Effects of specific rehabilitation for dizziness among patients in primary health care. A randomized controlled trial

Durable improvement in participant-reported measures of disability and objective posturography after computerized vestibular retraining

BACKGROUND

Unilateral vestibular deficits are associated with postural instability and loss of quality of life. Common treatments frequently fail to achieve satisfactory outcomes.

OBJECTIVE

To assess the durability of changes in participant-reported disability and objective posturography after computerized vestibular retraining.

METHODS

This was a single-group study. Individuals with persistent symptoms of an objectively determined unilateral vestibular deficit completed questionnaires and posturography assessments before and after twelve sessions of computerized retraining, and 4-6 months and 10-12 months after treatment.

RESULTS

13 participants completed the post-treatment assessments; 9 completed the follow up. Mean improvements in perceived disability at 4-6 months after retraining were: DHI 14.3 points (95% confidence interval 4.0 to 24.5), ABC scale 14.9 points (4.3 to 25.6), FES-I 11.6 points (-3.2 to 26.5).The SOT composite score increased by 11.4 points (95% CI 1.9 to 20.9; p = 0.0175) immediately after treatment, 8.9 points (-2.9 to 20.7; p = 0.1528) at 4-6 months, and 10.6 points (2.2 to 19.0; p = 0.0162) after 10-12 months. At the 10-12 month time point, the areas of the functional stability region increased significantly for both endpoint excursion (p = 0.0086) and maximum excursion (p = 0.0025).

CONCLUSION

Computerized vestibular retraining was associated with improved participant reported disability and objective measures of postural stability.

pessoa idosa na Atenção Primária à Saúde

Introdução: O envelhecimento da população mundial é uma conquista da humanidade, que também se mostra um dos maiores desafios, uma vez que ocasionará novos paradigmas e demandas políticas, sociais, econômicas e de saúde. Desse modo, torna-se essencial discutir os aspectos que envolvem a pessoa idosa e a Atenção Primária à Saúde (APS). Objetivo: Realizar uma análise bibliométrica da produção científica referente aos fatores relacionados com a pessoa idosa e a APS. Métodos: Trata-se de uma revisão bibliométrica que utilizou os termos “primary health care” AND “aged*” na base de dados Web of Science, entre os anos de 1945 e 2016. O estudo analisou os registros com base em revisão de literatura sobre a temática em questão com o auxílio do software HistCite. Resultados: Foram identificados 700 artigos em 313 periódicos, de 2.834 autores vinculados a 1.138 instituições de 61 países, o que totalizou 19.745 referências, com média de aproximadamente 28 referências por artigo. A revista Scandinavian Journal of Primary Health Care possui 4% dos textos e o International Journal of Geriatric Psychiatry, o maior fator de impacto. Os autores mais citados estão reunidos em apenas cinco universidades, com destaque para a Linkoping University, que detém 4% do total de publicações, e três países: Suécia, Brasil e Estados Unidos da América. O Brasil ocupa a primeira colocação, com 2% dos textos. Conclusões: Os estudos revelam aspectos importantes associados à pessoa idosa e à APS, como problemas de inobservância quanto aos cuidados de saúde para essa população, tanto por profissionais quanto pelos próprios idosos, apontando para a desumanização e consequente falta de priorização dessa faixa etária no âmbito da saúde. Com o envelhecimento das populações, é imprescindível que esse tema venha a ser priorizado, ampliando o debate sobre essa transição demográfica e suas consequências para toda a população e visando a alternativas que possam minimizar os impactos dela, bem como a novos paradigmas para produtos e serviços voltados para a população idosa. Isso especialmente na atenção primária, que é porta de entrada para todo o serviço de saúde e principal elo social entre o idoso e a qualidade de vida. Destaca-se ainda a necessidade de educação continuada dos profissionais e de aperfeiçoamento desse nível de atenção para o atendimento a essa população, quantitativamente cada vez maior.

Lian gong as a Therapeutic Treatment Option in Primary Care for Patients with Dizziness: A Randomized Controlled Trial

Introduction  Dizziness is one of the most common reasons for seeking primary health care. Vestibular rehabilitation (VR) is a conventional treatment method for peripheral balance disorders that effectively decreases symptoms. Lian gong [LG] is believed to benefit patients with dizziness and to reduce the impact of the condition on quality of life by stimulating visual fixation, attention, body balance, and neuroplasticity. Objective  The present study aimed to evaluate the effects of LG on the impact of dizziness on quality of life and fear of falling in primary health care patients. Methods  This was a two-arm, parallel randomized clinical trial that included 36 patients with dizziness not caused by central changes. After specific medical evaluations and indications for treatment, the participants were randomly assigned to 3 groups: the LG group ( n  = 11), the VR group ( n  = 11), and the control group ( n  = 14). The interventions were conducted collectively over a period of 12 weeks. Results  Lian gong reduced the influence of dizziness on quality of life in physical (1.8 points, 95% confidence interval [CI]: 0.2-3.4), functional (4.0 points, 95% CI: 2.1-5.9), and emotional domains of quality of life (4.4 points, 95% CI: 1.7-7.2), with no differences compared with VR. There were similar concerns among the groups about the risk of falling. Conclusion  Lian gong was shown to be an effective balance rehabilitation strategy to reduce the impact of dizziness on quality of life, with similar results to those of VR.

The Effects of Vestibular Rehabilitation on Gait Performance in Patients with Stroke: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Patients with post-stroke hemiparesis have poor postural stability; nevertheless, it is unclear whether vestibular rehabilitation affects gait performance after a stroke or not. We performed a systematic review of randomized controlled trials to investigate the effects of vestibular rehabilitation on gait performance in patients with post stroke.

METHODS

The Medline, Cochrane Central Register of Controlled Trials, Physiotherapy Evidence Database, and Cumulative Index to Nursing and Allied Health Literature databases were comprehensively searched. All literature published from each source's earliest date to June 2019 was included. Study selection and data extraction were performed independently by paired reviewers. Outcomes of gait performance were the 10-Meter Walking Test, Timed Up and Go Test, and Dynamic Gait Index. We applied the Physiotherapy Evidence Database scale to evaluate the risk of bias and the Grading of Recommendations Assessment, Development and Evaluation system to evaluate the quality of a body of evidence.

RESULTS

Three studies were included, and two out of three trials showed beneficial effects of vestibular rehabilitation in post-stroke patients. Quality assessment using the Grading of Recommendations Assessment, Development and Evaluation criteria found very low-quality evidence of all included studies due to inadequate allocation concealment, low participant numbers, and lack of blinding.

CONCLUSION

This review found beneficial effects of vestibular rehabilitation on gait performance in patients with stroke. However, due to the very low-quality evidence of previous randomized controlled trials as assessed by the Grading of Recommendations Assessment, Development and Evaluation criteria, definitive conclusions on the effectiveness of vestibular rehabilitation cannot be made. Hence, more high-quality and large-scale randomized controlled trials of vestibular rehabilitation after stroke are needed.

