collected during routine clinical practice. All data were analyzed anonymously. Inclusion criteria for the study are as follows: (a) Patients referred for vestibular rehabilitation due to persistent unsteadiness, disequilibrium and/or chronic dizziness (duration over 3 months) aged between 40 and 65 years who concluded an 8-weeks program; (b) diagnosis of a vestibular disorder according to Barany Society diagnostic criteria, including medical conditions involving central vestibular processing such as Persistent Postural-Perceptual Dizziness (PPPD) and Vestibular Migraine (VM); (c) subjective dizziness perception greater than 16/100 on the Dizziness Handicap Inventory (DHI); and (d) functional gait score greater than 14/30 on the Functional Gait Assessment (FGA). Exclusion criteria include: (a) central pathologies, except PPPD and VM, (b) age less than 40 years and over 65 years, (c) mild dizziness symptoms (DHI < 16/100) and/or severe imbalance (FGA < 14/30), and (d) evidence of severe cognitive impairment (MoCA < 18/30).

Participants included in the study had complete records in the hospital's electronic database, including sex, age, diagnosis, symptom duration, and both initial and final evaluations. Diagnoses were made based on the Barany criteria, following a standardized laboratory testing protocol. All participants in the study were referred with a single vestibular diagnosis. Participants with peripheral vestibular pathologies were included after the acute phase had concluded. During the initial assessment, dizziness severity was evaluated using the DHI, functional balance using the FGA, and cognitive function using the MoCA, performed by certified personnel. During the final assessment, dizziness severity and functional gait testing were repeated. All data were anonymized, making participant identification impossible.

DHI is a self-report questionnaire that assesses the perceived impact of dizziness on daily life and provides a quantitative estimate (as a percentage) of the subjective burden associated with vestibular disorders (Nikitas et al., 2017). The minimal clinically significant difference (MCID) for vestibular disorders has been established at 18 points (Wellons et al., 2022). FGA is a clinical tool that measures walking ability under varying conditions, integrating dynamic balance and adaptability components, and is widely used to assess fall risk (Wrisley et al., 2004). The threshold for high fall risk is set at 22/30, is defined as four points (Wellons et al., 2022). The MoCA is a brief neuropsychological test that assesses multiple cognitive domains, including memory, attention, executive functions, and visuospatial abilities, and serves as a sensitive indicator of mild cognitive impairment (Konstantopoulos et al., 2016). Normal cognition is defined as a score of 26/30 or higher, mild cognitive impairment as 18–25, and moderate impairment as 10–17 (Jaywant et al., 2020).

In our retrospective study, one hundred (100) participants with vestibular pathology were included and divided into two groups based on their cognitive function assessment: the group with indications of mild cognitive impairment (MCI) scoring less than 26/30 in the MoCA test and the group without indications of mild cognitive impairment (no-MCI) scoring 26/30 and above. No differences were observed in age, sex, symptom duration, or medical diagnoses, as indicated in Table 1.

Table 1. Participant characteristics between groups.

y, years; m, months; n, number; %, percentage; DHI, Dizziness Handicap Inventory; FGA, Functional Gait Assessment; BPPV, Benign Paroxysmal Positional Vertigo; MD, Meniere's Disease; VM, Vestibular Migraine; PPPD, Persistent Postural Perceptual Dizziness; VN, Vestibular Neuritis; MoCA, Montreal Cognitive Assessment. Statistically significant differences indicated by asterisks reflect differences between groups.

^*p < 0.05,

^**p < 0.01.

The VRT protocol was a home-based rehabilitation program with no more than five prescribed, individualized exercises per daily session, with at least 1 min interval between them. Participants conducted all sessions and exercises at home, which were personalized according to a treatment plan designed by an expert physiotherapist following the baseline assessment. Each session included head-eye coordination, postural, and gait retraining, depending on the evaluation findings. Participants had to perform the sessions at least twice a day and were advised to do so at their tolerance level, which caused mild to moderate dizziness and instability. If their symptoms were exaggerated significantly, patients were asked to stop and move on to the next session. Every 10 days, an institutional-based session was held with an experienced physiotherapist to re-evaluate and, if necessary, prescribe a new regimen of progressively difficult exercises. The final assessment was carried out within 10 days of the completion of the rehabilitation protocol. None of the participants had previously undergone vestibular rehabilitation.

