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Aquatic physiotherapy for vestibular rehabilitation in patients with unilateral vestibular hypofunction: Exploratory prospective study
Abstract
To explore the effects of aquatic physiotherapy on individuals with unilateral vestibular hypofunction and examine the association of therapeutic effects with age, time since symptom onset and use of antivertigo medication.
Exploratory study.
Tertiary referral center.
Twenty-one patients presenting chronic dizziness with uncompensated unilateral vestibular loss.
All patients underwent a regimen of 10 sessions of aquatic physiotherapy for vestibular rehabilitation.
Patient evaluation prior to and following rehabilitation involved the application of the Brazilian version of the Dizziness Handicap Inventory (DHI), dynamic computerized posturography and the self-perception scale of dizziness intensity. Statistical analysis compared average variables prior to and following rehabilitation using the Student t test.
Brazilian DHI total scores were lower following rehabilitation (p = 0.001). Posturography revealed a reduction in the variation of body displacement following rehabilitation in the average stability and anterior/posterior stability indexes (p = 0.001) and in the average medial/lateral stability index (p = 0.003). Self-perception of dizziness intensity was lower following rehabilitation (p = 0.001). No association between age, time since symptom onset and use of antivertigo medication and rehabilitation therapeutic effects were found.
Unilateral vestibular hypofunction patients undergoing aquatic physiotherapy for vestibular rehabilitation achieved an improvement in quality of life, body balance and self-perception of dizziness intensity, regardless of age, time since symptom onset, and use of antivertigo medication.
... Unilateral vestibular hypofunction (UVH) is a heterogeneous disorder in which a partial or complete loss of one of the vestibular organs and/or nerves is present (1,2). UVH occurs either suddenly or gradually, depending on the etiology. ...
... The VAS, which can be used to assess different aspects (e.g., dizzines intensity, dizziness frequency, visual vertigo), subjectively evaluates the perception of vestibular symptoms related to vertigo, dizziness, imbalance, and oscillopsia. In the VAS, dizziness severity is categorized as none (1); slight (2)(3); mild (4-5); moderate (6-7); severe (8)(9); and extreme (10) (29). A semi-structured interview, which is a combination of a structured and unstructured interview, can also be performed to evaluate symptoms related to UVH. ...
... After removing duplications (1,268 studies) via Endnote, a total of 842 citations were screened on title and abstract. After the second screening phase, 47 articles (2,14,16,17,24, met the in-and exclusion criteria (Figure 1). ...
Objective
To systematically evaluate the full spectrum of self-reported chronic symptoms in patients with unilateral vestibular hypofunction (UVH) and to investigate the effect of interventions on these symptoms.
Methods
A systematic review was conducted following the guidelines of the Preferred Reporting Items for Systematic Review and Meta-Analysis Statement (PRISMA). A literature search was performed in Pubmed, Web of Science, Embase, and Scopus to investigate self-reported symptoms and self-report questionnaires in patients with UVH. All original studies ranging from full-text clinical trials to case reports, written in English, German, and French, were included. The frequency of self-reported symptoms was presented. For self-report questionnaires, a meta-analysis was carried out to synthesize scale means by the pre- and post-intervention means and mean changes for studies that investigated interventions.
Results
A total of 2,110 studies were retrieved. Forty-seven studies were included after title-abstract selection and full-text selection by two independent reviewers. The symptoms of UVH patients included chronic dizziness (98%), imbalance (81%), symptoms worsened by head movements (75%), visually induced dizziness (61%), symptoms worsened in darkness (51%), and oscillopsia (22%). Additionally, UVH could be accompanied by recurrent vertigo (77%), tiredness (68%), cognitive symptoms (58%), and autonomic symptoms (46%). Regarding self-report questionnaires, UVH resulted on average in a moderate handicap, with an estimated mean total score on the Dizziness Handicap Inventory (DHI) and the Vertigo Symptom Scale (VSS) of 46.31 (95% CI: 41.17–51.44) and 15.50 (95% CI: 12.59–18.41), respectively. In studies that investigated the effect of vestibular intervention, a significant decrease in the estimated mean total DHI scores from 51.79 (95% CI: 46.61–56.97) (pre-intervention) to 27.39 (95% CI: 23.16–31.62) (post intervention) was found (p < 0.0001). In three studies, the estimated mean total Visual Analog Scale (VAS) scores were 7.05 (95% CI, 5.64–8.46) (pre-intervention) and 2.56 (95% CI, 1.15–3.97) (post-intervention). Finally, a subgroup of patients (≥32%) persists with at least a moderate handicap, despite vestibular rehabilitation.
Conclusion
A spectrum of symptoms is associated with UVH, of which chronic dizziness and imbalance are most frequently reported. However, semi-structured interviews should be conducted to define the whole spectrum of UVH symptoms more precisely, in order to establish a validated patient-reported outcome measure (PROM) for UVH patients. Furthermore, vestibular interventions can significantly decrease self-reported handicap, although this is insufficient for a subgroup of patients. It could therefore be considered for this subgroup of patients to explore new intervention strategies like vibrotactile feedback or the vestibular implant.
Systematic review registration
[https://www.crd.york.ac.uk/prospero/], identifier [CRD42023389185].
... Eight included studies report data on a total of 434 adults (167 men (38%) and 267 women (62%)) with sample sizes ranging between 21 37 and 106 38 and ages between 20 37 and 84 years 39 . Three studies objectified the level of physical activity in UVD patients 38,43,44 and 5 interventional studies investigated the effect of a physical activity intervention in UVD patients. ...
... Eight included studies report data on a total of 434 adults (167 men (38%) and 267 women (62%)) with sample sizes ranging between 21 37 and 106 38 and ages between 20 37 and 84 years 39 . Three studies objectified the level of physical activity in UVD patients 38,43,44 and 5 interventional studies investigated the effect of a physical activity intervention in UVD patients. ...
... Three studies objectified the level of physical activity in UVD patients 38,43,44 and 5 interventional studies investigated the effect of a physical activity intervention in UVD patients. 37,39,[40][41][42] Different terminologies were used to describe UVD patients: (unilateral) peripheral dizziness, 40,41 unilateral/ peripheral vestibular hypofunction, 37,38,[42][43][44] and acute vestibular neuritis 39 (Supplementary Table 7). The 3 cross-sectional studies aimed at objectifying physical activity during everyday life through a wrist-worn device, 38 an accelerometer, 44 and a questionnaire. ...
... Unilateral vestibular hypofunction (UVH) is a disorder that creates a reduced total or partial reduction in vestibular function on one side of the body (9). Patients with UVH frequently report symptoms such as dizziness, oscillopsia, postural instability, and gait disorders (9)(10)(11)(12). ...
... Unilateral vestibular hypofunction (UVH) is a disorder that creates a reduced total or partial reduction in vestibular function on one side of the body (9). Patients with UVH frequently report symptoms such as dizziness, oscillopsia, postural instability, and gait disorders (9)(10)(11)(12). These impairments produce significant limitations in activity and participation in the affected patient (10,13). ...
Introduction
Although vestibular rehabilitation therapy (VRT) methods are relatively popular in treating patients with body balance deficits of vestibular origin, only limited studies have been conducted into customized exercises for unilateral vestibular hypofunction (UVH). Furthermore, very little evidence is available on the outcomes of VRT in the elderly population with chronic UVH.
Materials and Methods
A total of 21 patients, aged 61 to 74 years, with UVH participated in this study. The dizziness handicap inventory (DHI) was performed immediately before, and 2 and 8 weeks after treatment.
Results
All patients showed a reduction in DHI scores during the study. The average decrease in DHI score was 25.98 points after 2 weeks’ intervention (P<0.001) and 32.54 points at the end of the study. This improvement was observed in all DHI subscores, and was most profound in the functional aspect. The correlation between the degree of final recovery and canal paresis was not significant (P>0.05). There were no relationships between the scores and gender.
Conclusion
Our study demonstrates that VRT is an effective method for the management of elderly patients with UVH, and shows maximal effect on functional aspects.
... Unilateral vestibular hypofunction (UVH) is a heterogeneous condition characterized by partial or total impairment of one of the vestibular organs or nerves [1,2]. The condition presents with a web of vexatious symptoms including vertigo that instigates a profound whirling sensation, which may be short-lived or extend over a longer period, and nystagmus. ...
Unilateral vestibular dysfunction is a one-sided impairment of vestibular function in one ear. Incorporating health education in treatment and rehabilitation plans can improve vestibular function, keep negative emotions at bay, and reduce the extent of the condition. This letter investigates the impact of the information-motivation-behavioral skills model as a medium for health education on patient outcomes. While offering encouraging observations, there are certain limitations, such as the study’s retrospective design, small sample size, use of subjective measures, and lack of longer follow-ups that challenge the cogency of the study. The study is a step toward transforming vestibular dysfunction treatment through health education.
... 255 This supports a previous study indicating improved balance (measured by computerized posturography) and dizziness for individuals with UVH after VPT provided in an aquatic setting. 256 Traditional land-based protocols may limit participation in VPT for individuals with UVH/BVH with comorbid severe arthritis or other weight-bearing restrictions. 257 Several investigators have proposed using lenses to stabilize oscillopsia, 258,259 a primary complaint for individuals with BVH. ...
