Menière's disease is a fluctuating pressure pathology featuring successive hydropic episodes of varying frequency and intensity. The accumulation of these episodes and of the certain treatments can induce vestibular deficit and episodes of chronic instability. Vestibular rehabilitation aims to limit everyday impact by developing compensation and adaptation. How and when should it be introduced?

A systematic review of the literature for the period 1963–2022 was conducted by an expert group comprising of ENT physicians and vestibular physiotherapists. For each reference, the level of evidence was recorded as 1, 2, 3, 4 or expert opinion. Recommendations were graded A, B or C according to the methodological quality of the underlying studies; when there was no evidence-based consensus, an “expert opinion” was formulated based on the group members’ clinical practices.

Eighteen articles were selected via 4 scientific search engines (PubMed, Google Scholar, PEDro, Science Direct) and 3 keywords “Rehabilitation”, “Vestibular rehabilitation”, and “Menière's disease”.

Vestibular rehabilitation is recommended in Menière's disease in case of uncompensated spontaneous progressive vestibular deficit or surgical or medical vestibular suppression (gentamicin injection). Rehabilitation should await a period of 3 months’ stability, and be adapted to the individual complaint. It should be supervised by a rehabilitation professional: self-rehabilitation is not recommended.

# Abbreviations

AA0-HNS
                        
                           American Association of Otolaryngology–Head and Neck Surgery
                        
                        ABC
                        
                           Activities-specific Balance Confidence Scale
                        
                        DHI
                        
                           Dizziness Handicap Inventory

# Introduction

Menière's disease is a chronic pathology. Clinical diagnostic characteristics were updated in 2015 on consensus between several scientific societies concerned by balance disorder: the Bárány Society, the Japan Society for Equilibrium Research, the European Academy of Otology and Neuro-Otology (EAONO), the Equilibrium Committee of the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS), and the Korean Balance Society [1]. Diagnosis is certain in case of recurrent vertigo without trigger lasting between 20minutes and 12hours, associated with ≥30dB bone conduction hearing loss compared to the contralateral ear on 2 contiguous frequencies below 2 KHz. In case of bilateral low-frequency sensorineural hearing loss, bone conduction loss must be ≥35dB on 2 contiguous frequencies below 2 KHz. There must also be fluctuating auditory signs such as tinnitus, hypoacusis and/or sensation of full ear; and all differential diagnoses must be ruled out [1].

The intensity of the rotational vertigo syndrome and of the vegetative signs (nausea, vomiting, diarrhea) and the duration of the episodes have social, personal and occupational impact, which can lead to social isolation, prolonged sick leave, occupational invalidity and diminished personal activity [2,3].

Management was defined by the French Society of ENT and Head and Neck Surgery (SFORL): gradual, progressive and symptomatic. The aim is to reduce the frequency and intensity of the acute clinical signs, which occur only during vertigo episodes (acute period). Conservative treatments target vestibular function: oral drugs, transtympanic corticosteroid injection, endolymphatic sac surgery. Vestibular function suppression treatment induces deficits ranging from clipping to destruction: transtympanic gentamicin injection, vestibular neurotomy or complete surgical destruction is reserved for specific situations of resistance to conservative treatment or Tumarkin drop attacks [4].

In the intercritical periods of remission without rotational attacks, many patients report persistent balance disorder, with instability or a pitching sensation, as in the study by Pyykkö et al., analyzing questionnaire responses from 539 patients with Menière's disease [5]. The disorder can be relieved by the above-mentioned drug treatments. It results from vestibular damage caused by the disease [6], with 3 situations: function naturally conserved but fluctuating; function naturally deficient, whether fluctuating or not [4,7]; or deficit, partial or total (areflexia), intentionally induced as treatment for the vertigo [8]. The vestibular damage may be isolated or associated with other vestibular pathologies (benign paroxysmal positional vertigo [BPPV] [9]) or neurologic pathology unrelated to Menière's disease. Vestibular rehabilitation is often prescribed to limit functional decline and impact on quality of life. There is, however, no European multidisciplinary consensus on the timing or modalities of rehabilitation in Menière's disease.