2.1 Statistical analysis

Statistical analysis was conducted using IBM SPSS Statistics 29. Initially, all variables were presented descriptively (means, confidence intervals), and variance homogeneity was assessed. The primary hypothesis was tested using appropriate tests. Due to the inability to meet the normality criteria, non-parametric tests (Wilcoxon signed-rank test, Mann-Whitney U-test) were applied in order to determine whether there are changes in dizziness and balance outcomes across the sample, and whether cognitive function (as measured by the overall MoCA score and its subcategories) influences treatment effectiveness. Further analyses (secondary exploratory analysis) investigated differences between purely peripheral vestibular conditions, such as Neuritis, BPPV, and Meniere's disease, and central vestibular processing, such as PPPD and VM, in initial and final assessments of outcome measures and improvements in symptom severity and functional gait performance. Furthermore, differences within the same sample, stratified by MoCA subdomains and educational level, known to influence cognitive performance (Borda et al., 2019), were examined using the same comparisons. By analyzing the distribution of variables within the MoCA subdomains, we established cut-off points to enhance the clarity of the results. Based on the distributions of the variables, parametric (two-sample t-test) and/or non-parametric (Mann-Whitney U-test) tests were used appropriately. The level of statistical significance was set at p < 0.05.

3 Results

During the initial assessment, the two groups exhibited differences only in cognitive function, as derived from the total score of the MoCA test, as well as in their educational level, a factor known to be associated with this specific test (Education difference: 1.53 years, 95% CI: 0.11–2.96, and p = 0.01). Regarding the MoCA subcategories, statistically significant differences were observed in the executive function, attention, language, and delayed recall domains. However, no statistically significant differences were observed across the subcategories of naming, abstraction, and orientation. Additionally, the two groups showed no statistically significant differences in gender or age.

Within-group analysis for the MCI group revealed statistically significant changes in both outcome measures, dizziness severity (z = 6.14, p < 0.001) and functional gait performance (z = 6.10, p < 0.001), with large effect sizes (r = 0.84 and 0.83, respectively). Participants in the no-MCI group also reported statistically significant changes in both outcome measures, dizziness severity (z = 5.91, p < 0.001) and functional gait performance (z = 5.63, p < 0.001), with large effect sizes (r = 0.87 and 0.83, respectively).

Between-group analysis revealed no significant baseline differences, as previously mentioned. However, statistically significant differences were observed at the final assessment for dizziness severity (p = 0.02) and functional gait performance (p = 0.01), with MCI participants reporting worse scores than the no-MCI group for both outcome measures.

Furthermore, the improvement from pre- to post-treatment was compared between the MCI and the no-MCI groups for both FGA and DHI. Pre-post improvement in the no-MCI group was larger for DHI at a statistically significant level of severity (U = 1,542, p = 0.038; Figure 1).

Moreover, the achievement of the minimally clinically important difference (MCID) for dizziness severity appeared to be associated with cognitive function, as measured by the MoCA test, [x² (1, n = 100): 3.86, and p = 0.049], with a 2.3 times higher probability of achieving the MCID for the participants without MCI [OR: 2.36 (95% CI: 0.99–5.61)].

According to a linear regression model, the results were statistically significant [R² = 0.144, F₍₃₎ = 5.397, and p = 0.002]. The difference in intervention effectiveness related to dizziness severity, estimated by the DHI questionnaire, appeared to be significantly predicted by age (β = 6.41, 95% CI: 1.99–10.83; p = 0.005), symptom duration (β = −2.21, 95% CI: −4.32 to −0.10; p = 0.046), and the cognitive function (β = 7.98, 95% CI: 0.96–15.00; p = 0.02). No statistically significant difference was observed between groups regarding the effectiveness of the intervention in improving functional gait performance (U = 1,237.5, p = 0.87; Figure 2).