Vestibular rehabilitation for persons with stroke and concomitant dizziness-a pilot study

BACKGROUND

Dizziness is common among patients with first time stroke. It affects self-perceived health and is a risk factor for falls. Vestibular rehabilitation (VR) is effective for treating dizziness among various conditions, but the effect of dizziness with origin in the central nervous system is poorly studied.This pilot study of a randomized controlled trial aimed at investigating a vestibular rehabilitation programme among patients with first time stroke and concomitant dizziness. A second aim was to study the feasibility of performing the randomized controlled trial.

METHODS

The participants were computer generated randomized to either an intervention or a control group. The intervention comprised of four different vestibular rehabilitation exercises, adapted for each patient and usual rehabilitation. The control group received usual rehabilitation without the vestibular rehabilitation exercises. Outcome measures used were The Activities-specific Balance Confidence Scale, the Berg Balance Scale, the Functional Gait Assessment Scale and the EuroQol-5D. Feasibility was studied in terms of recruitment, adherence and retention rates, also as the ability to collect primary and secondary outcomes as well as to find indications of treatment differences.

RESULTS

Self-rated health improved for all participants. No other differences between baseline and follow-up were detected neither within nor between groups. Recruitment rate was 23%, adherence to the intervention 90%, retention rate 69% and ability to collect outcome measures 90%. No adverse events occurred.

CONCLUSION

Both the intervention and the control groups improved in self-perceived health. The measures of feasibility were satisfactory in this study, apart from a low recruitment rate.

Clinical Balance Testing to Screen for Patients With Vestibular Disorders: A Retrospective Case-control Study

OBJECTIVE

Identify clinical screening tests to proficiently screen for patients with vestibular disorders.

STUDY DESIGN

Retrospective case-control study.

SETTING

Tertiary referral center.

PATIENTS

318 healthy individuals and 331 subjects with vestibular disorders.

INTERVENTIONS

All subjects performed Romberg and Jendrassic maneuver with eyes closed (ROMJec), standing on foam with eyes open (SOFeo) and eyes closed (SOFec), Tandem Romberg with eyes open (TReo) and eyes closed (TRec), single leg stance with eyes open (SLSeo) and eyes closed (SLSec), Tandem gait (TG) and Timed Up and Go (TUG).

MAIN OUTCOME MEASURES

Significant differences in performance on the balance tests.

RESULTS

For the age-group <40 years, TUG >6 seconds (OR 102.4; p <0.0001) and SLSec <30 seconds (OR 48.0; p <0.0001) proved to be the most predictive combination of testing (AUC 0.9; LR+ 15.8; LR- 0.2), with a positive predictive value (PPV) of 88.4%. For the age-group 40-60, TUG >7 seconds (OR 4.0; p = 0.0107) and TRec <30 seconds (OR 63.1; p < 0.0001) was the most predictive combination of tests (AUC 0.9 LR+ 6.0; LR- 0.1), with a PPV of 93.8%. For the age-group >60 the combination of TUG >8 seconds (OR 17.4; p < 0.0001) and SOFec <30 seconds (OR 10.4; p < 0.0001) was the most predictive (AUC 0.9 LR+ 6.3; LR- 0.2), with a PPV of 84.8%.

CONCLUSIONS

Combinations of clinical tests are proposed to promptly screen for vestibular disorders in specific age groups. To interpret the results for the individual patient, the physician must take the history and the general examination into consideration.

Reducing the burden of dizziness in middle-aged and older people: A multifactorial, tailored, single-blind randomized controlled trial

BACKGROUND

Dizziness is common among older people and is associated with a cascade of debilitating symptoms, such as reduced quality of life, depression, and falls. The multifactorial aetiology of dizziness is a major barrier to establishing a clear diagnosis and offering effective therapeutic interventions. Only a few multidisciplinary interventions of dizziness have been conducted to date, all of a pilot nature and none tailoring the intervention to the specific causes of dizziness. Here, we aimed to test the hypothesis that a multidisciplinary dizziness assessment followed by a tailored multifaceted intervention would reduce dizziness handicap and self-reported dizziness as well as enhance balance and gait in people aged 50 years and over with dizziness symptoms.

METHODS AND FINDINGS

We conducted a 6-month, single-blind, parallel-group randomized controlled trial in community-living people aged 50 years and over who reported dizziness in the past year. We excluded individuals currently receiving treatment for their dizziness, those with degenerative neurological conditions including cognitive impairment, those unable to walk 20 meters, and those identified at baseline assessment with conditions that required urgent treatment. Our team of geriatrician, vestibular neuroscientist, psychologist, exercise physiologist, study coordinator, and baseline assessor held case conferences fortnightly to discuss and recommend appropriate therapy (or therapies) for each participant, based on their multidisciplinary baseline assessments. A total of 305 men and women aged 50 to 92 years (mean [SD] age: 67.8 [8.3] years; 62% women) were randomly assigned to either usual care (control; n = 151) or to a tailored, multifaceted intervention (n = 154) comprising one or more of the following: a physiotherapist-led vestibular rehabilitation programme (35% [n = 54]), an 8-week internet-based cognitive-behavioural therapy (CBT) (19% [n = 29]), a 6-month Otago home-based exercise programme (24% [n = 37]), and/or medical management (40% [n = 62]). We were unable to identify a cause of dizziness in 71 participants (23% of total sample). Primary outcome measures comprised dizziness burden measured with the Dizziness Handicap Inventory (DHI) score, frequency of dizziness episodes recorded with monthly calendars over the 6-month follow-up, choice-stepping reaction time (CSRT), and gait variability. Data from 274 participants (90%; 137 per group) were included in the intention-to-treat analysis. At trial completion, the DHI scores in the intervention group (pre and post mean [SD]: 25.9 [19.2] and 20.4 [17.7], respectively) were significantly reduced compared with the control group (pre and post mean [SD]: 23.0 [15.8] and 21.8 [16.4]), when controlling for baseline scores (mean [95% CI] difference between groups [baseline adjusted]: -3.7 [-6.2 to -1.2]; p = 0.003). There were no significant between-group differences in dizziness episodes (relative risk [RR] [95% CI]: 0.87 [0.65 to 1.17]; p = 0.360), CSRT performance (mean [95% CI] difference between groups [baseline adjusted]: -15 [-40 to 10]; p = 0.246), and step-time variability during gait (mean [95% CI] difference between groups [baseline adjusted]: -0.001 [-0.002 to 0.001]; p = 0.497). No serious intervention-related adverse events occurred. Study limitations included the low initial dizziness severity of the participants and the only fair uptake of the falls clinic (medical management) and the CBT interventions.

CONCLUSIONS

A multifactorial tailored approach for treating dizziness was effective in reducing dizziness handicap in community-living people aged 50 years and older. No difference was seen on the other primary outcomes. Our findings therefore support the implementation of individualized, multifaceted evidence-based therapies to reduce self-perceived disability associated with dizziness in middle-aged and older people.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12612000379819.

Subjective visual vertical assessment with mobile virtual reality system

BACKGROUND AND OBJECTIVE

The subjective visual vertical (SVV) is a measure of a subject's perceived verticality, and a sensitive test of vestibular dysfunction. Despite this, and consequent upon technical and logistical limitations, SVV has not entered mainstream clinical practice. The aim of the study was to develop a mobile virtual reality based system for SVV test, evaluate the suitability of different controllers and assess the system's usability in practical settings.