The present article provides guidelines on the role and modalities of vestibular rehabilitation for health professionals managing patients with Menière's disease.

# Materials and method

Drawing up the guidelines was confided in 2023 to a French National Multidisciplinary Workgroup coordinated by Pr. Vincent Darrouzet of the Bordeaux University Hospital, under the aegis of the SFORL. The French Health Authority's formalized expert consensus methodology for good-practice guidelines (http://www.has-sante.fr) was implemented. A rationale was formulated, enabling clinical recommendations to be drawn up according to the methodology. The present article is a narrative review summarizing the data available on rehabilitation in Menière's disease and presenting clinical recommendations based on critical analysis of the literature and expert opinion. Unlike an exhaustive systematic review, it was not based on a pre-established registered PROSPERO protocol, but on a selection of the literature on the topic.

The PubMed, Google Scholar, PEDro and Science Direct databases were searched for the period 1963–2022. The narrative review search strategy was structured. Keywords comprised “rééducation”, “rééducation vestibulaire”, “maladie de Menière” and “vestibular rehabilitation”, “balance therapy”, “vestibular exercises”, “Ménière's disease” and “Meniere disease”. When relevant, MeSH terms were applied in PubMed: e.g., “Vestibular Rehabilitation” [MeSH], “Meniere Disease” [MeSH]. Search was extended by using Boolean operators (AND, OR) to cross the search terms and enhance exhaustiveness.

Only articles in French or English, concerning adults with Menière's disease, assessing vestibular rehabilitation, were selected. Reports on peripheral vestibulopathy without clearly distinguishing Menière's disease, or in which rehabilitation was not a focus, were excluded. All types of study (controlled trials, observational studies, reviews) were acceptable.

Levels of evidence were recorded as 1, 2, 3, 4 or expert opinion. Recommendations were graded A, B or C by decreasing levels of evidence, following the French National Agency of Health Accreditation and Evaluation (ANAES) 2000 guide to literature analysis and recommendation grading (Table 1
                     : table of the present study references). They were the assessed by a reviewing group and modified according to the comments made.

Progression in Menière's disease was divided into three periods: acute (for 2 weeks after symptom onset), subacute (for the following 3 months) and intercritical (beyond 3 months) [10].

# Role of vestibular rehabilitation

The role of vestibular rehabilitation in Menière's disease is poorly codified. Prescription should meet the patient's complaint, regardless of disease stage and progression. It should also take account of the timing of the complaint and the severity of the vestibular deficit.

## Without stabilized vestibular deficit

The efficacy of rehabilitation, whatever the deficit, motor, sensory, cognitive…, depends partly on the stability of the original deficit. Menière's disease is inherently fluctuating, and a certain interval is required between the last episode and initiation of rehabilitation for the vestibular deficit to stabilize.
                           
                              
                                 Recommendation 1
                              
                              
                                 
                                    Balance therapy should not be implemented in patients who are not stable in the critical period (expert opinion).

## With stabilized vestibular deficit

Stabilization may be found in two situations: in the intercritical period, or when definitive partial or total deficit was induced by vestibular suppression treatment.

The SFORL and AAOHNS guidelines [4,11] recommend vestibular rehabilitation when the patient reports chronic instability with stabilized vestibular deficit. It can thus only be initiated in the intercritical period or if vestibular suppression treatment has been implemented.

### With stabilized vestibular deficit in the intercritical period

In stabilized Menière's disease more than 3 months after the last episode, vestibular rehabilitation improves postural control and limits discomfort. This was confirmed in the level-4 prospective non-comparative interventional study by Gottshall et al. [12]. In 26 patients, rehabilitation was based on gaze stabilization exercises and balance training, with weekly sessions for 8 weeks. Clinical scales showed improvement in postural control and discomfort, on the Dizziness Handicap Inventory (DHI) and Activities-specific Balance Confidence (ABC) scales, and on posturography. However, patients had not all received the same prior treatment, notably as concerns the number of transtympanic corticosteroid injections.
                              