Background:
Uncompensated vestibular hypofunction can result in symptoms of dizziness, imbalance, and/or oscillopsia, gaze and gait instability, and impaired navigation and spatial orientation; thus, may negatively impact an individual's quality of life, ability to perform activities of daily living, drive, and work. It is estimated that one-third of adults in the United States have vestibular dysfunction and the incidence increases with age. There is strong evidence supporting vestibular physical therapy for reducing symptoms, improving gaze and postural stability, and improving function in individuals with vestibular hypofunction. The purpose of this revised clinical practice guideline is to improve quality of care and outcomes for individuals with acute, subacute, and chronic unilateral and bilateral vestibular hypofunction by providing evidence-based recommendations regarding appropriate exercises.
Methods:
These guidelines are a revision of the 2016 guidelines and involved a systematic review of the literature published since 2015 through June 2020 across 6 databases. Article types included meta-analyses, systematic reviews, randomized controlled trials, cohort studies, case-control series, and case series for human subjects, published in English. Sixty-seven articles were identified as relevant to this clinical practice guideline and critically appraised for level of evidence.
Results:
Based on strong evidence, clinicians should offer vestibular rehabilitation to adults with unilateral and bilateral vestibular hypofunction who present with impairments, activity limitations, and participation restrictions related to the vestibular deficit. Based on strong evidence and a preponderance of harm over benefit, clinicians should not include voluntary saccadic or smooth-pursuit eye movements in isolation (ie, without head movement) to promote gaze stability. Based on moderate to strong evidence, clinicians may offer specific exercise techniques to target identified activity limitations and participation restrictions, including virtual reality or augmented sensory feedback. Based on strong evidence and in consideration of patient preference, clinicians should offer supervised vestibular rehabilitation. Based on moderate to weak evidence, clinicians may prescribe weekly clinic visits plus a home exercise program of gaze stabilization exercises consisting of a minimum of: (1) 3 times per day for a total of at least 12 minutes daily for individuals with acute/subacute unilateral vestibular hypofunction; (2) 3 to 5 times per day for a total of at least 20 minutes daily for 4 to 6 weeks for individuals with chronic unilateral vestibular hypofunction; (3) 3 to 5 times per day for a total of 20 to 40 minutes daily for approximately 5 to 7 weeks for individuals with bilateral vestibular hypofunction. Based on moderate evidence, clinicians may prescribe static and dynamic balance exercises for a minimum of 20 minutes daily for at least 4 to 6 weeks for individuals with chronic unilateral vestibular hypofunction and, based on expert opinion, for a minimum of 6 to 9 weeks for individuals with bilateral vestibular hypofunction. Based on moderate evidence, clinicians may use achievement of primary goals, resolution of symptoms, normalized balance and vestibular function, or plateau in progress as reasons for stopping therapy. Based on moderate to strong evidence, clinicians may evaluate factors, including time from onset of symptoms, comorbidities, cognitive function, and use of medication that could modify rehabilitation outcomes.
Discussion:
Recent evidence supports the original recommendations from the 2016 guidelines. There is strong evidence that vestibular physical therapy provides a clear and substantial benefit to individuals with unilateral and bilateral vestibular hypofunction.
Limitations:
The focus of the guideline was on peripheral vestibular hypofunction; thus, the recommendations of the guideline may not apply to individuals with central vestibular disorders. One criterion for study inclusion was that vestibular hypofunction was determined based on objective vestibular function tests. This guideline may not apply to individuals who report symptoms of dizziness, imbalance, and/or oscillopsia without a diagnosis of vestibular hypofunction.
Disclaimer:
These recommendations are intended as a guide to optimize rehabilitation outcomes for individuals undergoing vestibular physical therapy. The contents of this guideline were developed with support from the American Physical Therapy Association and the Academy of Neurologic Physical Therapy using a rigorous review process. The authors declared no conflict of interest and maintained editorial independence.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A369).
... The scale of dizziness and balance was checked using a balance platform before and after the rehabilitation therapy. The authors demonstrated the improvement of the patients' quality of life, decreased intensity of dizziness, and improved body balance [10]. The objective of the study by Booth was to compare the impact of exercise at a gym and in the aquatic environment on gait and balance in two groups of females aged 65 and more. ...
The increase in the average age of our society represents a growing medical and social problem, which requires concentration on the issue concerning balance disorders. The aquatic environment has a number of complex properties that have miscellaneous effects on the human body. In the light of the above, water is becoming an ideal environment to learn correct neuromuscular communication, and a properly prepared training session in water helps to practice balance and movement coordination. The objective of the study was to assess the impact of rehabilitation in the aquatic environment on patients’ balance and compare the results obtained with patients who received rehabilitation at a gym. The study was carried out among patients hospitalised in the “Krzeszowice” Rehabilitation Centre. It encompassed 137 patients, randomly assigned to either the study group (the aquatic environment) or the control group (the gym). The preliminary examination included general medical history and a test on the stabilometric platform. The patients attended training sessions for 4 weeks, 5 times a week for 30 minutes. It was a single-blinded study wherein the authors did not know which group a given patient had been assigned to. Upon completion of a monthly therapy, the stabilometric test was carried out again. The study revealed that the patients from both groups experienced a significant improvement in balance. However, the improvement was slightly greater in those exercising in the pool. Physiotherapy in the aquatic environment makes a greater contribution to the improvement of body balance compared to physical exercises performed at a gym.
... Targeted hydrotherapy programs that include specific exercises can improve gait speed in patients with MS [66] . This improvement may be due to the appropriate combination of exercises and the properties of water as well as the fact that exercises can be performed by patients with MS in water, which cannot be performed on land [82] . ...
Aim: A review of the literature on the effect of hydrotherapy on the symptoms of fatigue, pain, spasticity as well as on the balance and gait of people with Multiple Sclerosis (MS). Method: Search databases such as MEDLINE, Cochrane Library, Science Direct and PEDro were used to search the literature. The inclusion criteria were studies that included physiotherapy and mainly hydrotherapy as a means of rehabilitation in MS. Results: Hydrotherapy programs significantly reduced the symptoms of fatigue, pain, spasticity as well as significantly improved balance and gait in patients with MS, as reflected in the evaluation tests. Conclusions: Hydrotherapy is proposed as a safe, effective and enjoyable method of rehabilitation in patients with MS to reduce symptoms and improve balance and gait.
... Os exercícios terapêuticos na água parecem ser os ideais para prevenir, manter, retardar, melhorar ou tratar as disfunções físicas características do envelhecimento (RUOTI, 1994). Esses exercícios têm sido amplamente utilizados em programas de fisioterapia para diferentes tipos de doenças (GABRIELSEN, 1993), por exemplo, mulheres com osteoporose (DEVEREUX, 2005) ou com artrite em extremidades inferiores (SUOMI, 2000), sendo também indicado para o tratamento de distúrbios neurológicos (GABILAN, 2008). A utilização do ambiente aquático pode promover resultados terapêuticos significativos, tais como diminuição nos tônus muscular (KESIKTAS, 2004), melhora da estabilidade postural (KOURY, 2004) e mobilidade funcional (KIVÁCS, 2002), além de reduzir o grau da espasticidade (KESIKTAS, 2004). ...
... Es posible añadir aquella tecnología de que se disponga, como juegos de equilibrio, estímulo OKN, sistemas de realidad virtual, feedback vibrotáctil [37][38] y la práctica del Tai-Chi que parece mejorar la sustitución sensorial incrementando la sensibilidad distal [39]. También se ha descrito la eficacia de una fisioterapia acuática [40]. En todo caso, se debe insistir en la importancia de la seguridad, especialmente en los programas de rehabilitación domiciliaria [37][38]. ...
Introducción y objetivos:
La rehabilitación vestibular (RV) basada en la terapia física, tiene el objetivo, en el caso de patología vestibular, de inducir la compensación del sistema nervioso central (SNC) a nivel de núcleos vestibulares y de otros niveles del SNC. Incluye ejercicios de habituación, adaptación y sustitución vestibular, ejercicios para mejorar el equilibrio y el control postural dinámico y ejercicios para el acondicionamiento general. En este capítulo discutimos los recientes avances sobre el adiestramiento del equilibrio y de la marcha, la estabilidad de la mirada y la habituación, en el contexto de los trastornos vestibulares uni y bilaterales.
Material y métodos:
Revisión narrativa.
Resultados:
Los ejercicios se prescriben para mejorar la función; fortaleciendo, y favoreciendo la flexibilidad y la resistencia, a través de la adaptación del RVO, la habituación, la sustitución sensorial, la marcha y el equilibrio postural. Son más eficaces los programas personalizados que los genéricos. El cumplimiento mejora con la personalización y las visitas de seguimiento a un fisioterapeuta.
Conclusiones:
La RV permite mejorar el déficit funcional y los síntomas subjetivos derivados de la hipofunción vestibular periférica uni y bilateral, así como las alteraciones del equilibrio de origen central. Los objetivos de la RV consisten en reducir los síntomas para mejorar la estabilidad postural y de la mirada (particularmente durante los movimientos de la cabeza) y devolver al individuo a sus actividades normales, incluyendo la actividad física, la conducción y el trabajo habitual. Los médicos deben ofrecer la RV a quienes muestren limitaciones funcionales relacionadas con un déficit vestibular, pues actualmente se considera el tratamiento estándar en la disfunción vestibular periférica.
