Optimizing Vestibular Rehabilitation: From Neuroplastic Mechanisms to Multimodal Therapeutic Strategies

Peripheral vestibulopathy (PV) is a common disorder that causes dizziness and balance impairment, substantially affecting patients' quality of life. When symptoms persist, they frequently lead to anxiety, depression, and an increased risk of social isolation. Although central vestibular compensation (CVC) often promotes functional recovery, current pharmacological options remain limited and are primarily aimed at symptom control. Consequently, they should be considered adjuncts rather than alternatives to rehabilitation-based strategies. Vestibular rehabilitation (VR) remains the cornerstone of treatment for promoting functional recovery in patients with PV. Based on the complementary mechanisms of adaptation, substitution, and habituation, VR enhances the central nervous system's ability to compensate for vestibular deficits by optimizing the integration of visual, proprioceptive, and residual vestibular inputs. Robust evidence from both clinical and preclinical studies has demonstrated its efficacy in improving postural stability, dynamic balance, gaze stabilization, and overall functional performance. Experimental studies using animal models have further highlighted the critical role of active sensorimotor training in ecologically relevant environments for enhancing vestibular compensation. Pharmacological interventions may further facilitate these adaptive processes by modulating the neurobiological mechanisms underlying vestibular compensation, thereby improving responsiveness to rehabilitation. Likewise, emerging neuromodulation approaches, including galvanic vestibular stimulation, have shown promising potential to enhance neural plasticity and augment the effects of rehabilitation. Consequently, combining VR with targeted pharmacological therapies and/or vestibular stimulation techniques may provide synergistic benefits and maximize functional recovery. In conclusion, vestibular rehabilitation should remain the foundation of PV management and be integrated with pharmacological and neuromodulatory approaches within a multidisciplinary therapeutic framework. Further research is needed to optimize rehabilitation protocols, identify the biological determinants of successful vestibular compensation, and develop personalized therapeutic strategies aimed at maximizing functional recovery and improving patients' quality of life.