In the secondary exploratory analysis, it was found that the intervention was equally effective across pathophysiological origins of diagnoses (peripheral vs. central processing), educational level, visuospatial ability (Alternating Trail Making and cube), total executive function, and long-term memory. However, participants with higher educational backgrounds demonstrated lower, statistically significant scores on the baseline [DHI mean difference: 17.82, 95% CI: (10.34–25.30), and p < 0.001] and the final assessment [DHI mean difference: 4.27, 95% CI: (5.57–22.54), and p = 0.001] of dizziness severity. Continuing the exploratory analysis, participants who were stratified by their ability to perform a trail (ATM), reported, at the baseline, statistically significant differences for both dizziness severity [DHI mean difference: 10.85, 95% CI: (1.75–19.95), and p = 0.02] and functional gait performance (U: 1,262.5, p = 0.01), in favor of those who achieved it. Differentiating participants based on their ability to recall more than three words in the delayed recall subcategory of the MoCA test demonstrated diagnostic sensitivity: participants who recalled fewer than four words reported more severe dizziness at baseline (U = 841, p = 0.01).

Finally, people with peripheral diseases (VN, Meniere's recurrent BPPV) present greater improvement, compared to people diagnosed with vestibular processing disorders (VM, PPPD) in functional gait performance (U = 903.5, p = 0.03). It should be emphasized, however, that these two subgroups exhibit a statistically significant difference in gender, since 88.6% (39/44) of those with peripheral lesions were female and symptom duration, as those with peripheral lesions reported a shorter duration of symptoms [mean difference symptoms duration: 15.40, 95% CI: (8.80–21.99), and p < 0.001].

Table 1 presents all participant characteristics overall and by group, including baseline and post-intervention clinical characteristics. In contrast, Table 2 presents MoCA total and subdomain scores for the entire sample and for each group. Table 3 demonstrated the results of the secondary exploratory analysis.

Table 2. Distributions of variables for the overall cognitive test and its subcategories.

MoCA, Montreal Cognitive Assessment; MCI, Mild Cognitive Impairment.

Statistically significant differences indicated by asterisks reflect differences between groups.

^**p < 0.001, ^*p = 0.002.

Table 3. Secondary exploratory analysis of variables.

Statistically significant differences indicated by asterisks reflect differences between groups. DHI, Dizziness Handicap Inventory; FGA, Functional Gait Assessment; MoCA, Montreal Cognitive Assessment; ATM, Alternating Trail Making.

^***p < 0.001, ^**p < 0.01, and ^*p < 0.05.

4 Discussion

In this specific clinical study, two age- and sex-matched groups of people with vestibular pathology, with or without signs of mild cognitive impairment according to their performance in MoCA, who completed an 8-week rehabilitation protocol, were compared regarding improvement in dizziness severity and functional gait performance, as well as the percentage of improvement in these two measures. Statistically significant differences were observed in the in-group analysis and in the magnitude of the reduction in dizziness severity, favoring the no-MCI group. The difference in intervention effectiveness appears to be associated with age, symptom duration, and the presence of mild cognitive impairment.

It is well-established that age affects cognitive function, particularly in domains such as speed of processing, working memory, and executive function (Murman, 2015). It is also well-documented that the MoCA test, although a reliable and repeatable brief cognitive measure, is influenced by age and educational level, especially in community-dwelling older adults (Malek-Ahmadi et al., 2015). In our clinical study, we minimized the effect of age by imposing a very narrow age range in the inclusion criteria. Interestingly, although we included individuals who were not considered older people, 54 out of 100 participants (mean age: 54.02, 95% CI: 52.98–56.86) presented with signs of MCI.