... e hydrostatic pressure provides longer times for vestibular processing for postural reactions and better movement perception. erefore, older adults with risk of falls can perform functional exercises safely [5][6][7]. ...
Objective:
To evaluate the additional effects of on balance an aquatic muscle strengthening and flexibility training program in healthy sedentary lifestyle elderly women.
Method:
This controlled clinical trial included 56 healthy sedentary women, aged from 65 to 70 years, divided into two groups. The aquatic group (AG) underwent aquatic training (45 minutes/session, 32 sessions), and the control group (CG) received no intervention. Data were collected pre- and post-intervention, during a one-week period. Lower limb muscle strength was measured by a force sensor (myometer). Flexibility was measured by biophotogrammetry. Functional balance was evaluated by the Performance Oriented Mobility Assessment (POMA) and the Berg Balance Scale (BBS).
Results:
Muscle strength, flexibility, and balance improved in AG (p < 0.001), but not in CG.
Conclusion:
The aquatic exercises program, which was originally developed to promote muscle strength and flexibility, also improved functional balance. Aquatic training is an option for physical health promotion for sedentary lifestyle elderly women.
... В клинических исследованиях был подтвержден положительный эффект при занятиях тай-цзи, йогой, аквааэробикой. Гимнастики тай-цзи и йога включают в себя также приемы релаксации, оказывающие дополнительное положительное воздействие на лиц с сопутствующими тревогой и депрессией [49][50][51]. ...
... A 2008 study in aquatic physiotherapy using whirlpool as part of an exercise protocol revealed positive effects on unilateral vestibular hypofunction. 9 Kao-ta (9- 10 Kao-ta was originally employed as a speed test. ...
Objective: To study the effect of Kao-ta (9-square step exercise) and Kao-ten (9-square dance exercise) on balance improvement in patients with balance disorders.
Methods: This prospective pilot study in patients with balance disorders was conducted at the outpatient clinic, Department of Otorhinolaryngology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand from December 2015 to December 2016. Patients diagnosed by clinical symptoms and at least one abnormal
condition on posturography were taught how to perform Kao-ta and Kao-ten exercise. Participants were provided with the equipment necessary to create a nine square grid at home. They were instructed to perform 3 minutes of Kao-ta followed by 2 minutes of Kao-ten twice per day for at least 45 days in an 8-week period. Posturography and visual analogue scale (VAS) of balance symptom severity were compared between before and after exercise program.
Results: Eleven patients with balance disorders were included. The mean age was 57.2±12.9 years (range: 33-70), and all patients were women. The average composite equilibrium score at baseline was 64.4±8.1. After 8 weeks of Kao-ta and Kao-ten, the average composite equilibrium score increased to 73.8±10.2 (p
... A body immersed in water experiences reduced gravitational stress in muscles and joints, especially of the lower limbs. The response from these receptors may be decreased as a result of buoyancy forces (6,27,28. This effect may interfere with the neuromuscular and proprioceptive systems, preventing the subject from having a similar performance to that achieved on the ground. ...
Introduction: Functional reach (FR) and lateral reach (LR) tests are widely used in scientific research and clinical practice. Assessment tools are useful in assessing subjects with greater accuracy and are usually adapted according to the limitations of each condition. Objective: To adapt FR and LR tests for use in an aquatic environment and assess the performance of healthy young adults. Methods: We collected anthro-pometric data and information on whether the participant exercised regularly or not. The FR and LR tests were adapted for use in an aquatic environment and administered to 47 healthy subjects aged 20-30 years. Each test was repeated three times. Results: Forty-one females and six males were assessed. The mean FR test score for men was 24.06 cm, whereas the mean value for right lateral reach (RLR) was 10.94 cm and for left lateral reach (LLR) was 9.78 cm. For females, the mean FR score was 17.57 cm, while the mean values for RLR was 8.84cm and for LLR was 7.76 cm. Men performed better in the FR (p < 0.001) and RLR tests than women (p = 0.037). Individuals who exercised regularly showed no differences in performance level when compared with their counterparts. Conclusion: The FR and LR tests were adapted for use in an aquatic
... Aquatic physiotherapy may also be benefi cial for people with chronic unilateral vestibular hypofunction. 53 In one study, patients performed 10 sessions of aquatic physiotherapy consisting of eye, head, and body movements that stimulate the vestibular system and other systems involved in body balance, which frequently generate dizziness in patients with unilateral vestibular hypofunction. As a group, patients had lower Brazilian Dizziness Handicap Inventory total scores, lower intensity of dizziness, and better postural stability after aquatic physiotherapy. ...
Background:
Uncompensated vestibular hypofunction results in postural instability, visual blurring with head movement, and subjective complaints of dizziness and/or imbalance. We sought to answer the question, "Is vestibular exercise effective at enhancing recovery of function in people with peripheral (unilateral or bilateral) vestibular hypofunction?"
Methods:
A systematic review of the literature was performed in 5 databases published after 1985 and 5 additional sources for relevant publications were searched. Article types included meta-analyses, systematic reviews, randomized controlled trials, cohort studies, case control series, and case series for human subjects, published in English. One hundred thirty-five articles were identified as relevant to this clinical practice guideline.
Results/discussion:
Based on strong evidence and a preponderance of benefit over harm, clinicians should offer vestibular rehabilitation to persons with unilateral and bilateral vestibular hypofunction with impairments and functional limitations related to the vestibular deficit. Based on strong evidence and a preponderance of harm over benefit, clinicians should not include voluntary saccadic or smooth-pursuit eye movements in isolation (ie, without head movement) as specific exercises for gaze stability. Based on moderate evidence, clinicians may offer specific exercise techniques to target identified impairments or functional limitations. Based on moderate evidence and in consideration of patient preference, clinicians may provide supervised vestibular rehabilitation. Based on expert opinion extrapolated from the evidence, clinicians may prescribe a minimum of 3 times per day for the performance of gaze stability exercises as 1 component of a home exercise program. Based on expert opinion extrapolated from the evidence (range of supervised visits: 2-38 weeks, mean = 10 weeks), clinicians may consider providing adequate supervised vestibular rehabilitation sessions for the patient to understand the goals of the program and how to manage and progress themselves independently. As a general guide, persons without significant comorbidities that affect mobility and with acute or subacute unilateral vestibular hypofunction may need once a week supervised sessions for 2 to 3 weeks; persons with chronic unilateral vestibular hypofunction may need once a week sessions for 4 to 6 weeks; and persons with bilateral vestibular hypofunction may need once a week sessions for 8 to 12 weeks. In addition to supervised sessions, patients are provided a daily home exercise program.
Disclaimer:
These recommendations are intended as a guide for physical therapists and clinicians to optimize rehabilitation outcomes for persons with peripheral vestibular hypofunction undergoing vestibular rehabilitation.Video abstract available for more insights from the author (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A124).
... Gabilan et al. studied the use of aquatic physiotherapy as part of vestibular rehabilitation in patients presenting with chronic dizziness with unilateral vestibular hypofunction [23]. All rehabilitation exercises took place in a pool and included various tasks, and balance control during turbulence. ...
Four studies assessing vestibular compensation in Menière's disease patients undergoing unilateral vestibular neurotomy, using different analysis methods, are reviewed, with a focus on the different strategies used by patients according to their preoperative sensory preference.
Four prospective studies performed in a university tertiary referral center were reviewed, measuring the pattern of vestibular compensation in Menière's disease patients before and after unilateral vestibular neurotomy on various assessment protocols: postural syndrome assessed on static posturography and gait analysis; perceptual syndrome assessed on subjective visual vertical perception; and oculomotor syndrome assessed on ocular cyclotorsion.
Vestibular compensation occurred at variable intervals depending on the parameter investigated. Open-eye postural control and gait/walking returned to normal one month after neurotomy. Fine balance analysis found that visual perception of the vertical and ocular cyclotorsion impairment persisted at long-term follow-up. Clinical postural disturbance persisted only when visual afferents were cut off (eyes closed). These impairments were the expression of a postoperative change in postural strategy related to the new use of visual and non-visual references.
Understanding pre-operative interindividual variation in balance strategy is critical to screening for postural instability and tailoring vestibular rehabilitation.
Copyright © 2015 Elsevier Masson SAS. All rights reserved.
... Besides dizziness, the clinical picture of UVH may include nystagmus, ocular torsion, oscillopsia, postural instability, gait disorders, anxiety, depression, and fear. UVH patients commonly share the same symptoms, in spite of differences regarding the etiology, onset, and clinical findings of dysfunction or the type and extent of the vestibular deficit 1,2) . ...
[Purpose] This study investigated to determine whether the Sideways Stepping Test (SST)
is a useful test to detect unilateral vestibular hypofunction (UVH). [Subjects and
Methods] Twenty-eight subjects including both male and females between the ages of 25 and
55 who had been diagnosed with UVH were recruited for the study. All the subjects were
tested with the SST and followed by the head-shaking nystagmus (HSN) test using video
electronystagmography (VENG) to confirm the presence of UVH. The results of both tests
were then compared with each other to determine the correlation, sensitivity, and
specificity. [Results] The results showed that the SST is strongly correlated with the
gold standard HSN test using VENG and is highly sensitive and specific. [Conclusion] The
present study showed that the SST is a highly valid test that can be used as an
alternative method to the gold standard HSN test using VENG in detecting UVH.