MATERIALS AND METHODS

In this study, we describe a novel virtual reality based system that has been developed to test SVV using integrated software and hardware, and report normative values across healthy population. Participants wore a mobile virtual reality headset in order to observe a 3D stimulus presented across separate conditions - static, dynamic and an immersive real-world ("boat in the sea") SVV tests. The virtual reality environment was controlled by the tester using a Bluetooth connected controllers. Participants controlled the movement of a vertical arrow using either a gesture control armband or a general-purpose gamepad, to indicate perceived verticality. We wanted to compare 2 different methods for object control in the system, determine normal values and compare them with literature data, to evaluate the developed system with the help of the system usability scale questionnaire and evaluate possible virtually induced dizziness with the help of subjective visual analog scale.

RESULTS

There were no statistically significant differences in SVV values during static, dynamic and virtual reality stimulus conditions, obtained using the two different controllers and the results are compared to those previously reported in the literature using alternative methodologies. The SUS scores for the system were high, with a median of 82.5 for the Myo controller and of 95.0 for the Gamepad controller, representing a statistically significant difference between the two controllers (P<0.01). The median of virtual reality-induced dizziness for both devices was 0.7.

CONCLUSIONS

The mobile virtual reality based system for implementation of subjective visual vertical test, is accurate and applicable in the clinical environment. The gamepad-based virtual object control method was preferred by the users. The tests were well tolerated with low dizziness scores in the majority of patients.

Fractures among patients with dizziness - a ten-year follow-up

Background

The number of elderly people persons suffering from dizziness is substantial, and dizziness is a risk factor for falls and fractures. Fall-related fractures represent a major public health issue. Longitudinal studies can help find ways of predicting fall-related fractures among frail elderly persons with multisensory dizziness. The aim of the present study was therefore to investigate whether different measures of balance, being male/female or admission to hospital, could predict fracture at a ten-year follow-up in patients suffering from multisensory dizziness.

Methods

Patients who had participated in two earlier (ten years previous) dizziness studies were sought in the local health authority’s patient administrative system. Information was extracted regarding patient hospitalization, for fractures or for any other reason, during the ten-year period. Logistic regression was used to analyse the relations between clinical balance measures, vestibular rehabilitation, admission to hospital, sex, and fracture.

Results

There was no difference between the group of patients with fracture and the group of patients without fracture, regarding balance measures at baseline or admission to hospital for reasons other than fracture. There was no difference between men and women in any of the measures.

Conclusions

This study did not identify any predictors of fracture. Thus, among frail elderly, attention to fall risk should be equally high regardless of patient history.

Dizziness Handicap Inventory and Visual Vertigo Analog Scale in Vestibular Dysfunction

Introduction

 Dizziness is one of the most common symptoms among the population, producing numerous consequences for individual's quality of life. There are some questionnaires that can trace the patient's profile and quality of life impairment from dizziness, including the Dizziness Handicap Inventory (DHI) and the Visual Vertigo Analogue Scale (VVAS).

Objective

 This study aims to correlate the results of the DHI and VVAS in patients with vestibular dysfunction.

Methods

 This is a retrospective study of medical records of patients treated in a medical school between 2006 and 2012. Results of the DHI and EVA were collected and subjected to statistical analysis using Pearson's correlation test with p < 0.001. The significance level adopted for the statistical tests was p ≤ 0.05.

Results

 A total of 91 records were included in this study, 72 (79.1%) from female and 19 (20.9%) from male patients, aged 23 to 86 years, with a mean age of 52.5 years. The mean score on the DHI total was 43.9 and 5.2 points for the EVA. The result of Pearson's correlation test was 0.54.

Conclusion

 Self-perceived dizziness measured with the Dizziness Handicap Inventory has a regular and positive correlation with the Visual Vertigo Analog Scale in patients with vestibular dysfunction. The clinical trial is registered under number UTN U1111–1170–5065.

A combination of clinical balance measures and FRAX® to improve identification of high-risk fallers

Background

The FRAX® algorithm quantifies a patient’s 10-year probability of a hip or major osteoporotic fracture without taking an individual’s balance into account. Balance measures assess the functional ability of an individual and the FRAX® algorithm is a model that integrates the individual patients clinical risk factors [not balance] and bone mineral density. Thus, clinical balance measures capture aspects that the FRAX® algorithm does not, and vice versa. It is therefore possible that combining FRAX® and clinical balance measures can improve the identification of patients at high fall risk and thereby high fracture risk.

Our study aim was to explore whether there is an association between clinical balance measures and fracture prediction obtained from FRAX®.

Method

A cross-sectional study design was used where post hoc was performed on a dataset of 82 participants (54 to 89 years of age, mean age 71.4, 77 female), with a fall-related wrist-fracture between 2008 and 2012. Balance was measured by tandem stance, standing one leg, walking in the figure of eight, walking heel to toe on a line, walking as fast as possible for 30 m and five times sit to stand balance measures [tandem stance and standing one leg measured first with open and then with closed eyes] and each one analyzed for bivariate relations with the 10-year probability values for hip and major osteoporotic fractures as calculated by FRAX® using Spearman’s rank correlation test.

Results

Individuals with high FRAX® values had poor outcome in balance measures; however the significance level of the correlation differed between tests. Standing one leg eyes closed had strongest correlation to FRAX® (0.610 p = < 0.01) and Five times sit to stand was the only test that did not correlate with FRAX® (0.013).

Conclusion

This study showed that there is an association between clinical balance measures and FRAX®. Hence, the use of clinical balance measures and FRAX® in combination, might improve the identification of individuals with high risk of falls and thereby following fractures. Results enable healthcare providers to optimize treatment and prevention of fall-related fractures.

Trial registration

The study has been registered in Clinical Trials.gov, registration number NCT00988572.

The institutionalized elderly: sociodemographic and clinical-functional profiles related to dizziness

Introduction

Dizziness is among the most common complaints in the elderly population.

Objective

To determine the sociodemographic and clinical-functional profiles of institutionalized elderly people related to dizziness.

Methods

Cross-sectional prospective study with institutionalized elderly people aged 60 or more years. A questionnaire on sociodemographic and clinical-functional characteristics was applied, and an anamnesis of occurrence of dizziness was held, as well as the Dizziness Handicap Inventory questionnaire.

Results

48.9% of the elderly subjects had dizziness. The mean numbers of diseases and medications associated with dizziness were, respectively, 4.5 diseases and 7.8 medications. We found a significant association between the occurrence of dizziness and diseases of the musculoskeletal system, sub-connective tissue and genitourinary system, as well as the use of medications for the musculoskeletal system. The scores for handicap degree in functional DHI were significantly higher among elderly subjects who needed walking aids, who had suffered falls, and those manifesting anxiety.

Conclusion

Our sample included subjects of advanced age, primarily women, who were institutionalized less than five years, with multiple diseases and polypharmacy users. They presented long-standing short-duration mixed dizziness, that occurred more than once a month and affected mainly the functional aspect.