There is increasing evidence that vestibular dysfunction, as measured by cervical vestibular-evoked myogenic potentials, increases the risk of cognitive decline even in people younger than 65 years (Bosmans et al., 2024). In the same clinical trial, functional gait performance differed significantly between healthy controls and people with cognitive impairment, and a functional mobility test (Timed Up and Go test) was identified as a significant predictor, along with cVEMP parameters and sex, of overall cognitive function (Bosmans et al., 2024). VEMP testing appears promising for differentiating individuals with cognitive impairment from those with preserved cognitive function; however, at present, the results cannot be generalized, even to populations in which cognitive function is inherently threatened by age (Bosmans et al., 2021). Moreover, peripheral vestibular pathologies affect the hippocampus. This brain structure works as a multisensory processor transforming sensory inputs into modality-independent representations (Raccah et al., 2026). Moreover, it plays a significant role in spatial memory and mood regulation (Raccah et al., 2026; Kamil et al., 2018), and hippocampal volume loss is more pronounced in bilateral vestibulopathy, a pathological entity not included in our study (Miller et al., 2024). However, more research is needed to establish a robust correlation between specific vestibular deficits and cognitive decline, even from middle age and beyond. Hearing loss appears to be associated with faster cognitive decline even in this age group, suggesting a path for research on vestibular disorders (Verghese et al., 2002). Nevertheless, age does not affect the outcome of vestibular rehabilitation, as reported in the more recent version of the clinical guidelines (Hall et al., 2022).

The literature on the impact of cognitive function on the effectiveness of vestibular rehabilitation is not extensive. In the study by (Micarelli et al. 2019), the application of virtual reality in combination with traditional vestibular rehabilitation in older people with or without MCI was examined, revealing that posture, dizziness severity, and dynamic gait improved by the end of the intervention in both groups. Furthermore, older people without MCI improved more in vestibulo-ocular reflex gain, posture, dizziness, and dynamic gait compared to participants with MCI (Micarelli et al., 2019). This is consistent with our findings, as statistically significant differences in dizziness severity and functional gait performance were observed in favor of the no-MCI participants at the end of the intervention. Moreover, in the same study, cognitive function was found to be positively correlated with dynamic gait scores, confirming the close link between cognition and postural control (Verghese et al., 2002; Sugaya et al., 2018). Interestingly, the application of virtual reality provided an additional clinical improvement in individuals with MCI compared to individuals with the same pathology who only followed a vestibular rehabilitation exercise program. Thus, it appears that immersion in virtual reality environments may bypass cognitive decline as a parameter that impedes the effectiveness of vestibular rehabilitation. However, the study sample was small (47 participants divided into four groups), the duration of VRT intervention was 4-weeks, compared to the 8-weeks of our protocol, the mean age of the participants was higher than in our study, and a different psychometric tool was employed to distinguish between individuals with and without cognitive impairment.

In a subsequent clinical trial, improvements in posture, dizziness severity, and dynamic gait performance were observed in both the group with and the group without cognitive impairment undergoing a vestibular rehabilitation protocol (Micarelli et al., 2018). In the same study, between-group differences were statistically significant for static balance control, VOR gain, dizziness severity, and dynamic gait performance, in line with our findings. However, in this study, as in the previous one, the sample was small, older people with a mean age over 70 years were involved, and different psychometric tools were employed to distinguish between individuals with and without cognitive impairment (Micarelli et al., 2018). In both studies, which were published by the same research team, differences were observed in the improvement provided by vestibular rehabilitation in people with or without MCI, in line with our results, despite methodological differences.

On the other hand, two subsequent studies demonstrated the effect of vestibular rehabilitation on cognitive function, highlighting a two-way relationship. In the study of Sugaya et al., middle-aged people with chronic dizziness, it was reported that vestibular rehabilitation improved not only dizziness severity, which remained reduced after 4 months, functional ability, and psychological status, but also visuospatial ability, attention, and executive function, as measured by path-tracing tests (Sugaya et al., 2018). The improvement in both dizziness and psychological status may reflect a reduced demand for sensory integration, allowing a more efficient allocation of cognitive resources (Plummer and Eskes, 2015). This is likely due to automaticity through retraining, which enables enhanced cognitive performance, proving that both functions rely on attentional resourses (Plummer and Eskes, 2015). In our own study, individuals who completed the visuospatial ability task (ATM) showed clearly better scores at both the beginning and the end of the rehabilitation program, regarding both dizziness severity and functional gait performance, without showing a difference in the percentage of improvement. Therefore, whether this particular test (ATM) can serve as a biomarker of disability severity after vestibular disorders has yet to be established. Future trials should take this observation into consideration. Another interesting study showed that incorporating vestibular rehabilitation into cognitive therapy for people with MCI improves attention, executive function, memory, and spatial ability (Goswami et al., 2024). This study exhibited methodological issues: a small sample size and baseline differences in specific cognitive functions; nevertheless, specialized assessment tools were used such as the Digit Symbol Substitution Test, the Trail Making Test, the Stroop Test, so that the hypothesis that activation of the vestibular system has statistically significant effects on specific cognitive functions in older people with MCI can be clearly supported. A recent systematic review strengthened the above hypothesis of interaction between the two domains, highlighting that when the systems are trained simultaneously, they appear to be bilaterally reinforced (Magauina et al., 2025). Unfortunately, we did not re-evaluate cognitive function using the MoCA test, as we would not expect to detect changes in such a short period, consistent with the prevailing evidence (Cooley et al., 2015; Zadik et al., 2023).