                                 
                                    Recommendation 2
                                 
                                 
                                    
                                       Patients are deemed “stabilized” when there are no more rotational vertigo episodes but a persistent sensation of imbalance (expert opinion). The relevant period remains to be defined, although 3 months is often cited.

Types of rehabilitation vary, and the literature is sparse; thus, no gold standard can be defined.

Hsu et al. [10], for example, used virtual reality in 6 sessions over 4 weeks, with modified exercises taken from the Cawthorne-Cooksey protocol. Thirty-two patients were included, with 36 controls, in a single-blind randomized controlled trial. 3D vestibular rehabilitation significantly improved postural control (posturographic parameters) versus the control group.

Garcia et al. [13] associated virtual reality (gaze stabilization and optokinetics) to postural control exercises with visual biofeedback on a posturography platform, with 2 sessions per week for 6 weeks. The level-2 randomized controlled trial included 44 patients, with 23 in the stabilized Menière's disease group. Patients received 48mg/day betahistine and dietary counseling. However, the disease stabilization period was not defined. There was improvement in quality of life on the DHI and a VAS severity scale, and in certain posturographic parameters.

In a level-4 non-comparative interventional study, Nyabenda et al. [14] used a rotating chair, with the aim of inducing habituation. The patient is turned to the side with the deficit, to reduce response asymmetry (directional preponderance). Rehabilitation protocols for acute vestibular syndrome are partly based on early use of such chairs. The 23 patients included in the study presented 6–14 days’ balance disorder per year. Episode frequency varied between 20 and 10 per month. Rehabilitation comprised 2 sessions twice weekly for a mean 11 sessions. On the DHI, symptoms showed improvement and there was reduced rotational vestibular response asymmetry and reduced segmental deviation on Fukuda test and blind walking test.
                              
                                 
                                    Recommendation 3
                                 
                                 
                                    
                                       Rehabilitation sessions are recommended in patients with Menière's disease and balance disorder and/or chronic intercritical vertigo sensation (grade B).
                                    
                                 
                              
                           
                           
                              
                                 
                                    Recommendation 4
                                 
                                 
                                    
                                       It is recommended to adapt the type of vestibular rehabilitation according to the patient's complaint and change in objective vestibular assessment, which requires the intervention of a therapist to adapt rehabilitation correctly (expert opinion).

Pyykkö et al. reported that self-rehabilitation at home was equally effective if supervised, especially during rotational disorder. Seventy percent of respondents to a questionnaire on the type of rehabilitation (539 responses out of 1,035) reported performing exercises at home (level 4) [15]. Exercises were tailored to the patient's complaint: pitching, instability and tripping, rotational vertigo. They focused on stepping and balance, with or without help. The patients reporting pitching or tripping were the most assiduous. Patients reporting problems including rotation sensation preferred exercises performed with a professional [15].
                              
                                 
                                    Recommendation 5
                                 
                                 
                                    
                                       In case of intercritical vestibular disorder with rotation sensation, self-rehabilitation is not recommended. Supervision by a specialist is preferable (expert opinion).
                                    
                                 
                              
                           
                           
                              
                                 
                                    Recommendation 6
                                 
                                 
                                    
                                       Patients with persistent instability should practice physical activities involving the balance function (expert opinion).