The Use of Computer-Assisted Home Exercises to Preserve Physical Function after a Vestibular Rehabilitation Program: A Randomized Controlled Study

Objective. The purpose of this study was to evaluate whether elderly patients with vestibular dysfunction are able to preserve physical functional level, reduction in dizziness, and the patient's quality of life when assistive computer technology is used in comparison with printed instructions. Materials and Methods. Single-blind, randomized, controlled follow-up study. Fifty-seven elderly patients with chronic dizziness were randomly assigned to a computer-assisted home exercise program or to home exercises as described in printed instructions and followed for tree month after discharge from an outpatient clinic. Results. Both groups had maintained their high functional levels three months after finishing the outpatient rehabilitation. No statistically significant difference was found in outcome scores between the two groups. In spite of moderate compliance levels, the patients maintained their high functional level indicating that the elderly should not necessarily exercise for the first three months after termination of the training in the outpatient clinic. Conclusion. Elderly vestibular dysfunction patients exercising at home seem to maintain their functional level, level of dizziness, and quality of life three months following discharge from hospital. In this specific setup, no greater effect was found by introducing a computer-assisted training program, when compared to standard home training guided by printed instructions. This trial is registered with NCT01344408.

Disequilibrium in patients with posterior fossa arachnoid cysts

BACKGROUND

Arachnoid cysts (AC) are benign, congenital malformations of the leptomeninges. In our experience, dizziness and vertigo are common complaints in patients with such cysts.

OBJECTIVE

To quantify dizziness and imbalance in patients with arachnoid cysts in the posterior fossa using the Dizziness Handicap Inventory (DHI), Vertigo Symptom Scale Short-Form (VSS-SF) and Computerized Dynamic Posturography (CDP). We also wanted to investigate whether any dizziness and imbalance are reversible after surgical cyst decompression.

METHODS

The study includes four patients with AC in the posterior fossa (two in the cerebellopontine angle and two supracerebellar in the midline) and 15 control subjects undergoing ENT surgery for benign lesions of the larynx (n = 10) or the parotid glands (n = 5). All participants answered the DHI and VSS-SF and underwent CDP the day before, and at follow-up after surgery. The AC patients also graded their dizziness through the use of a Visual Analogue Scale (VAS).

RESULTS

Preoperatively, cyst patients scored higher than controls on subjective symptoms (DHI, VSS-SF A and VSS-SF V) and had a lower score on postural sway (CDP). Symptom scores decreased after surgery; the cyst patients improved in the subjective tests (DHI, VAS and VSS-SF), and three of the patients improved their CDP scores. In the controls, symptom and CDP scores were unchanged after surgery.

CONCLUSION

Patients with fossa posterior cyst had a significant preoperative impairment compared with the controls, and they exhibited post-operative improvement in their subjective dizziness.

Vestibular rehabilitation for unilateral peripheral vestibular dysfunction

BACKGROUND

This is an update of a Cochrane review first published in The Cochrane Library in Issue 4, 2007 and previously updated in 2011.Unilateral peripheral vestibular dysfunction (UPVD) can occur as a result of disease, trauma or postoperatively. The dysfunction is characterised by complaints of dizziness, visual or gaze disturbances and balance impairment. Current management includes medication, physical manoeuvres and exercise regimes, the latter known collectively as vestibular rehabilitation.

OBJECTIVES

To assess the effectiveness of vestibular rehabilitation in the adult, community-dwelling population of people with symptomatic unilateral peripheral vestibular dysfunction.

SEARCH METHODS

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The most recent search was 18 January 2014.

SELECTION CRITERIA

Randomised controlled trials of adults living in the community, diagnosed with symptomatic unilateral peripheral vestibular dysfunction. We sought comparisons of vestibular rehabilitation versus control (e.g. placebo), other treatment (non-vestibular rehabilitation, e.g. pharmacological) or another form of vestibular rehabilitation. Our primary outcome measure was change in the specified symptomatology (for example, proportion with dizziness resolved, frequency or severity of dizziness). Secondary outcomes were measures of function, quality of life and/or measure(s) of physiological status, where reproducibility has been confirmed and shown to be relevant or related to health status (for example, posturography), and adverse effects

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We included 39 studies involving 2441 participants with unilateral peripheral vestibular disorders in the review. Trials addressed the effectiveness of vestibular rehabilitation against control/sham interventions, medical interventions or other forms of vestibular rehabilitation. Non-blinding of outcome assessors and selective reporting were threats that may have biased the results in 25% of studies, but otherwise there was a low risk of selection or attrition bias.Individual and pooled analyses of the primary outcome, frequency of dizziness, showed a statistically significant effect in favour of vestibular rehabilitation over control or no intervention (odds ratio (OR) 2.67, 95% confidence interval (CI) 1.85 to 3.86; four studies, 565 participants). Secondary outcomes measures related to levels of activity or participation measured, for example, with the Dizziness Handicap Inventory, which also showed a strong trend towards significant differences between the groups (standardised mean difference (SMD) -0.83, 95% CI -1.02 to -0.64). The exception to this was when movement-based vestibular rehabilitation was compared to physical manoeuvres for benign paroxysmal positional vertigo (BPPV), where the latter was shown to be superior in cure rate in the short term (OR 0.19, 95% CI 0.07 to 0.49). There were no reported adverse effects.

AUTHORS' CONCLUSIONS

There is moderate to strong evidence that vestibular rehabilitation is a safe, effective management for unilateral peripheral vestibular dysfunction, based on a number of high-quality randomised controlled trials. There is moderate evidence that vestibular rehabilitation resolves symptoms and improves functioning in the medium term. However, there is evidence that for the specific diagnostic group of BPPV, physical (repositioning) manoeuvres are more effective in the short term than exercise-based vestibular rehabilitation; although a combination of the two is effective for longer-term functional recovery. There is insufficient evidence to discriminate between differing forms of vestibular rehabilitation.

Challenges in conducting a randomized clinical trial of older people with chronic dizziness: before, during and after vestibular rehabilitation

PURPOSE

This study aims to describe the process of conducting a randomized clinical trial of elderly with chronic dizziness subjected to vestibular rehabilitation (VR) and to verify its effectiveness on dizziness intensity.

METHODS

Older adults (≥65 years) with chronic dizziness from vestibular disorders referred to VR were enrolled to the trial. The control group (n=40) was submitted to the Cawthorne & Cooksey protocol and the experimental group (n=42) to the modified Cawthorne & Cooksey protocol which included multiple components. Protocols were performed during individual 50-minute sessions, twice-weekly, for eight weeks. Main measures were: recruitment data (refusal and eligibility), baseline characteristics, dropout rate, session attendance, protocol adherence, adverse effects, exercise adaptation and follow-up events. The Visual Analog Scale (VAS) was used to measure dizziness intensity.

RESULTS

144 elderly were referred to VR, 26.4% declined to participate and 16.7% were ineligible. There were 51 session non-attendances, with disease being the most frequent reason. Regardless of VR protocol, VAS dizziness intensity diminished along sessions (p<0.001). 88.6% of the participants reported improvement after treatment, and 22.9% mentioned an increase in dizziness on follow-up. Home exercises were no longer being performed by 21.4% of the subjects after 3 months from discharge. The final dropout rate was 14.6%. There were no differences between VR protocols on recruitment, dropout, session's attendance, adherence to protocol and treatment effects.

CONCLUSIONS

Our results revealed many challenges in conducting a rehabilitation trial with an elderly sample. The VR protocols showed to be feasible and suitable to reduce dizziness in older adults.