... Gabilan et al. studied the use of aquatic physiotherapy as part of vestibular rehabilitation in patients presenting with chronic dizziness with unilateral vestibular hypofunction [23]. All rehabilitation exercises took place in a pool and included various tasks, and balance control during turbulence. ...
The aim of this review is to present the current knowledge of the mechanisms underlying the vestibular compensation and demonstrating how the vestibular rehabilitation is conducted to help the recovery of balance function. Vestibular rehabilitation is based on improving the natural phenomenon called vestibular compensation that occurs after acute vestibular disturbance or chronic and gradual misbalance. Central compensation implies three main mechanisms namely adaptation, substitution and habituation. The compensation, aided by the rehabilitation aimed to compensate and/or to correct the underused or misused of the visual, proprioceptive and vestibular inputs involved in the postural control. As the strategy of equilibration is not corrected, the patient is incompletely cured and remains with inappropriate balance control with its significance on the risk of fall and impact on quality of life. The vestibular rehabilitation helps to correct inappropriate strategy of equilibrium or to accelerate a good but slow compensation phenomenon. Nowadays, new tools are more and more employed for the diagnosis of vestibular deficit (that may include various sources of impairment), the assessment of postural deficit, the control of the appropriate strategy as well to facilitate the efficiency of the rehabilitation especially in elderly people.
... O questionário Dizziness Handicap Inventory (DHI) foi elaborado e validado com objetivo de avaliar a autopercepção dos efeitos incapacitantes impostos pela tontura [5][6] . Esse questionário, utilizado em muitos países, também foi traduzido e adaptado para aplicação na população brasileira, sendo utilizado em diversas pesquisas em nosso meio [7][8][9][10] . ...
Dizziness impact on the quality of life (QoL) of elderly patients with chronic vestibular dysfunction.
To evaluate the association between the impact of dizziness on the QoL of elderly patients with chronic vestibular dysfunction and demographic and clinical variables.
A prospective study. A hundred and twenty elderly patients with chronic vestibular dysfunction underwent the Brazilian version of the Dizziness Handicap Inventory (DHI). In order to verify the association between the QoL and the demographic and clinical variables, the following testes were used: Mann-Whitney, Kruskal-Wallis and Spearman's correlation coefficient.
There were significant associations between the presence of rotating and non-rotating dizziness with the total score of the DHI (p = 0.010) and physical (p = 0.049) and functional (p = 0.009) subscales; between recurrent falls with total DHI (p = 0.004) and physical (p = 0.045), functional (p = 0.010) and emotional (p = 0.011) subscales. Significant correlations were found between functional incapacity and total DHI (r = + 0.557; p < 0.001) and physical (r = + 0.326; p < 0.001), functional (r = + 0.570; p < 0.001) and emotional (r = + 0.521; p < 0.001) subscales.
The impact of dizziness on the QoL is higher in elderly patients with rotating and non-rotating dizziness, recurrent falls and functional incapacity.
Background
Opting to use aquatic or land-based physical therapy exercises to improve balance, gait, quality of life and reduce fall-related outcomes in community-dwelling older adults (CDOAs) is still a questionable clinical decision for physiotherapists.
Objective
Assess the quality of evidence from randomized or quasi-randomized controlled trials that used aquatic physical therapy exercises to improve balance, gait, quality of life and reduce fall-related outcomes in CDOAs.
Methods
Articles were surveyed in the following databases: MEDLINE/PubMed, EMBASE, SCOPUS, LILACS, Web of Science, CENTRAL (Cochrane Central Register of Controlled Trials), PEDro, CINAHL, SciELO and Google Scholar, published in any language, up to July 31, 2023. Two independent reviewers extracted the data and assessed evidence quality. The risk of bias of the trials was evaluated by the Cochrane tool and evidence quality by GRADE approach. Review Manager software was used to conduct the meta-analyses.
Results
3007 articles were identified in the searches, remaining 33 studies to be read in full, with 11 trials being eligible for this systematic review. The trials included presented low evidence quality for the balance, gait, quality of life and fear of falling. Land-based and aquatic physical therapy exercises improved the outcomes analyzed; however, aquatic physical therapy exercises were more effective in improving balance, gait, quality of life and reducing fear of falling in CDOAs. The meta-analysis showed that engaging in aquatic physical therapy exercises increases the functional reach, through of the anterior displacement of the center of pressure of CDOAs by 6.36cm, compared to land-based physical therapy exercises, assessed by the Functional Reach test: [CI:5.22 to 7.50], (p<0.00001), presenting low quality evidence.
Conclusions
Aquatic physical therapy exercises are more effective than their land-based counterparts in enhancing balance, gait, quality of life and reducing the fear of falling in CDOAs. However, due to methodological limitations of the trials, this clinical decision remains inconclusive. It is suggested that new trials be conducted with greater methodological rigor, in order to provide high-quality evidence on the use of the aquatic physical therapy exercises to improve the outcomes analyzed in CDOAs.
Objective
To review the epidemiology, pathogenesis, diagnosis, and treatment of unilateral vestibular weakness (UVW), and critically assess the related evidence.
Methods
Literature research in Medline and other database sources until August 2020.
Results
The total number of included studies was 39.
Conclusion
The lifetime prevalence of UVW in the general population is 0.2%; the respective incidence is unknown. UVW frequently overlaps with other diagnoses; nevertheless, there is usually a history of a single, preceding, monophasic event. The respective criteria include unsteadiness of more than two months, clinical exclusion of BPPV, and exclusion of Meniere’s disease, central lesion, or bilateral vestibular dysfunction, and more than 25% inter-aural asymmetry in the caloric test. The latter represents the golden testing standard in suspected patients, and should be complemented with vestibulo-ocular reflex assessment via rotation-testing and video head-impulse test. Posturography can be useful to evaluate postural stability. Questionnaire-based assessments may assess symptom severity, the ensuing disability, and the subjective perception of patients’ overall balance status. MRI is advised in vertiginous patients in the presence of neurologic signs and symptoms, risk factors for cerebrovascular disease, or progressive unilateral hearing loss. Vestibular rehabilitation is effective in patients with UVW, whilst pharmacological treatment is of limited value.
The study aimed to examine the effects of vestibular rehabilitation on kinesiophobia, quality of life, dynamic visual acuity, and balance. Thirty vestibular hypofunction patients aged 18–65 years who were diagnosed by videonystagmography (VNG) voluntarily participated in the study. Before and after treatment Tampa Kinesiophobia Scale, World Health Organization Quality of Life Scale-Turkish Short Form, Tandem Stance Test, Dynamic Visual Acuity, Visual Analog Scale to measure dizziness, Subjective Visual Vertical and Subjective for verticality and horizontality perception Visual Horizontal tests were applied. The exercise program was applied for 8 weeks. Patients were observed in the hospital every two weeks. The exercises given in the session were given as home exercises, 3 times a day, for 10 repetitions. As a result of the study, statistical correlations were found tandem stance test, subjective visual vertical and subjective visual horizontal tests for the perception of verticality and horizontality, visual analog scale to measure the severity of dizziness, dynamic visual acuity, quality of life and tampa kinesiophobia scales (p < 0.05). It can be said that vestibular rehabilitation improves the quality of life, balance, dynamic visual acuity, and overcomes kinesiophobia in patients.
Trial registration number: NCT05070936, Date of registration:10/06/2021 (Retrospectively registered).
Objective:
The investigation of supervised vestibular rehabilitation treatment role for individuals with dizziness and imbalance due to peripheral, unilateral vestibular disorders.
Databases reviewed:
Cochrane, PubMed, and Physiotherapy Evidence Database (PEDro) were utilized to identify relevant studies.
Methods:
The key search terms used were "Vestibular Rehabilitation and Unilateral Vestibular Hypofunction," "Vestibular Rehabilitation and Unilateral Vestibular Loss," and "Vestibular Rehabilitation and Supervision." A manual search was performed by exploring the references of included articles to identify studies not captured through the computer-based searches. The quality of the studies was assessed according to the PEDro scale. Inclusion criteria were: 1) studies with patients, aged from 18 to 80 years, with acute or chronic dizziness and disequilibrium due to unilateral vestibular dysfunction, 2) randomized control trials (RCTs), 3) studies comparing supervised vestibular rehabilitation program with an unsupervised vestibular rehabilitation program or home-based training or standard care or placebo, and 4) articles written in the English language. Studies reporting cases of vertigo and imbalance due to possible recurrent pathologies, acute benign paroxysmal positional vertigo, or central neurological/orthopedic deficits, were excluded.
Results:
A total of 448 articles were retrieved from the systematic database search strategy. Five of them were included in the systematic review after full-text analysis, plus one more after manual searching of their references. All studies involved supervised vestibular rehabilitation treatment programs compared with unsupervised home training, the performance of daily activities and, standard care. Based on PEDro's scoring system, one study rated as high-quality RCT, three studies were considered of fair quality and one scored as low-quality RCT.
Conclusions:
Although most RCTs report better outcomes with a supervised vestibular rehabilitation treatment program regarding the emotional status, dizziness, and balance improvement, this systematic review failed to provide a strong evidence that supervision is superior to unsupervised protocols in patients with UNH. The self-reported subjective measures used by the included RCTs represent a serious limitation of their results.