### Vestibular deficit secondary to vestibular suppression treatment

Data are sparse regarding the type and effect of vestibular rehabilitation in case of deficit induced by partial or total vestibular suppression in Menière's disease. Onset is secondary to transtympanic gentamicin injection following vestibular neurotomy or labyrinthectomy. In a level-4 non-comparative prospective interventional study, Perez et al. reported improvement in post-labyrinthectomy postural control and posturographic parameters following vestibular rehabilitation based on visual biofeedback on a posturography platform [16]. There are no data for the aftermath of vestibular neurotomy or gentamicin injection. However, vestibular rehabilitation has proven efficacy after onset of vestibular deficit in contexts other than Menière's disease, such as schwannoma resection, and thus seems indicated immediately after vestibular suppression treatment [17]. The deficit, induced deliberately due to disabling Menière's disease, is irreversible; it can be total (vestibular neurotomy, translabyrinthine route) or partial (moderate-dose transtympanic gentamicin injection “on demand”), in contrast to “natural” deficit, which may be spontaneously reversible. There is consensus as to the usefulness of vestibular rehabilitation after treatments causing acute vestibular deficit [4,11].
                              
                                 
                                    Recommendation 7
                                 
                                 
                                    
                                       Vestibular rehabilitation sessions are recommended in case on non-compensated spontaneous deficit, whether progressive or due to vestibular suppression treatment (surgical, or gentamicin injection) (expert opinion).

## Vestibular rehabilitation in Menière's disease with benign paroxysmal positional vertigo (BPPV)

Treatment of BPPV [9,18,19] is the same as in patients without Menière's disease. Diagnosis is based on the Bárány Society criteria. It requires interview and clinical, neurological, otological and vestibular examination. Interview reveals rotational vertigo that differs from that found in Menière's disease: limited in time, to a few minutes, without prodroma, without auditory signs and triggered by a specific head position. Patients often report severe disability [9,20]. Clinical examination rules out central causes, and diagnostic maneuvers determine the side and the canal involved. Treatment requires adapted liberatory maneuvers, whatever the stage of the Menière's disease. This treatment can be associated to vestibular rehabilitation for BPPV in intercritical periods of Menière's disease. A level-2 observational study by Socher et al. [20], in 13 patients with BPPV in intercritical periods of Menière's disease, found improvement on the DHI (Brazilian version), especially as regards the physical aspect of the disability [20], after Epley liberatory maneuver associated to Brandt-Daroff habituation maneuver and Cawthorn-Cooksey rehabilitation. However, the study had methodological shortcomings, with no control group, and did not specify the number of sessions, and further studies are needed to determine the role of vestibular rehabilitation in this context: rehabilitation may be more effective against instability caused by the Menière's disease than that caused by the BPPV treatment. Moreover, although rehabilitation seems to be effective, the success rate according to some authors is lower than in patients with de novo BPPV [19].
                           
                              
                                 Recommendation 8
                              
                              
                                 
                                    Vestibular rehabilitation is recommended for patients with Menière's disease and benign paroxysmal positional vertigo in intercritical periods (grade B).

# Funding

None.

The authors thank the members of the pilot group and grading and review group who took part in drawing up and validating the present guidelines: Dr. Pierre Bertholon, Mr. Éric Blin, Dr. Didier Bouccara, Dr. Christian Chabert, Pr. Anne Charpiot, Mr. Sébastien Doutreligne, Dr. Xavier Dubernard, Mr. Thomas Dujardin, Dr. Maya Elziere, Dr. Marie-José Fraysse, Pr. Caroline Froment, Dr. Philippe Guillou, Dr. Charlotte Hautefort, Pr. Martin Hitier, Dr. Michel Kossowski, Ms. Marie-Laure Laborie, Pr. Benoite Lassalle-Kinic, Mr. Gael Le Perf, Dr. Elena Laura Lemaitre, Dr. Stéphanie Leplaideur, Dr. Carole Masgnaux, Dr. Laura Mechtouff, Dr. Émeline Michel, Pr. Cécile Parietti-Winkler, Dr. Cécile Nicolas-Puel, Pr. François Puisieux, Pr. Jean-Claude Quintyn, Dr. Edwin Regrain, Pr. Sébastien Schmerber, Dr. Christian Van Nechel, Dr. Alexandra Weckel.