In our clinical study, a difference in improvement in dizziness severity, as measured by the DHI questionnaire, was observed among people without MCI. Based on our knowledge, this is the first time a significant difference in improvement in dizziness severity has been observed among middle-aged people with vestibular disorders. Participants in the no-MCI group were 2.3 times more likely to meet the MCID (76 vs. 57% in the MCI group).

The secondary exploratory analysis was conducted to further investigate specific characteristics of the two groups. Consequently, these results are considered supportive of the primary findings and should be interpreted with caution. The initial comparison focused on the neurophysiological origin of the medical conditions, distinguishing between peripheral conditions (VN, BPPV, and Meniere) and central conditions (PPPD, VM). In this context, statistically significant differences emerged only in improvements in functional gait performance. Vestibular rehabilitation induces central compensation through neuroplastic changes, leading to sensory reweighting (Wijesinghe and Camp, 2020; Zhou et al., 2015; Carver et al., 2006). This likely explains why individuals with PPPD and VM are included in studies of vestibular rehabilitation, with two recent meta-analyses confirming that physical therapy is effective in managing vestibular symptoms (Piatti et al., 2025; Sfakianaki et al., 2026). The observed discrepancy in functional gait improvement between the two subgroups can possibly be explained, based on the available data, by differences in symptom duration and gender. As there are currently no studies to confirm such a mechanism, further research is warranted to evaluate the impact of symptom chronicity and, primarily, psychological factors on these pathologies, given their known effect on reducing adaptability (Powell et al., 2020; Ibrahim et al., 2024).

Furthermore, in our secondary exploratory analysis, people with higher educational levels, a variable associated with cognitive function as reflected in the MoCA test, exhibited statistically lower dizziness severity at the beginning and the end of the intervention. This may occur for several reasons. Higher levels of education are associated with a more realistic perception of symptoms (Weigel et al., 2022). Within the context of vestibular rehabilitation, health literacy is an integral part of the intervention, as it facilitates clinical outcomes (Kalderon et al., 2024). Consequently, individuals with a higher cognitive profile are better equipped to comprehend the structured goals of rehabilitation and the underlying mechanisms employed to achieve them. This enables them to distinguish subjective beliefs from clinical reality, effectively decoupling physical symptoms from the anxiety they may provoke.

People with peripheral vestibular disorders experience high levels of anxiety (Sciscent et al., 2025). It is well-known that anxiety affects cognitive function performance, as reflected in the MoCA test (Freire et al., 2017). Therefore, whether it is a real decline in cognitive function because of vestibular pathology or because of the effect of stress on cognitive function, it appears that mental disorders affect both those closely related variables. Reduced sensory integration due to cognitive deficits associated with vestibular pathologies can also limit the brain's compensatory abilities (Lacroix et al., 2021). That is probably why, in our secondary exploratory analysis, people with higher levels of education and/or better delay recall experience milder dizziness. This fact could influence the extent of dizziness reduction as sensory reweighting constitutes the core principle of vestibular rehabilitation (Carver et al., 2006; Ueta et al., 2017). Recent literature also indicates a correlation between vestibular pathology and MCI (Bosmans et al., 2024). As we mentioned above, people with MCI, who are older than our participants, are significantly more likely to experience vestibular dysfunction (Bosmans et al., 2024, 2021; Wei et al., 2019). In our case, it would be interesting to examine whether middle-aged people with vestibular pathology are more likely to experience long-term cognitive decline than those without.

