Comparative efficacy of non-pharmacological interventions for persistent postural-perceptual dizziness: a systematic review and network meta-analysis of balance, anxiety, and depression outcomes

Persistent postural-perceptual dizziness (PPPD) is a chronic functional vestibular disorder characterized by persistent dizziness, postural instability, and visual hypersensitivity. Although several non-pharmacological interventions have been proposed, their comparative efficacy remains unclear. PubMed, Embase, and the Cochrane Library were searched from inception to January 2026 for randomized controlled trials involving adults with PPPD or equivalent conditions. Interventions included CBT, vestibular rehabilitation therapy (VRT), neuromodulation, galvanic vestibular stimulation (GVS), and combined approaches. Random-effects network meta-analysis was performed using standardized mean differences (SMDs) and 95% confidence intervals (CIs). Eleven RCTs comprising 518 patients were included. For balance outcomes (518 participants), neuromodulation significantly outperformed control (SMD −1.22, 95% CI −1.90 to −0.54). It also demonstrated superiority over CBT (SMD −1.03, 95% CI −1.96 to −0.09) and VRT (SMD −1.33, 95% CI −2.49 to −0.18). For anxiety outcomes (518 participants), neuromodulation demonstrated significant superiority over control (SMD −0.87, 95% CI −1.40 to −0.33), CBT (SMD −0.88, 95% CI −1.62 to −0.14), and Advanced VRT (SMD −1.36, 95% CI −2.31 to −0.41). No significant effects were observed for any intervention on depression outcomes; moderate-to-substantial heterogeneity was detected (I 2 : 47.8%–68.9%), while no significant inconsistency was found. Most studies (81.8%) were at high risk of bias, with overall evidence quality rated low to moderate. Neuromodulation may provide relative benefits for balance and anxiety in PPPD, whereas evidence for alleviation of depression remains inconclusive. Given the limited and low-quality evidence base, further high-quality randomized controlled trials are needed. PROSPERO (CRD420261285141).