Fighting for control in an unpredictable life - a qualitative study of older persons' experiences of living with chronic dizziness

Background

Dizziness in older people is associated with disability and reduced quality of life. Few studies have investigated how daily life is affected from the older person’s perspective. Identifying barriers and resources in daily life could guide health care in how to direct efficient interventions. The aim of this study was to explore older persons’ experiences of living with chronic dizziness.

Methods

In this qualitative study seven women aged 74–84 years and six men aged 73–87 years with chronic dizziness (≥3 months) recruited from a primary health care centre in 2012 participated in semi-structured interviews. The interviews were analysed by content analysis.

Results

Interpretation of the interviews resulted in the overall theme “Fighting for control in an unpredictable life” with two themes. The first theme “Striving towards normality” revealed a struggle in daily life in searching for a cure or improvement and finding a way to maintain ordinary life. This process could result in feelings of resignation or adaption to daily life, and factors that supported living with chronic dizziness were described. The second theme “Having a precarious existence” revealed that daily life included being exposed to threats such as a fear of recurrent attacks or of falling, which resulted in an insecure and inflexible way of life. A feeling that symptoms were not taken seriously was described.

Conclusions

The present study showed that older persons with chronic dizziness have needs that are not met by health care. Despite the fact that frequent contact with health care was described, the respondents described barriers in daily life that led to a restricted, inflexible and insecure daily life. Health care should therefore be individually tailored with focus on aspects of daily life, especially safety aspects. Support should also be continued until the older persons with chronic dizziness have developed coping strategies to gain control of their daily life.

Pre- and post-operative dizziness and postural instability in temporal arachnoid cyst patients

OBJECTIVES

Arachnoid cysts (AC) are benign, congenital malformations of the leptomeninges, with a predilection for the temporal fossa. In our clinical experience, patients with temporal AC often complain of dizziness and imbalance. However, these symptoms and the effect of surgery on them have not been studied before.

MATERIALS AND METHODS

Dizziness and imbalance in patients with temporal AC were quantified before and after surgical cyst decompression, using the Dizziness Handicap Inventory (DHI), Vertigo Symptom Scale - Short-Form (VSS-SF) and computerized dynamic posturography (CDP). The study includes 16 patients with temporal AC and 15 control subjects undergoing surgery for benign lesions of the larynx (n = 10) or the parotid glands (n = 5). All participants answered the DHI and VSS-SF and underwent CDP the day before and 3-6 months after surgery. The patients with AC also graded their dizziness through the use of a visual analogue scale (VAS).

RESULTS

Preoperatively, cyst patients scored higher than controls on subjective symptoms (DHI, VSS-SF A and VSS-SF V), but not on postural sway (CDP). Symptom scores decreased after surgery; the cyst patients improved significantly in the subjective tests (DHI, VAS and VSS-SF), while CDP scores did not. In the controls, symptom and CDP scores were unchanged after surgery.

CONCLUSIONS

Patients with temporal AC have a significant preoperative impairment and post-operative improvement in their subjective dizziness, but not in postural sway as measured by CDP.

[Kinesitherapy in patients with the peripheral vestibular system disorders]

INTRODUCTION

Kinesitherapy is widely accepted management in patients with vertigo and imbalance, but there has been inadequate evidence that one form of therapy is superior to another.

THE AIM

of the study was to compare effectiveness of two kinesitherapy protocols in patients with the peripheral vestibular system disorders.

MATERIAL AND METHODS

Fifty patients (mean age 46.0±13.1 year) with vertigo and balance instability lasting over 3 months with unilateral vestibular disorder, confirmed in Videnystagmography, were included in the study. Thirty patients underwent supervised and 20 patients home-based exercise programs. All of them were assessed three times at the baseline, after 4 weeks and 3 months, on vertigo intensity and frequency with the Vertigo Syndrome Scale (VSS), Vertigo Visual Analog Scale (VAS) and clinical unsteadiness with tests (Romberg, Amended Motor Club Assesment (AMCA), Eurofit test - standing on one leg.

RESULTS

In both groups the clinical tasks and the intensity of vertigo in VAS significantly decreased. The mean value of VSS (part physical and emotional)score significantly decreased only in supervised group at the end of 4 weeks and 3 months (p=ns). Recovery was more dynamic in supervised group than home-based exercises group, in AMCA test (3.9 vs. 1.3 s, p<0.05) in Eurofit tests eye open (14.1 vs. 0.9 s, p<0.05) and eye closed (3.5 vs. 1 s, p<0.05).

CONCLUSIONS

In patients with unilateral peripheral vestibular dysfunction supervised and home-based group kinesitherapy is an effective treatment method. In supervised group patients recovery has been faster.

[Impact of physiotherapy on quality of life improvement in patients with central vestibular system dysfunction]

THE AIM of the study was to evaluate the impact of physiotherapy on balance stability and quality of life improvement in patients with central vestibular system dysfunction.

MATERIAL AND METHODS

The study was conducted on 31 patients (23 females, 8 males) with vertigo/dizziness and unsteadiness diagnosed for central vestibular system impairment based on videonystagraphy examinations, in ENT Department Medical University of Lodz between 2010-2011 years. Patients' history of diseases were collected. The physiotherapeutic programme was individually introduced during four weeks (five time a week). The intervention included balance training and habituation exercises. At baseline and after patients were evaluated therapy with WHO Quality of Life-BREF (WHOQOL-BREF) and Dizzeness Handicap Inventory (DHI) self-assessment scales. Clinical examination with Romberg and stand one leg tests (eyes opened and closed) was performed.

RESULTS

After therapy statistically significant differences in total DHI score (p<0.005) and 3 subscales: physical, emotional, functional (p<0.05) and WHOQOL-BREF only physical subscale (p<0.05) compared baseline were found. There were no statistical differences between psychological, social relationships and environment subscales. In clinical evaluation significant reduction of unsteadiness in Romberg test (p<0.05) and in stand one leg tests eyes opened and closed tests (p<0.05) were found.

CONCLUSION

In patients with central vestibular system impairment after physical therapy betterment in clinical examination and some subjective self-assessment scales were observed. Lack of significant improvement in psychological, social relationships and environment domain in WHOQOL-BREF subscale indicated that these patients may need more psychological support or extensions in physiotherapy.

Effects of primary caregiver participation in vestibular rehabilitation for unilateral neglect patients with right hemispheric stroke: a randomized controlled trial

INTRODUCTION

The current study aims to investigate the effects of primary caregiver participation in vestibular rehabilitation (VR) on improving the measures of neglect, activities of daily living (ADL), balance, and falls of unilateral neglect (UN) patients.

METHODS

This study is a single-blind randomized controlled trial. Both experimental (n = 24) and control groups (n = 24) received conventional rehabilitation. The experimental group undertook VR for a month. During the first and second weeks, a registered nurse trained the experimental group in VR. The primary caregivers in the experimental group supervised and guided their patients in VR during the third and fourth weeks. The outcome measures were neglect, ADL, balance, and falls.

RESULTS

The two groups of UN patients showed a significant improvement in neglect, ADL, and balance over time. Based on the generalized estimating equations model, an interaction was observed between groups and times. Significant interactions were observed between the VR group at days 14 and 28 in the areas of neglect, ADL, and balance. No significant difference was observed between the two groups in the number of falls.