Background and Objective: Vestibular rehabilitation therapy (VRT) is an exercise-based program designed to improve balance function and alleviate problems related to dizziness, including vestibular hypofunction. This study aimed to evaluate the therapeutic effects of VRT exercises on balance function in adults with unilateral vestibular hypofunction (UVH). Methods: Thirty-one patients (mean age: 39.48 (±10.96) years old) with confirmed UVH participated in this study. The VRT program consisted of habituation and adaptation exercises in combination with gait and balance exercises. The handicapping influences of dizziness were measured with a dizziness handicap inventory (DHI) scale to measure the level of respondent’s performance on physical, emotional, and functional dimensions. Visual analogue scale (VAS) was also used to rate the severity of dizziness symptoms. The DHI and VAS scales were assessed pre-intervention and post-intervention at one, two, and four weeks follow-ups after the last rehabilitation session. Results: An analysis of variance showed a significant reduction and a consequent improvement in DHI scores after vestibular exercises in all domains: emotional, physical and functional (p < 0.001). The mean total DHI score significantly decreased by 15 points after one week, 24 points after two weeks and 15 points after four weeks of the last VRT session. The mean baseline VAS score was 7.71 (±0.91) that significantly decreased at one, two, and four weeks post-intervention to 4.81 (±0.73), 3.77 (±0.61), and 3.16 (±0.97), respectively (p<0.001). Conclusion: The exercise-based VRT shows benefits for adult patients with chronic dizziness concerning improvement in the vertigo symptom scale, fall risk, balance and emotional status.
Opinion statement:
Vestibular rehabilitation of persons with peripheral and central vestibular disorders requires a thorough evaluation and a customized plan of care. Collaboration of the various members of the treatment team optimizes outcomes. Early intervention appears to be better than referring patients who have developed chronic symptoms of balance loss, dizziness, anxiety, and depression. There is a body of emerging evidence that supports that the central nervous system has the capability to reweigh sensory inputs in order to improve function. There continues to be a dearth of knowledge related to how to treat persons with otolithic dysfunction as compared to those with semicircular canal damage. With the use of vestibular rehabilitation, patients are less likely to fall, are less dizzy, balance and gait improve, and quality of life is enhanced. Recent Cochrane reviews and a clinical practice guideline support the use of vestibular rehabilitation for persons with vestibular dysfunction. Typical symptoms and their management including dysregulated gait, falling, fear of falling, increased sway in standing, visual blurring, symptoms with complex visual scenes in the periphery, and weakness are all discussed with ideas for intervention. Any patient with a vestibular disorder may benefit from a trial of vestibular rehabilitation. A discussion of recent evidence and innovations related to vestibular rehabilitation is also included.
Aquatic therapy (AT) has been used for decades to provide physical therapy for patients with lower extremity deformities. Recently, investigators also have shown potential benefits for patients with neurological conditions, such as balance disorders, Parkinson's disease, and post-stroke effects. This case report documents a patient with severe Alzheimer's disease who responded well to Halliwick-concept AT, and both subjective and objective evidence is presented to document his improvement. This case suggests a need to further investigate the potential of AT to improve the quality of life of patients with dementia.
The purposes of this study were to examine whether aquatic exercise has influence on the neuroplasticity and vestibulo-motor function in diffuse brain injury rats. 80 Sprague-Dawley rats were assigned to four groups; Group I: control group (n=20), Group II: aquatic exercise (n=20), Group III: treadmill exercise with change of velocity and inclination (n=20), Group IV: simple treadmill exercise (n=20). And we applied exercise each groups for 3 weeks except Group I. Before the rats were sacrificed to identify immunohistochemistry study at each time of measurement day, Rota-Rod test was given to assess changes in vestibulomotor function. then, the immunohistochemistry study of GAP-43 in discrete regions of the rat brain was performed to measure changes in neuroplasticity. The results demonstrate that aquatic exercise group is more effective than other groups. expression of GAP-43 and vestibulo-motor function were increased most in aquatic exercise group. Therefore, this study suggest that aquatic exercise may effective therapeutic approach to increase neuroplasticity and vestibulo-motor function in traumatic brain injury.
This article presents an overview of balance disorders for the practicing otolaryngologist. The demographics of balance disorders, anatomy and physiology of human balance, clinical features, differential diagnosis, and treatment, within the framework of an holistic approach, are discussed.
AIM: To verify the effect of the aquatic physiotherapy protocol for vestibular rehabilitation (APVR) upon the head alignment of patients with unilateral peripheral vestibular hypofunction through computerized biophotogrammetry (CB), and to verify the association between those effects and the variables sex and age. METHOD: Experimental study with a sample of 21 patients with unilateral peripheral vestibular hypofunction, ranging in age from 20 to 63 years, and with complaints of chronic dizziness. Patients underwent the APVR protocol and were assessed by CB before and after the treatment, using the measure of two angles to quantify the head's anteriorization and inclination. The difference between the evaluation and the reevaluation results was calculated. The tests used were Paired-T (AC7) and Wilcoxon (AIC) for related samples. The T-Student or the Mann-Whitney tests were used to verify the association between the analyzed differences and the sex. The Spearman linear correlation coefficient was used to verify the association between the analyzed differences and the age. RESULTS: Eighteen patients (85.7%) were female and three
Dizziness and imbalance occur in most elderly. These symptoms are frequently caused by vestibular dysfunction. This article aims to present the most common vestibular causes of dizziness and imbalance in elderly and how to treat them.
Balance dysfunction and falls-related injuries represent serious public health issues, resulting in great expense and human suffering. The physical problems leading to balance dysfunction include musculoskeletal-related structural limitations, diminished sensory capabilities, motor coordination deficits, and loss of anticipatory control mechanisms. The water has been described as an effective environment for addressing balance dysfunction through both rehabilitation and fitness activities. This article describes the underlying physical problems leading to balance dysfunction, provides a rationale for using aquatic therapy to positively influence balance control, and presents evidence to support the use of aquatic therapy for the management of balance dysfunction.
The Barany Society Ad Hoc Committee on Vestibular Rehabilitation Therapy has developed guidelines for developing educational programs for continuing education. These guidelines may be useful to individual therapists who seek to learn about vestibular rehabilitation or who seek to improve their knowledge bases. These guidelines may also be useful to professional organizations or therapists who provide continuing education in vestibular rehabilitation. We recommend a thorough background in basic vestibular science as well as an understating of current objective diagnostic testing and diagnoses, understanding of common tests used by therapists to assess postural control, vertigo and ability to perform activities of daily living. We recommend that therapists be familiar with the evidence supporting efficacy of available treatments as well as with limitations in the current research.
To assess and compare 2 different protocols of physiotherapy (land or water therapy) for people with Parkinson's disease (PD) focused on postural stability and self-movement, and to provide methodological information regarding progression within the program for a future larger trial.
Randomized, controlled, open-label pilot trial.
Outpatients, Parkinson's disease Center of Ferrol-Galicia (Spain).
Individuals (N=11) with idiopathic PD in stages 2 or 3 according to the Hoehn and Yahr Scale completed the investigation (intervention period plus follow-up).
After baseline evaluations, participants were randomly assigned to a land-based therapy (active control group) or a water-based therapy (experimental group). Participants underwent individual sessions for 4 weeks, twice a week, for 45 minutes per session. Both interventions were matched in terms of exercise features, which were structured in stages with clear objectives and progression criteria to pass to the next phase.
Participants underwent a first baseline assessment, a posttest immediately after 4 weeks of intervention, and a follow-up assessment after 17 days. Evaluations were performed OFF-dose after withholding medication for 12 hours. Functional assessments included the Functional Reach Test (FRT), the Berg Balance Scale (BBS), the UPDRS, the 5-m walk test, and the Timed Up and Go test.
A main effect of both therapies was seen for the FRT. Only the aquatic therapy group improved in the BBS and the UPDRS.
In this pilot study, physiotherapy protocols produced improvement in postural stability in PD that was significantly larger after aquatic therapy. The intervention protocols are shown to be feasible and seem to be of value in amelioration of postural stability-related impairments in PD. Some of the methodological aspects detailed here can be used to design larger controlled trials.
To investigate head and shoulder alignment among patients with unilateral vestibular hypofunction (UVH), using computerized biophotogrammetry (CB) and to correlate these measurements with gender, age, duration of clinical evolution, self-perception of intensity of dizziness and occurrences of falls.
This was a cross-sectional study. Thirty individuals with UVH and 30 with normal vestibular function and without complaints of dizziness underwent CB in the anterior, right and left and posterior views, in an upright standing position. Alcimage™ 2.0 was used to evaluate three angles in order to verify the anterior deviation and inclination of the head, and the alignment of the shoulders. The groups were paired according to age, gender and height. The statistical analysis consisted of the Mann-Whitney test, Kruskal-Wallis test followed by the Dunn test, and the Spearman Correlation Coefficient.
The patients with UVH had greater forward (55.44 ± 16.33) and lateral (2.03 ± 1.37) head deviation angles than did the normal individuals (34.34 ± 4.60 and 1.34 ± 1.05 respectively), with a statistically significant difference (p<0.001). The increment of forward and lateral deviation in the UVH group was 38.05% and 33.78% respectively. Forward head was associated with the duration of clinical symptoms of the vestibular disease (p=0.003), age (p=0.006), intensity of dizziness (p<0.001) and occurrence of falls (p=0.002).
Patients with UVH had greater forward and lateral head deviations. Forward head deviation increased with age, duration of clinical symptoms and greater self-perception of the intensity of dizziness. Forward head deviation was also greater among patients who reported having had falls.
