Discussion
peripheral hypofunction, visual overload
In this pilot randomized trial patients demonstrated significant, clinically important differences over time in both groups with no evidence of significant differences between groups. Specifically on the FGA both groups began on average at fall risk (below 22) and came closer to maximal score (on average 28 or 26 points out of 30) following the intervention. These changes of a little over 20% are similar to the ones reported in a recent systematic review [C.S.I. is a viable and good intervention option that patients enjoyed with limited symptoms that is not expensive and is feasible in a clinical setting. We designed the app with free graphics that can create sensory load without requiring high computational power [While we did not formally measure enjoyment, most participants were interested in the study because virtual reality was offered and patients in the C.S.I. group appreciated the engagements in salient environments. Greater enjoyment in computerized interventions has been reported before [The two interventions in this study were inherently different, i.e., context specific training (salient balance challenges with dynamic visual load) versus traditional vestibular rehab (gait training and gaze stability exercises), yet the results were remarkably similar. That brings the question of whether the more important aspect to therapy is the home exercise program, including vestibular-specific exercises regardless of method of delivery (i.e. head turning, walking, visual overload). Note that the only difference between the home exercise programs was that the C.S.I group did not perform exercises with eyes closed. It is also possible that research creates a selection bias where patients who agree to be involved in research tend to be more motivated, which could be key to improvement. At the conclusion of our study, the question remains regarding the importance of incorporating different contexts in balance training. More research needs to be done regarding the importance of context in vestibular rehabilitation and what crucial features in virtual reality may help patients the most. In addition, our app allowed for a complete freedom in clinical decision making. The therapists could choose how and when to progress based on patients’ subjective response. Broad implementation of virtual reality technology could allow future studies to incorporate machine learning approaches and potentially design a progression algorithm and test whether such algorithm could enhance patients’ outcomes.We used functional outcome measures that are recommended by the APTA Vestibular Edge Taskforce [Moderate to weak evidence from the clinical practice guidelines for peripheral hypofunction recommend 5–7 weeks of vestibular rehabilitation once a week [Recent CPG guidelines state that clinicians may prescribe static and dynamic balance exercises for a minimum of 20 min for at least 4 to 6 weeks although the strength of the recommendation is weak [