CONCLUSION

Neglect, ADL, and balance among UN patients with right hemispheric stroke can be improved through the participation of primary caregivers in VR. Trained informal caregivers were recommended to provide VR guidance and supervision to patients who suffer from UN.

Efficacy of a vibrotactile neurofeedback training in stance and gait conditions for the treatment of balance deficits: a double-blind, placebo-controlled multicenter study

OBJECTIVE

Vestibular rehabilitation strategies mostly require a long-lasting training in stance conditions, which is finally not always successful. The individualized training in everyday-life conditions with an intuitive tactile neurofeedback stimulus seems to be a more promising approach. Hence, the present study was aimed at investigating the efficacy of a new vibrotactile neurofeedback system for vestibular rehabilitation.

STUDY DESIGN

Double-blinded trial.

PATIENTS

One hundred five patients who experience one of the following balance disorders for more than 12 months were included in the study: canal paresis, otolith disorder, removal of an acoustic neuroma, microvascular compression syndrome, Parkinson's disease, and presbyvertigo.

INTERVENTIONS

Vibrotactile neurofeedback training was performed daily (15 min) over 2 weeks with the Vertiguard system in those 6 tasks of the Standard Balance Deficit Test with the most prominent deviations from the normative values.

MAIN OUTCOME MEASURES

Trunk and ankle sway, dizziness handicap inventory, and vestibular symptom score were measured in the verum and placebo group before the training, on the last training day and 3 months later.

RESULTS

A significant reduction in trunk and ankle sway as well as in the subjective symptom scores were observed in the verum group. Such an effect could not be found in any of the outcome parameters of the placebo group.

CONCLUSION

The vibrotactile neurofeedback training applied in the present study is a highly efficient method for the reduction of body sway in different balance disorders. Because the rehabilitation program is easy to perform, not exhausting, and time saving, elderly patients and those with serious, long-lasting balance problems also can participate successfully.

Effect of Tai Chi on body balance: randomized controlled trial in elderly men with dizziness

The purpose of this study was to assess the effect of 18-week Tai Chi training on body balance in a dynamic trial among elderly men with dizziness. The study covered subjects aged 60 to 80 years. We identified 40 men who reported a history of dizziness. The subjects were recruited using direct mailings and a community information campaign. The participants were randomly assigned to either the exercise intervention (n = 20) or control group (n = 20). The Tai Chi group participated in an 18-week exercise class held for 45 minutes twice a week. Body balance was studied in two ways: using the "8 foot up and go test" (Rikli and Jones 2001) and using a Computer Posturographic System PE 90 (manufactured by Military Institute of Aviation Medicine in Warsaw and outfitted with Pro-Med modified software). The ability to perform specific tasks (maximal deflections in four directions) was measured on the posturographic platform. The variation in results obtained on the first and second date of tests in the experimental and control groups was confirmed statistically using four parameters, i.e. "8 foot up to and go test (H = 8.21;p = 0.003), forward deflection (H = 3.70;p = 0.050), backward deflection (H = 5.04;p = 0.024) and maximum sway area (H = 8.86;p = 0.002). Consequently, we found that the 18-week period of Tai-Chi exercises, with a frequency of twice a week for 45 minutes, is beneficial for dynamic balance, which is important for the reduction of fall risk factors among elderly men with dizziness.

Vestibular rehabilitation strategies and factors that affect the outcome

Ever since the introduction of Cawthorne-Cooksey exercises, vestibular rehabilitation (VR) has been gaining popularity in the treatment of the dizzy patient. Numerous studies support the effectiveness of VR in improving balance/walking skills, eye-head coordination and the quality of life of the patient. Different rehabilitation protocols have been used to treat patients with peripheral and central vestibular disorders. Assessment of the patients' progress is based on the patients' selfperception of dizziness and their functional skills. Factors such as age, medication, time of onset of vertigo and home based VR have been evaluated on their effect on the rehabilitation's outcome. The aim of this review is to evaluate rehabilitation strategies and discuss the factors that affect the outcome.

Vestibular rehabilitation for unilateral peripheral vestibular dysfunction

BACKGROUND

This is an update of a Cochrane Review first published in The Cochrane Library in Issue 4, 2007.Unilateral peripheral vestibular dysfunction (UPVD) can occur as a result of disease, trauma or postoperatively. The dysfunction is characterised by complaints of dizziness, visual or gaze disturbances and balance impairment. Current management includes medication, physical manoeuvres and exercise regimes, the latter known collectively as vestibular rehabilitation (VR).

OBJECTIVES

To assess the effectiveness of vestibular rehabilitation in the adult, community-dwelling population of people with symptomatic unilateral peripheral vestibular dysfunction.

SEARCH STRATEGY

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The most recent search was 1 July 2010, following a previous search in March 2007.

SELECTION CRITERIA

Randomised trials of adults living in the community, diagnosed with symptomatic unilateral peripheral vestibular dysfunction. We sought comparisons of VR versus control (placebo etc.), other treatment (non-VR, e.g. pharmacological) or another form of VR. We considered the outcome measures of frequency and severity of dizziness or visual disturbance; changes in balance impairment, function or quality of life; and measure/s of physiological status with known functional correlation.

DATA COLLECTION AND ANALYSIS

Both authors independently extracted data and assessed trials for risk of bias.

MAIN RESULTS

We included 27 trials, involving 1668 participants, in the review. Trials addressed the effectiveness of VR against control/sham interventions, medical interventions or other forms of VR. Individual and pooled data showed a statistically significant effect in favour of VR over control or no intervention. The exception to this was when movement-based VR was compared to physical manoeuvres for benign paroxysmal positional vertigo (BPPV), where the latter was shown to be superior in cure rate in the short term. There were no reported adverse effects.

AUTHORS' CONCLUSIONS

There is moderate to strong evidence that VR is a safe, effective management for unilateral peripheral vestibular dysfunction, based on a number of high quality randomised controlled trials. There is moderate evidence that VR provides a resolution of symptoms and improvement in functioning in the medium term. However, there is evidence that for the specific diagnostic group of BPPV, physical (repositioning) manoeuvres are more effective in the short term than exercise-based vestibular rehabilitation; although a combination of the two is effective for longer-term functional recovery. There is insufficient evidence to discriminate between differing forms of VR.

Effect of an education programme for patients with osteoarthritis in primary care--a randomized controlled trial

BACKGROUND

Osteoarthritis (OA) is a degenerative disease, considered to be one of the major public health problems. Research suggests that patient education is feasible and valuable for achieving improvements in quality of life, in function, well-being and improved coping. Since 1994, Primary Health Care in Malmö has used a patient education programme directed towards OA. The aim of this study was to evaluate the effects of this education programme for patients with OA in primary health care in terms of self-efficacy, function and self-perceived health.

METHOD

The study was a single-blind, randomized controlled trial (RCT) in which the EuroQol-5D and Arthritis self-efficacy scale were used to measure self-perceived health and self-efficacy and function was measured with Grip Ability Test for the upper extremity and five different functional tests for the lower extremity.

RESULTS

We found differences between the intervention group and the control group, comparing the results at baseline and after 6 months in EuroQol-5D (p < 0.001) and in standing one leg eyes closed (p = 0.02) in favour of the intervention group. No other differences between the groups were found.