The purpose of this study was to determine the feasibility of providing a community-based aquatic exercise programme and to examine the effects of a group aquatic exercise programme in individuals with multiple sclerosis. This study illustrates the implementation of a multidisciplinary community-based programme in a university community wellness centre coordinated with a local advocacy group.
Eleven subjects with multiple sclerosis participated in a 5-week community-based aquatic exercise programme. Aquatic exercises were held twice weekly for 60 minutes and included aerobic exercises, strength training, flexibility exercises, balance training and walking activities. The 10-Metre Walk test, the Berg Balance Scale (BBS), the 'Timed Up and Go' (TUG) test, grip strength and the Modified Fatigue Impact Scale were used to assess motor function.
Analysis of the scores demonstrated improved gait speed, BBS, TUG test and grip strength. The average attendance of the training sessions was good (88%), and no incidence of injuries, no incidence of falls and no adverse effects related to the exercise programme were reported. All participants reported that they enjoyed the programme, and they had improved after the training.
A community-based aquatic exercise programme is feasible and resulted in improvement in motor functions of individuals with multiple sclerosis. These findings indicate that an aquatic training programme is appropriate and beneficial for individuals with multiple sclerosis and should be considered to augment the rehabilitation of those individuals. This programme may provide a viable model for a community-based wellness programme for people with disability including individuals with multiple sclerosis.
A tontura é considerada um dos sintomas mais comuns entre adultos, podendo interferir na qualidade de vida dos pacientes que apresentam este sintoma. OBJETIVOS: Descrever os resultados obtidos à aplicação do DHI brasileiro na população estudada e compará-los com a conclusão do exame vestibular dos respectivos pacientes. FORMA DE ESTUDO: Clínico randomizado. MATERIAL E MÉTODO: Vinte e cinco pacientes consecutivos que procuraram o Ambulatório da Disciplina de Otoneurologia da UNIFESP/EPM com queixa de tontura e hipótese diagnóstica de síndrome vestibular periférica submeteram-se ao questionário DHI brasileiro. Estes pacientes, adultos de ambos os sexos apresentaram idade variando entre 44 e 88 anos. Os resultados obtidos à aplicação do DHI foram comparados aos resultados do exame vestibular dos respectivos sujeitos. RESULTADOS: Os pacientes avaliados apresentaram prejuízo na qualidade de vida devido à tontura, principalmente nos aspectos funcionais avaliados pelo DHI brasileiro. Os aspectos funcionais apresentaram-se mais comprometidos nos pacientes com Síndrome Vestibular Periférica Deficitária (SVPD), independente do acometimento vestibular uni ou bilateral, e estas diferenças foram estatisticamente significantes. CONCLUSÕES: Os pacientes com tontura crônica apresentam prejuízo na qualidade de vida, em relação aos aspectos físicos, funcionais e emocionais verificados à aplicação do DHI brasileiro. Os pacientes com SVPD apresentam maior prejuízo na qualidade de vida nos aspectos funcionais à aplicação do DHI brasileiro, em relação aos pacientes com Síndrome Vestibular Periférica Irritativa.
Vestibular rehabilitation is a specific approach to physical therapy aimed at reducing dizziness and imbalance by facilitating central nervous system compensation for peripheral vestibular dysfunction. This article reports preliminary results of studies concerning the relative effectiveness of vestibular rehabilitation, general conditioning exercises, and vestibular suppressant medication on dizziness and imbalance in patients with chronic vestibular symptoms of at least 6 months duration. Patients with positional and/or movement-related dizziness and abnormal posturography were randomly assigned to the three treatment groups. Preliminary results suggest that although all three treatment approaches reduce dizziness, only vestibular rehabilitation also improves balance. This study takes the first step toward determining the efficacy of a specific exercise approach for reducing dizziness and imbalance in patients with chronic peripheral vestibular disorders.
A prospective observational study of the performance of patients enrolled in an individually customized program of habituation and balance rehabilitation physical therapy was conducted from January 1988 to January 1990. Patients ranged in age from 20 to 89 years, with a wide variety of diagnoses. Two global outcome measures--posttherapy symptom response score and pretherapy and posttherapy disability score--were developed and used to judge overall patient performance. In addition, two specific indicators--one for balance performance (dynamic posturography) and one for sensitivity to rapid head movements (motion sensitivity quotient)--were used to measure performance in these two areas. Results indicate statistically significant changes before versus after therapy for both specific measures, and 80% to 85% of the patients showed a reduction in symptoms and disability score following therapy. Analysis of variance and multiple regression analysis indicate that nature of symptoms, pretherapy disability level, history of head injury, and results on dynamic posturography were the variables most predictive of therapy outcome, while age and duration of symptoms made no difference. Other variables, such as medications and site of lesion, were found to affect the length of therapy but not the outcome.
Vestibular neuritis is the second most common cause of peripheral vestibular vertigo. Its assumed cause is a reactivation of herpes simplex virus type 1 infection. Therefore, corticosteroids, antiviral agents, or a combination of the two might improve the outcome in patients with vestibular neuritis.
We performed a prospective, randomized, double-blind, two-by-two factorial trial in which patients with acute vestibular neuritis were randomly assigned to treatment with placebo, methylprednisolone, valacyclovir, or methylprednisolone plus valacyclovir. Vestibular function was determined by caloric irrigation, with the use of the vestibular paresis formula (to measure the extent of unilateral caloric paresis) within 3 days after the onset of symptoms and 12 months afterward.
Of a total of 141 patients who underwent randomization, 38 received placebo, 35 methylprednisolone, 33 valacyclovir, and 35 methylprednisolone plus valacyclovir. At the onset of symptoms there was no difference among the groups in the severity of vestibular paresis. The mean (+/-SD) improvement in peripheral vestibular function at the 12-month follow-up was 39.6+/-28.1 percentage points in the placebo group, 62.4+/-16.9 percentage points in the methylprednisolone group, 36.0+/-26.7 percentage points in the valacyclovir group, and 59.2+/-24.1 percentage points in the methylprednisolone-plus-valacyclovir group. Analysis of variance showed a significant effect of methylprednisolone (P<0.001) but not of valacyclovir (P=0.43). The combination of methylprednisolone and valacyclovir was not superior to corticosteroid monotherapy.
Methylprednisolone significantly improves the recovery of peripheral vestibular function in patients with vestibular neuritis, whereas valacyclovir does not.
Postural control is no longer considered simply a summation of static reflexes but, rather, a complex skill based on the interaction of dynamic sensorimotor processes. The two main functional goals of postural behaviour are postural orientation and postural equilibrium. Postural orientation involves the active alignment of the trunk and head with respect to gravity, support surfaces, the visual surround and internal references. Sensory information from somatosensory, vestibular and visual systems is integrated, and the relative weights placed on each of these inputs are dependent on the goals of the movement task and the environmental context. Postural equilibrium involves the coordination of movement strategies to stabilise the centre of body mass during both self-initiated and externally triggered disturbances of stability. The specific response strategy selected depends not only on the characteristics of the external postural displacement but also on the individual's expectations, goals and prior experience. Anticipatory postural adjustments, prior to voluntary limb movement, serve to maintain postural stability by compensating for destabilising forces associated with moving a limb. The amount of cognitive processing required for postural control depends both on the complexity of the postural task and on the capability of the subject's postural control system. The control of posture involves many different underlying physiological systems that can be affected by pathology or sub-clinical constraints. Damage to any of the underlying systems will result in different, context-specific instabilities. The effective rehabilitation of balance to improve mobility and to prevent falls requires a better understanding of the multiple mechanisms underlying postural control.
Drug treatment is an important option for the treatment of peripheral vestibular diseases.
To identify the drug component associated with optimal integrated balance therapy (IBT) for Ménières disease or other peripheral vestibular disorders.
Analysis of a series of patients with Ménières disease patients or patients with other peripheral vestibular disorders that received IBT involving either no medication or betahistine, cinnarizine, clonazepam, flunarizine or Ginkgo biloba during 120 days.
In Ménières disease, significant differences were observed for all drug therapies (60 days) versus no medication; betahistine was significantly more effective than all other drugs at 60 and 120 days. For non-Ménières disorders, significant differences were observed among betahistine, cinnarizine, clonazepam and flunarizine and no medication after 60 days; all drug therapies were significantly more effective than no medication after 120 days; betahistine, cinnarizine or clonazepam were equally effective and betahistine was more effective than flunarizine and EGb 761. All treatment options were well tolerated.
Drug therapies were more effective than no medication in the IBT for patients with Ménières disease or other peripheral vestibular disorders. Betahistine was the most effective medication for patients with Ménières disease and was as effective as cinnarizine and clonazepam for other peripheral vestibular disorders.