The magnitude of the improvement in functional gait performance did not differ between the groups, although the values at the end of the intervention showed a statistically significant difference. But why does the intervention have the same effect on both groups? One explanation could be that the neural circuits involved in motor learning remain intact. A recent study, measuring brain activity, showed that while there are differences in brain activation, specifically in the primary and secondary motor cortices and parietal regions, between individuals with MCI and the normal population, this did not affect their walking speed (Li et al., 2025). This most likely occurs because neural compensation was successful, allowing functionality to be maintained. However, these differences become apparent when gait is examined in dual tasks (Bahureksa et al., 2017), which was not the case in our study. In a recent systematic review, gait speed, stride length, and time discriminated against MCI participants under dual-task conditions than under cognitive tasks (Wang et al., 2022). Moreover, a recent cross-sectional study found that functional gait performance is strongly influenced by vigilance, underscoring the importance of attention for locomotion (Nikitas et al., 2023). On the other hand, the tool used to detect cognitive decline may not have been the most appropriate. The MoCA test is a reasonably good and fast screening tool for detecting MCI, but many factors influence its outcome, as already mentioned above (Malek-Ahmadi et al., 2015; Bugallo-Carrera et al., 2024). It is recommended to use the overall test score rather than the subcategory scores (Moafmashhadi and Koski, 2013) and to conduct further investigation if signs of cognitive decline are detected (Dautzenberg et al., 2020). Besides, not all MoCA subcategories are affected in people with vestibular pathologies (Table 2). Thus, the distinction between MCI may not be entirely accurate and may reflect evidence of specific cognitive deficits resulting from vestibular pathologies. Nonetheless, it offers a discriminative capability that clinicians may utilize in the future to reliably, prospectively, and swiftly identify potential factors influencing symptoms in individuals with vestibular disorders. A recent review advocates using this specific screening tool, among other instruments, to assess vestibular-cognitive dysfunction. The review highlights its widespread application while noting a lack of specificity in the vestibular-cognitive domains. It is imperative that the scientific community transition from generalized cognitive screening to more targeted assessments to enhance sensitivity and advance further classification (Smith et al., 2024).

Our clinical study has limitations. Although the groups studied were matched for age and sex, they were not randomized, which may introduce selection bias. As a result, the findings should be interpreted carefully. Also, cognitive assessments at the start and end of the intervention could enhance the reliability of our findings by evaluating whether vestibular rehabilitation improves cognitive deficits related to vestibular disorders.

Furthermore, participants' adherence to the therapeutic protocol was based on self-reported questions.

An additional factor influencing MoCA performance is auditory acuity (Moradi et al., 2024). In the present study, hearing was not taken into account, as it does not constitute a factor affecting vestibular compensation or the mechanisms of vestibular rehabilitation, and the audio-dependent components do not appear to influence the outcome (Moradi et al., 2024).

Given the multifactorial origin of postural control, the assessment of functional gait may be influenced by various other parameters, such as peripheral polyneuropathy, diabetes mellitus, and/or central nervous system lesions. It is recommended that future studies incorporate these factors, as they could potentially impact rehabilitation outcomes.

5 Conclusion

This clinical study showed that middle-aged individuals with vestibular disorders and indications of mild cognitive impairment, as measured by a standard screening tool, reported worse scores in dizziness perception and functional gait performance after vestibular rehabilitation. Furthermore, cognitive function influences the effective modification of dizziness perception after vestibular rehabilitation.

Generative AI statement

The author(s) declared that generative AI was not used in the creation of this manuscript.

Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Footnotes

Edited by: Eugen Constant Ionescu, Hospices Civils de Lyon, France

Reviewed by: Maura Cosetti, New York Eye and Ear Infirmary, United States

Marlon Bruno Nunes Ribeiro, Universidade Federal de Viçosa, Brazil