CONCLUSION

This study has shown that patient education for patients with osteoarthritis is feasible in a primary health care setting and can improve self-perceived health as well as function in some degree, but not self-efficacy. Further research to investigate the effect of exercise performance on function, as well as self-efficacy is warranted.

TRIAL REGISTRATION

The trial is registered with ClinicalTrials.gov.

REGISTRATION NUMBER

NCT00979914.

An evaluation of the cost-effectiveness of booklet-based self-management of dizziness in primary care, with and without expert telephone support

Background

Dizziness is a very common symptom that often leads to reduced quality of life, anxiety and emotional distress, loss of fitness, lack of confidence in balance, unsteadiness and an increased risk of falling. Most dizzy patients are managed in primary care by reassurance and medication to suppress symptoms. Trials have shown that chronic dizziness can be treated effectively in primary care using a self-help booklet to teach patients vestibular rehabilitation exercises that promote neurological adaptation and skill and confidence in balance. However, brief support from a trained nurse was provided in these trials, and this model of managing dizzy patients has not been taken up due to a lack of skills and resources in primary care. The aim of this trial is to evaluate two new alternative models of delivery that may be more feasible and cost-effective.

Methods/Design

In a single blind two-centre pragmatic controlled trial, we will randomise 330 patients from 30 practices to a) self-help booklet with telephone support from a vestibular therapist, b) self-help booklet alone, c) routine medical care. Symptoms, disability, handicap and quality of life will be assessed by validated questionnaires administered by post at baseline, immediately post-treatment (3 months), and at one year follow-up. The study is powered to test our primary hypothesis, that the self-help booklet with telephone support will be more effective than routine care. We will also explore the effectiveness of the booklet without any support, and calculate the costs of treatment in each arm.

Discussion

If our trial indicates that patients can cost-effectively manage their dizziness in primary care, then it can be easily rolled out to relieve the symptoms of the many patients in primary care who currently have chronic, untreated, disabling dizziness. Treatment in primary care may reduce the development of psychological and physical sequelae that cause handicap and require treatment. There is also the potential to reduce the cost to the NHS of treating dizziness by reducing demand for referral to secondary care for specialist assessment and treatment.

Trial Registration

ClinicalTrials.gov trial registration ID number: NCT00732797

Models for integrating rehabilitation and primary care: a scoping study

OBJECTIVE

To describe the scope and breadth of knowledge currently available regarding the integration of rehabilitation and primary care services.

DATA SOURCES

Peer-reviewed journals were searched using CINAHL, MEDLINE, and EBM Reviews for the years 1995 through 2007. This process identified 172 items.

STUDY SELECTION

To be considered for the subsequent review, the article had to describe a service delivery program that offered primary care and rehabilitation, or services specifically designed for people with chronic conditions/disabilities. Further, it had to be available in English or French. No methodological limitations were applied to screen for levels of evidence.

DATA EXTRACTION

Based on these criteria, 38 articles remained that pertained to both primary care and rehabilitation. These were reviewed, sorted, and categorized to discover commonalities and differences among the approaches used to integrating rehabilitation into primary care.

DATA SYNTHESIS

In consultation with the team of investigators, it was determined that there were 6 different models for providing primary health care and rehabilitation services in an integrated approach: clinic, outreach, self-management, community-based rehabilitation, shared care, and case management. In addition, a number of themes were identified across models that may act as either supports or impediments to the integration of rehabilitation services into primary care settings: team approach, interprofessional trust, leadership, communication, compensation, accountability, referrals, and population-based approach.

CONCLUSIONS

Rehabilitation providers interested in working in the primary care sector may be assisted in conceptualizing the benefits that they bring to the setting by considering these models and issues.

One-leg standing test for elderly populations

BACKGROUND

The one-leg standing (OLS) test is one of the balance tests used to diagnose musculoskeletal ambulation disability symptom complex (MARS), a condition newly defined by three professional Japanese medical societies in 2006 to help identify the symptoms of motor organ deterioration and establish preventive strategies. Although many studies have used the OLS test, none has shown conclusively that the test can be used as a practical marker of frailty among elderly people, especially in community settings. Based on the type of epidemiological study -- i.e., descriptive epidemiology and analytical epidemiology (observational and intervention studies) -- we reviewed evidence on three fundamental issues related to the OLS test: (1) testing procedures and reference values; (2) the associations between the OLS time and negative events; (3) improvement of the OLS time by intervention. These issues are key to any discussion of whether the OLS test can be used as a practical marker for predicting frailty in community-dwelling elderly populations.

METHODS

Articles were collected from MEDLINE databases using the search terms "one- leg standing" and the other names included in the same category.

RESULTS

Because various procedures are used to carry out the OLS test, the measured values for the OLS time varied widely from study to study. Some observational studies showed that the OLS time is related to negative events such as falls, declines in activity of daily living, and other morbidity. OLS times could be improved by several interventions.

CONCLUSIONS

This review suggests that the OLS test can be a tool for predicting frailty in community-dwelling elderly populations. However, our review should be interpreted with caution because we did not confirm the evidence level of each of the studies we selected. Further research on this topic is needed.

The effect of early customized vestibular rehabilitation on balance after acoustic neuroma resection

OBJECTIVE

To compare the effect of early customized vestibular rehabilitation with general instructions in patients after acoustic neuroma surgery.

SETTING

Tertiary referral centre.

SUBJECTS

Fifty-three patients after surgery.

DESIGN

A prospective assessor-blinded, randomized controlled trial.

INTERVENTIONS

After stratification for age (<50 years; >or=50 years), patients were randomly allocated into groups receiving general instructions or customized vestibular rehabilitation protocols for 12 weeks.

OUTCOME MEASURES

Standing Balance Sum, Timed Up and Go test, Tandem Gait and Dynamic Gait Index. Balance performance was assessed preoperatively, at discharge (one week after surgery), three, six, nine, 12, 26 and 52 weeks after surgery.

RESULTS AND DISCUSSION

All subjects clearly improved within the first six weeks after surgery. However, older subjects receiving vestibular rehabilitation performed significantly (P<0.05) better on standing balance, Timed Up and Go test and Tandem Gait, when compared with the older group that received only general instructions. This effect persisted up to 12 weeks and also became apparent on the Dynamic Gait Index. In addition, the older vestibular rehabilitation group had better balance scores at 12 weeks when compared with their original preoperative scores (P<0.05). This pattern remained even up to one year after surgery (P<0.05).

CONCLUSION

In patients over 50, early vestibular rehabilitation facilitates recovery of postural control after acoustic neuroma surgery. Customized vestibular rehabilitation should be given in addition to general instructions that stress the need of exposure to movement. Retention of the early beneficial effects even one year after surgery stresses the importance of customized vestibular rehabilitation.