PurposeThe purpose of this study was to search for, appraise the quality of and collate the research evidence supporting the clinical effectiveness of hydrotherapy.MethodA systematic search of literature was performed using ten medical and allied health databases from which studies relevant to physiotherapeutic hydrotherapy practice were retrieved. Patient trials were critically appraised for research merit using recognised published guidelines and the results were collated into clinical, functional and affective outcomes for the investigated populations.ResultsSeventeen randomised control trials, two case-control studies, 12 cohort studies and two case reports were included in the appraisal. Two trials achieved appraisal scores indicating high quality evidence in a subjectively evaluated merit categorisation. Fifteen studies were deemed to provide moderate quality evidence for the effectiveness of hydrotherapy.DiscussionFlaws in study design and reporting attenuated the strength of the research evidence. Recommendations were made for the future direction of clinical hydrotherapy research. Randomised controlled trials with larger sample sizes, assessor blinding and the use of validated and reliable outcome measures in subjects with neurological conditions and acute orthopaedic injuries are particularly required.ConclusionThe balance of high to moderate quality evidence supported benefit from hydrotherapy in pain, function, self-efficacy and affect, joint mobility, strength, and balance, particularly among older adults, subjects with rheumatic conditions and chronic low back pain.
• Conventional vestibulometric techniques are inadequate for quantifying the impact of dizziness on everyday life. The 25-item Dizziness Handicap Inventory (DHI) was developed to evaluate the selfperceived handicapping effects imposed by vestibular system disease. The development of the preliminary (37 items) and final versions (25 items) of the DHI are described. The items were subgrouped into three content domains representing functional, emotional, and physical aspects of dizziness and unsteadiness. Cronbach's α coefficient was employed to measure reliability based on consistency of the preliminary version. The final version of the DHI was administered to 106 consecutive patients and demonstrated good internal consistency reliability. With the exception of the physical subscale, the mean values for DHI scale scores increased significantly with increases in the frequency of dizziness episodes. Test-retest reliability was high.
(Arch Otolaryngol Head Neck Surg. 1990;116:424-427)
The use of physical therapy in the treatment of vertigo is based on the plasticity and the restoration and adaptive qualities of the vestibular apparatus. Indications for physical therapy and the choice of techniques are based on the location of the lesions: exercises aimed at habituation in positional vertigo, with use of the rocking manoeuvre in the case of cupulolithiasis, and stimulation of spinal, labyrinth, visual or extraocular muscle proprioceptors in the case of unilateral lesions of the first neuron or in ototoxic destruction. These techniques give lasting effects and avoid prolonged treatment by anti-vertigo drugs which, by impairing the development of compensation, often lead to persisting functional disorders.
Clinicians and researchers without a suitable health-related quality of life (HRQOL) measure in their own language have two choices: (1) to develop a new measure, or (2) to modify a measure previously validated in another language, known as a cross-cultural adaptation process. We propose a set of standardized guidelines for this process based on previous research in psychology and sociology and on published methodological frameworks. These guidelines include recommendations for obtaining semantic, idiomatic, experiential and conceptual equivalence in translation by using back-translation techniques and committee review, pre-testing techniques and re-examining the weight of scores. We applied these guidelines to 17 cross-cultural adaptation of HRQOL measures identified through a comprehensive literature review. The reporting standards varied across studies but agreement between raters in their ratings of the studies was substantial to almost perfect (weighted kappa = 0.66-0.93) suggesting that the guidelines are easy to apply. Further research is necessary in order to delineate essential versus optional steps in the adaptation process.
Although the concept of using exercises as part of the treatment for patients with persistent vertigo was introduced several decades ago, organized vestibular rehabilitation therapy programs have only recently been introduced. These programs typically involve a three-pronged approach, customized to the needs of the individual patient: (1) habituation exercises designed to facilitate central nervous system compensation by extinguishing pathologic responses to head motion, (2) postural control exercises, and (3) general conditioning activities. This article provides an update regarding the status of vestibular rehabilitation, reviewing the concept of vestibular compensation and patient selection criteria for current rehabilitative techniques.
This article reviews the general literature regarding the clinical evaluation and treatment of a unilateral vestibular deficit. The clinical approach by the authors is highlighted with a focus on bedside examinations and cyclodeviation measurements. Vestibular rehabilitation is currently considered the best approach to rehabilitation at present, and its physiologic basis is reviewed. When applied early in the course of recovery, vestibular rehabilitation can hasten compensation and also reduce symptoms resulting from permanent deficits caused by vestibular injury.
Recovery of gaze and postural stability in human beings with vestibular deficits is well documented. The mechanisms that contribute to this recovery form the basis for the exercises used in the rehabilitation of these patients. These mechanisms include the central preprogramming of eye movements and of postural responses, the potentiation of the cervico-ocular reflex, modification of saccadic eye movements, and the substitution of visual and somatosensory cues for the lost vestibular cues. The mechanism most successful in contributing to recovery, however, is probably adaptation of the vestibular system itself. Understanding the various compensatory mechanisms and their limitations for improving gaze and postural stability should lead to more effective treatment of these patients.
A retrospective study in 205 patients with a chief complaint of tinnitus and associated hyperinsulinemia/euglycemia is presented. Dietary control if umpaired insulin metabolism has resulted in a significant degree of tinnitus control. The methods and research are reported.
To examine the reliability of postural sway assessment in women with lower extremity arthritis and to ascertain the effects of an aquatic exercise intervention program on these measures.
The reliability of postural sway measures was analyzed by within-subjects (Subject times Trial) analysis of variance (ANOVA). The effects of aquatic exercise were analyzed by repeated measures ANOVA using a planned comparison approach with an independent 2 x 2 (Group times Test) design.
Testing in a motor control research laboratory; aquatic exercise in a warm water pool at an area YMCA.
Volunteer sample, 24 women with lower extremity arthritis (rheumatoid [RA] n = 11, osteo [OA] n = 13) randomly assigned into an aquatic exercise group (n = 14) or control group (n = 10).
Postural sway measures under a two-legged stance test on two separate test days: day 1, pretest; day 2, posttest, administered after a 6-week aquatic exercise program.
Reliability correlation coefficients for postural sway measures ranged from .64 to .94 for both subject groups. Aquatic exercise subjects significantly reduced lateral sway and total sway area scores (by 18% to 30%) under both visual conditions after the 6-week intervention. Postural sway scores were significantly higher under the no-vision condition than under the vision condition in each group for both test sessions. Both OA and RA groups had normal sagittal/lateral ratio scores.
Women with lower extremity arthritis can be reliably assessed on postural sway measures on a stable two-legged stance test. Although they had normal sagittal/lateral sway ratio scores (ie, scores typical for nonarthritic peers), vision played an important role in their postural stability for this balance task. Aquatic exercise reduced postural sway in women with lower extremity arthritis, as demonstrated by a two-legged stance test, and this exercise program appears to be a viable treatment for increasing postural stability in this population.
To determine the outcome of vestibular rehabilitation protocols in subjects with peripheral vestibular disorders compared with normal and abnormal control subjects.
Prospective study using repeated measure, matched control design. Subjects were solicited consecutively according to these criteria: vestibular disorder subjects who had abnormal results of computerized dynamic posturography (CDP) sensory organization tests (SOTs) 5 and 6 and underwent rehabilitation; vestibular disorder subjects who had abnormal results of SOTs 5 and 6 and did not undergo rehabilitation; and normal subjects (normal SOTs).
Tertiary neurotology clinic.
Men and women over age 18 with chronic vestibular disorders and chief complaints of unsteadiness, imbalance, and/or motion intolerance, and normal subjects.
Pre- and post-rehabilitation assessment included CDP, vestibular disability, and activities of daily living questionnaires. Individualized rehabilitation plans were designed and implemented to address the subject's specific complaints and functional deficits. Supervised sessions were held at weekly intervals, and self-administered programs were devised for daily home use.
CDP composite and SOT scores, number of falls on CDP, and self-assessment questionnaire results.
Subjects who underwent rehabilitation (Group A) showed statistically significant improvements in SOTs, overall composite score, and reduction in falls compared with abnormal (Group B) control groups. Group A's performances after rehabilitation were not significantly different from those of normal subjects (Group C) in SOTs 3 through 6, and close to normal on SOTs 1 and 2. Subjects in Group A also reported statistically significant symptomatic improvement.
Outcome measures of vestibular protocol physical therapy confirmed objective and subjective improvement in subjects with chronic peripheral vestibular disorders. These findings support results reported by other investigators.
To evaluate the specific effects of general dynamic water exercise in individuals with late effects of poliomyelitis.
Before-after tests.
A university hospital department.
Twenty-eight individuals with late effects of polio, 15 assigned to the training group (TG) and 13 to the control group (CG).
The TG completed a 40-minute general fitness training session in warm water twice weekly. Assessment instruments included the bicycle ergometer test, isokinetic muscle strength, a 30-meter walk indoors, Berg balance scale, a pain drawing, a visual analog scale, the Physical Activity Scale for the Elderly, and the Nottingham Health Profile (NHP).
Peak load, peak work load, peak oxygen uptake, peak heart rate (HR), muscle function in knee extensors and flexors, and pain dimension of the NHP.
The average training period was 5 months; compliance was 75% (range, 55-98). No negative effects were seen. The exercise did not influence the peak work load, peak oxygen uptake, or muscle function in knee extensors compared with the controls. However, a decreased HR at the same individual work load was seen, as well as a significantly lower distress in the dimension pain of the NHP. Qualitative aspects such as increased well-being, pain relief, and increased physical fitness were reported.
A program of nonswimming dynamic exercises in heated water has a positive impact on individuals with late effects of polio, with a decreased HR at exercise, less pain, and a subjective positive experience. The program was well tolerated (no adverse effects were reported) and can be recommended for this group of individuals.
The purpose of the study was to assess the efficacy of physical therapy for patients with bilateral vestibular loss.
Retrospective case series.
