# Treatment-related modulation of visuo-vestibular integration in post-earthquake dizziness syndrome: a longitudinal virtual reality–based study

## TL;DR

This study shows that combining virtual reality and cognitive therapy helps reduce dizziness and imbalance after earthquakes by improving how the brain processes visual and balance information.

## Contribution

The study provides longitudinal evidence that integrated VR and CBT modulates visuo-vestibular processing in PEDS.

## Key findings

- Dizziness and trauma symptoms improved over time across all treatment groups.
- VR + CBT showed the most consistent and durable improvement in visually demanding visuo-vestibular tasks.
- RFT improvements suggest reduced visual frame dependence in active treatment arms.

## Abstract

Post-earthquake dizziness syndrome (PEDS) is increasingly recognized as a condition marked by persistent dizziness and imbalance after major earthquakes, often without clear peripheral vestibular pathology. Despite proposed roles of visuo-vestibular dysfunction and sensory conflict, longitudinal objective evidence remains limited.

To examine the longitudinal effects of virtual reality–based vestibular rehabilitation (VR), cognitive behavioral therapy (CBT), and their integration (VR + CBT) on objective visuo-vestibular processing and symptom burden in adults with PEDS.

In a four-arm longitudinal study, 48 earthquake-exposed adults with PEDS were evaluated at baseline, post-intervention, and 3-month follow-up following an 8-week intervention. Objective visuo-vestibular outcomes were assessed using an immersive virtual reality–based system, including static and dynamic subjective visual vertical (SVV/DSVV), rod-and-frame test (RFT), and visual motion sensitivity (VMS) tests. Subjective outcomes included dizziness-related handicap (DHI) and post-traumatic stress symptoms (PCL-5).

Dizziness-related disability and trauma-related symptoms improved over time across groups, indicating clinical modifiability of PEDS. Objective measures demonstrated a domain-specific response profile: SVV and DSVV remained largely stable, whereas RFT showed improvement in active treatment arms, suggesting reduced visual frame dependence. VMS outcomes exhibited differential trajectories, with the integrated VR + CBT group showing the most consistent and durable modulation under visually provocative conditions.

Recovery in PEDS appears to involve selective modulation of context-dependent visuo-vestibular processing rather than uniform changes across all spatial orientation measures. Integrated VR + CBT yields the most coherent and durable benefits in visually demanding domains, supporting multidisciplinary models that jointly address sensory conflict and cognitive–emotional mechanisms after major earthquakes.

The online version contains supplementary material available at 10.1007/s00415-026-13767-4.