Vestibular rehabilitation by auditory feedback in otolith disorders

Rehabilitation strategies have been applied successfully over the last few decades to initiate central compensation of the tonus imbalance and to facilitate substitution in different types of peripheral vestibular dysfunction. However, these vestibular rehabilitation strategies are often not successful in patients with isolated otolith disorders. The aim of the present study was therefore to evaluate a specific rehabilitation strategy for patients with an isolated otolith disorder by using an auditory feedback system. Thirteen patients, which suffered from different types of otolith disorders, but no other vestibular pathology and 13 normal controls were included in this study. Vestibular rehabilitation exercises were performed daily over a 2-week period (weekends excluded). During all exercises the patients of the test group (n=13) obtained an acoustic feedback signal when their trunk angle velocity exceeded a preset level while the patients of the control group (n=13) performed the same exercises without auditory feedback. The most effective exercise in the test group was "walking eight tandem steps on a foam support surface". Approximately 85% of the patients showed a significant decrease of trunk sway in this condition. In contrast to these results, patients of the control group showed no significant improvement of postural control after the training. The results indicate that an auditory feedback rehabilitation program with exercises related to the specific neurotological disease could significantly improve the postural control in patients with otolith disorders.

Vestibular rehabilitation for unilateral peripheral vestibular dysfunction

BACKGROUND

Unilateral peripheral vestibular dysfunction (UPVD) can occur as a result of disease, trauma or post-operatively. The dysfunction is characterized by complaints of dizziness, visual or gaze disturbances and balance impairment. Current management includes medication, physical manoeuvres and exercise regimes, the latter known collectively as vestibular rehabilitation (VR).

OBJECTIVES

To assess the effectiveness of vestibular rehabilitation in the adult, community dwelling population of people with symptomatic unilateral peripheral vestibular dysfunction.

SEARCH STRATEGY

The search included the Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library Issue 1 2007, MEDLINE (1950 to 2007) and EMBASE (1974 to 2007). The date of the last search was March 2007.

SELECTION CRITERIA

Randomised trials of adults living in the community, diagnosed with symptomatic unilateral peripheral vestibular dysfunction. Comparisons sought were: Vestibular rehabilitation versus control (placebo etc.). Vestibular rehabilitation versus other treatment (non-vestibular rehabilitation e.g. pharmacological). Vestibular rehabilitation versus another form of vestibular rehabilitation. Outcome measures that were considered included: frequency and severity of dizziness or visual disturbance; changes in balance impairment, function or quality of life; measure/s of physiological status with known functional correlation.

DATA COLLECTION AND ANALYSIS

Both authors independently extracted data and assessed trials for quality.

MAIN RESULTS

Thirty-two trials were identified and eleven were excluded because of mixed/unclear vestibular pathology, leaving twenty-one trials in the review. Included studies addressed the effectiveness of vestibular rehabilitation against control/sham interventions, non-vestibular rehabilitation interventions or other forms of vestibular rehabilitation, by comparing the subjects in each group who had significant resolution of symptoms and/or improved function. Individual and pooled data showed a statistically significant effect in favour of the vestibular rehabilitation over control or no intervention. The exception to this was when movement based vestibular rehabilitation was compared to physical manoeuvres for benign paroxysmal positional vertigo, where the latter was shown to be superior in cure rate in the short term. There were no reported adverse effects.

AUTHORS' CONCLUSIONS

There is moderate to strong evidence that vestibular rehabilitation is a safe, effective management for unilateral peripheral vestibular dysfunction, based on a number of high quality randomised controlled trials. There is moderate evidence that vestibular rehabilitation provides a resolution of symptoms in the medium term. However there is evidence that for the specific diagnostic group of benign paroxysmal positional vertigo, physical (repositioning) manoeuvres are more effective in the short term than exercise based vestibular rehabilitation. There is insufficient evidence to discriminate between differing forms of vestibular rehabilitation.

Vestibular Rehabilitation in Individuals with Inner-Ear Dysfunction: A Pilot Study

A randomised control prospective study was carried out examining patient outcomes after performing a 10-week vestibular home exercise programme. Thirty-two adults with vestibular dysfunction who reported vestibular symptoms negatively affecting daily life were enrolled. Test subjects were provided with an individualised vestibular rehabilitation programme designed by a physiotherapist. Control subjects received a set of strength and endurance exercises only. All subjects performed their exercises 3 times a day for 10 weeks. Subjective and objective patient measures were collected at 0, 6, 10 and 26 weeks. Results showed that both groups improved after beginning exercise, and that test subjects significantly benefited compared to the controls. These benefits were long term and measurable 6 months later. This study provides evidence that individualised vestibular exercises promote better outcomes for patients with vestibular dysfunction.

The Dizziness Handicap Inventory and Its Relationship With Functional Balance Performance

OBJECTIVE

The purpose of this study was to describe the relation between the Dizziness Handicap Inventory (DHI) and balance performance measures.

STUDY DESIGN

Retrospective case series.

SETTING

Outpatient balance clinic in a tertiary referral center.

PATIENTS

Patients referred with dizziness or imbalance of vestibular and nonvestibular origin.

OUTCOME MEASURES

DHI, Romberg with Jendrassik maneuver, standing on foam, tandem Romberg, single-leg stance, the timed up and go test, the Dynamic Gait Index (DGI), tandem gait, and the 10-m walking test.

RESULTS

The mean age of participants (n = 214) was 53.9 years. The mean DHI total score was 35.1, ranging from 0 to 96. Spearman rank correlation coefficients (rS) between DHI and the static balance tests were fair and ranged between -0.42 (p < 0.01) for single-leg stance with eyes closed and -0.51 (p < 0.01) for single-leg stance with eyes open. Only the Romberg test with Jendrassik maneuver correlated weakly (rS = -0.25; p < 0.01) with the DHI. Correlations with the walking tests were moderate, the connection with the DGI being the strongest one (rS = -0.69; p < 0.01). Forty-two percent of the variance in DHI scores in our patients was accounted for by the DGI score (r = 0.417).

CONCLUSION

Functional balance tests involving locomotion correlate better with DHI scores when compared with static balance measures. The DGI explains a large component of handicap in dizzy and unsteady patients, which advocates its use in these patients.

Disability and rehabilitation in the dizzy patient

PURPOSE OF REVIEW

This review focuses on prospective studies of vertigo and balance therapy in the past 3 years, including advances in vertigo-habituation exercises for adults, pediatric intervention, and virtual reality techniques, and, in more depth, the literature pertinent to driving motor vehicles.

RECENT FINDINGS

Increased support has been generated for the efficacy of a minimal, home-based vertigo-habituation program for adults with peripheral vestibular disorders. Vestibular rehabilitation has been shown to be associated with improvements in independence and dynamic visual acuity. Community-based vestibular rehabilitation has been shown to be efficacious for selected patients, after careful screening, when trained personnel provide intervention. Vestibular rehabilitation has been incorporated into the rehabilitation program for head-injured military personnel who will be returned to duty, and multifactorial balance rehabilitation has been shown to be useful for children with hearing and balance impairments. Virtual reality techniques have made significant advances, so immersive environments have potential for rehabilitation for patients with vestibular disorders and for developing training regimens for astronauts to ameliorate some effects of exposure to microgravity. Driving skill, in general, is affected by use of benzodiazepines. For many patients with vestibular impairments driving is a particularly problematic activity of daily living.

SUMMARY

Progress has been made in studies of acute care, community-based, and pediatric vestibular rehabilitation. Work on simulator-based paradigms has moved toward readiness for implementation. Studies of driving have provided some insight into the problems of these patients. More work remains to be done on all of these problems.