Twenty-four patients with a diagnosis of bilateral vestibular loss were identified by a retrospective chart review. Thirteen of the 24 patients met the inclusion criteria of having a moderate or greater loss of vestibular function bilaterally as rated by an otoneurologist based on the patient's vestibular function tests. These patients were treated with a custom-designed physical therapy program for a mean of 4.6 visits over an average period of 3.8 months. Patients completed the Dizziness Handicap Inventory and the Activities-specific Balance Confidence Scale at initial evaluation and discharge. Patients were asked to perform the balance and gait tasks of the Dynamic Gait Index, Sensory Organization Test of computerized dynamic posturography, and the Timed "Up and Go" test at their first and last physical therapy sessions. The number of falls in the previous 4 weeks and the use of an assistive device at initial evaluation and discharge were reported. Composite score, an overall score of clinical outcome, was calculated to determine clinically significant changes in physical performance and subjective information.
On a population basis, statistically significant improvement was observed after physical therapy for each of the outcome measures including the composite score (P < .05). Clinically significant changes were demonstrated by 33% to 55% of the patients on the various outcome measures. No change was noted in the patients' risk of falling, their number of falls, and the use of assistive devices.
Many patients with bilateral vestibular loss benefit from an individualized vestibular physical therapy exercise program based on improved physical function and reduced self-perceived levels of handicap.
The purpose of the retrospective chart review was to compare vestibular rehabilitation outcomes in young versus older adults.
Retrospective matched design.
Twenty-three persons with vestibular disorders aged 20 to 40 years were matched by gender, vestibular diagnosis, and vestibular function test results to 23 older adults aged 60 to 80 years. The patients were treated with a custom-designed physical therapy exercise program. Patients completed the Dizziness Handicap Inventory, the Activities-Specific Balance Confidence (ABC) scale, and the Dynamic Gait Index; number of falls; and rated the severity of their dizziness. The two-sample test, the Mann-Whitney test, and McNemar's test for correlated proportions were used to determine whether there was a difference in scores between the two age groups at the beginning and end of physical therapy.
During the initial evaluation, older adults reported having statistically greater space and motion discomfort and more severe symptoms on a scale of 0 to 100. Younger adults had more impaired DGI scores and a higher proportion of caloric testing abnormalities. After rehabilitation, overall improvement was seen in both the younger and older populations. There were no statistical differences between the two groups on the DHI, the DGI, reported symptoms at discharge, or number of falls. When only the complete matched-pair data were analyzed, there were no statistically significant differences between the age groups in the proportion of patients demonstrating clinical improvement.
Age does not significantly influence the beneficial effects of vestibular rehabilitation for persons with vestibular disorders.
We sought to determine the effectiveness in decreasing some symptoms, such as vertigo, and increasing performance of daily life skills after vestibular rehabilitation.
Patients who had chronic vertigo due to peripheral vestibular impairments were seen at a tertiary care center. They were referred for vestibular rehabilitation and were assessed on vertigo intensity and frequency with the use of the Vertigo Symptom Scale, the Vertigo Handicap Questionnaire, the Vestibular Disorders Activities of Daily Living Scale, and the Dizziness Handicap Inventory. They were then randomly assigned to 1 of 3 home program treatment groups.
Vertigo decreased and independence in activities of daily living improved significantly. Improvement was not affected by age, gender, or history of vertigo.
For many patients a simple home program of vestibular habituation head movement exercises is related to reduction in symptoms and increasing independence in activities of daily living.
We sought to use a clinical decision support system (CDSS) to save costs and to improve scheduling of vestibular patients in an otolaryngology clinic.
We conducted a concurrent review of 50 vestibular patients scheduled in the University of Missouri otolaryngology clinic with or without testing based on the outcome of a CDSS. The CDSS was implemented using Web-based technology. Charges incurred by the health care system through tests determined by the CDSS were compared with those incurred using the standard procedure of ordering hearing tests and electronystagmography for all patients.
Thirty-nine tests were prescheduled using the CDSS. Twenty-five additional tests were ordered after the visit. The CDSS resulted in savings of $37,904.00 in charges to the health care system. The CDSS showed high specificity and variable sensitivity.
A Web-based CDSS can be used to better manage and coordinate patient encounters.
One important reason to use a CDSS in health care management is to lower costs.
To determine the effect of vestibular rehabilitation on reduction of fall risk in individuals with unilateral vestibular hypofunction and to identify those factors that predict fall risk reduction.
Retrospective chart review.
Tertiary referral center.
Forty-seven patients with unilateral vestibular hypofunction, aged 28 to 86 years, who were at risk for falls on initial assessment.
All patients underwent vestibular rehabilitation including adaptation exercises, designed to improve gaze stability, and gait and balance exercises.
Fall risk (Dynamic Gait Index), visual acuity during head movements (Dynamic Visual Acuity), and subjective complaints were measured initially, at 2-week intervals, and at completion of physical therapy.
As a group, the patients had significantly reduced risk for falls (p <0.001) after rehabilitation. Time from onset of symptoms did not affect the efficacy of vestibular rehabilitation. Both older (> or = 65 yr) and younger (< 65 yr) adults showed significant reductions in fall risk with vestibular rehabilitation (p <0.001). However, a significantly greater proportion (Chi2= 0.016) of older adults remained at risk for falls at discharge compared with young adults (45% versus 11%). Initial Dynamic Gait Index and Dynamic Visual Acuity scores predicted fall risk reduction in patients with unilateral vestibular hypofunction. A model was developed using initial Dynamic Gait Index and Dynamic Visual Acuity scores to predict fall risk reduction.
Vestibular rehabilitation is effective in significantly reducing fall risk in individuals with unilateral vestibular deficit. The model predicts fall risk reduction with good sensitivity (77%) and specificity (90%).
Dizziness is a very common symptom and is usually managed in primary care. Vestibular rehabilitation for dizziness is a simple treatment that may be suitable for primary care delivery, but its effectiveness has not yet been determined.
To evaluate the effectiveness of nurse-delivered vestibular rehabilitation in primary care for patients with chronic dizziness.
Single-blind randomized, controlled trial.
20 general practices in southern England.
170 adult patients with chronic dizziness who were randomly assigned to vestibular rehabilitation (n = 83) or usual medical care (n = 87).
Each patient received one 30- to 40-minute appointment with a primary care nurse. The nurse taught the patient exercises to be carried out daily at home, with the support of a treatment booklet.
Primary outcome measures were baseline, 3-month, and 6-month assessment of self-reported spontaneous and provoked symptoms of dizziness, dizziness-related quality of life, and objective measurement of postural stability with eyes open and eyes closed.
At 3 months, improvement on all primary outcome measures in the vestibular rehabilitation group was significantly greater than in the usual medical care group; this improvement was maintained at 6 months. Of 83 treated patients, 56 (67%) reported clinically significant improvement compared with 33 of 87 (38%) usual care patients (relative risk, 1.78 [95% CI, 1.31 to 2.42]).
Psychological elements of the therapy may have contributed to outcomes, and the treatment may be effective only for well-motivated patients.
Vestibular rehabilitation delivered by nurses in general practice improves symptoms, postural stability, and dizziness-related handicap in patients with chronic dizziness.
This retrospective study was undertaken to assess balance recovery and dizziness handicap in 32 patients after a vestibular and balance rehabilitation program. Outcomes were compared between 12 patients with peripheral vestibular disorders and 20 patients with central or mixed balance disorders. The patients were tested with posturography (sensory organization test [SOT]) and the Dizziness Handicap Inventory (DHI) before and after their therapy program. The vestibular SOT, composite SOT, and functional DHI scores obtained before and after exercise were significantly improved in both the peripheral and central groups. The visual SOT mean scores obtained before and after therapy were significantly different only for the group with central or mixed vestibular disorders. Changes in SOT scores were not directly correlated with changes in DHI scores. Outcome measures of vestibular rehabilitation protocols confirmed objective and subjective improvement of balance and dizziness handicap in patients with peripheral and central vestibular disorders.
Four groups, between-subjects study.
To investigate the effects of exercise on adaptation of normal subjects who had been artificially spatially disoriented.
Many patients referred for rehabilitation experience sensory changes, due to age or disease processes, and these changes affect motor skill. The best way to train patients to adapt to these changes and to improve their sensorimotor skills is unclear. Using normal subjects, we tested the hypothesis that active, planned head movement is needed to adapt to modified visual input.
Eighty male and female subjects who had normal balance on computerized dynamic posturography (CDP) and the dynamic gait index (DGI), were randomly assigned to four groups. All groups donned diagonally shift lenses and were again assessed with CDP and DGI. The four groups were then treated for 20 min. Group 1 (control group) viewed a video, Group 2 performed exercise that involved translating the entire body through space, but without separate, volitional head movement, Group 3 performed exercises which all incorporated volitional, planned head rotations, and Group 4 performed exercises that involved translating the body (as in Group 2) and incorporated volitional, planned head motion (as in Group 3). All subjects were post-tested with CDP and DGI, lenses were removed, and subjects were retested again with CDP and DGI.
The groups did not differ significantly on CDP scores but Groups 3 and 4 had significantly better DGI scores than Groups 1 and 2.
Active head movement that is specifically planned as part of the exercise is more effective than passive attention or head movements that are not consciously planned, for adapting to sensorimotor change when it incorporates active use of the changed sensory modality, in this case head motion.
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