Vestibular Rehabilitation Therapy and Corticosteroids for Vestibular Neuritis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background and Objectives: Besides corticosteroids, clinicians found that vestibular rehabilitation therapy (VRT) has a potential effect on vestibular neuritis (VN) improvement. This study aimed to investigate the efficacy of both corticosteroid therapy (CT) compared to VRT, and each group compared to their combination (CT vs. (CT+VRT) and VRT vs. (CT + VRT). Materials and Methods: Systematic searches were performed in PubMed, CINAHL, and Scopus for randomized controlled trials (RCTs) reporting the administration of at least CT and VRT for VN. The outcome of interest was VN’s subjective and objective improvement parameters. Results: Four RCTs involving a total of 182 patients with VN were eligible for systematic review and meta-analysis. The weighted mean difference (WMD) of canal paresis (objective parameter) in the CT group is significantly lower than in the VRT group after a 1 month follow-up (8.31; 95% CI: 0.29, −16.32; p = 0.04; fixed effect). Meanwhile, the WMD of Dizziness Handicap Inventory (DHI) (subjective parameter) in the VRT group is significantly lower than in the CT group after a 1 month follow-up (−3.95; 95% CI: −7.69, −0.21; p = 0.04; fixed effect). Similarly, the WMD of DHI in the combination group (CT+VRT) is significantly lower than in the CT group after a 3 month follow-up (3.15; 95% CI: 1.50, 4.80; p = 0.0002; fixed effect). However, there is no significant difference in all outcomes after 12 months of follow-ups in all groups (CT vs. VRT, CT vs. combination, and VRT vs. combination). Conclusions: This study indicates that CT enhances the earlier canal paresis improvement, as the objective parameter, while VRT gives the earlier DHI score improvement, as the subjective parameter. However, their long-term efficacy does not appear to be different. VRT has to be offered as the primary option for patients with VN, and corticosteroids can be added to provide better recovery in the absence of its contraindication. However, whether to choose VRT, CT, or its combination should be tailored to the patient’s condition. Future studies are still needed to revisit this issue, due to the small number of trials in this field. (PROSPERO ID: CRD42021220615).

Effects of stabilizing reversal technique and vestibular rehabilitation exercise on dizziness and balance ability in patients with vestibular neuritis: An observational study

Vestibular neuritis is a common disease of peripheral dizziness. Studies have shown that vestibular rehabilitation exercise (VRE) and proprioceptive neuromuscular facilitation (PNF) are effective to treat the symptoms of vestibular neuritis. However, the effect of VRE and PNF on the balance ability and dizziness in this patient cohort remains unclear.The aim of our observational study was to determine the changes in dizziness and balance ability of patients with vestibular neuritis who participated in the VRE program with stabilizing reversal technique (SRT).The reporting of this study conforms to the STROBE statement. Ten men and women aged ≥ 20 years who were diagnosed with vestibular neuritis were included. Patients performed VRE with SRT for 4 weeks with assistance from a therapist. VRE without SRT can also be performed at home. Dizziness was evaluated using the dizziness handicap inventory (DHI) and visual analog scale (VAS). Balance ability was assessed using the Berg's balance scale (BBS) and timed up and go test (TUG). At pre- and post-exercise, paired t test was performed to compare the within-group differences.After the program, DHI (45.40 ± 6.74 to 21.00 ± 7.07), VAS (5.90 ± 1.20 to 2.80 ± 0.92), BBS (45.10 ± 2.77 to 52.70 ± 1.83), and TUG (15.29 ± 1.13 to 12.06 ± 1.61) scores improved significantly in the VRE program group (P = .05).The VRE program combined with SRT was effective in reducing dizziness and increasing balance ability in patients with vestibular neuritis.

Efficacy of a New Treatment Maneuver for Posterior Canal Benign Paroxysmal Positional Vertigo

Existing treatment maneuvers for posterior canal benign paroxysmal positional vertigo (PC-BPPV) include the Semont liberatory maneuver (SLM) and canalith repositioning maneuver (CRM). Independent investigations reveal that these maneuvers provide an excellent outcome for most patients. However, certain aspects of these maneuvers, such as hyperextension of the neck for CRM and brisk lateral motion for the SLM, are contraindicated for patients with vertebrobasilar insufficiency, cervical spondylosis, back problems, and so forth. A hybrid approach, the Gans repositioning maneuver (GRM) was developed for use with these patients. The purpose of this project was to assess efficacy of the GRM for treatment of PC-BPPV. Two-hundred seven participants were enrolled in this prospective study. All participants were treated with the GRM. Six different clinicians performed the treatments. Participants returned for follow-up at one-week intervals until it was determined that the PC-BPPV was clear. On average, 1.25 GRM treatments were required to resolve the PC-BPPV. The majority of the participants (80.2%) were cleared with one GRM treatment, and 95.6% were clear after two treatments. Recurrence rate was 5%. There was no difference in outcome based on clinician. The GRM is an efficacious treatment maneuver for PC-BPPV and may be preferential for use in patients with neck, back, hip, and/or mobility issues that contraindicate the use of SLM or CRM.

Rehabilitation of dynamic visual acuity in patients with unilateral vestibular hypofunction: earlier is better

PURPOSE

Patients with acute peripheral unilateral hypofunction (UVH) complain of vertigo and dizziness and show posture imbalance and gaze instability. Vestibular rehabilitation therapy (VR) enhances the functional recovery and it has been shown that gaze stabilization exercises improved the dynamic visual acuity (DVA). Whether the effects of VR depend or not on the moment when it is applied remains however unknown, and investigation on how the recovery mechanisms could depend or not on the timing of VR has not yet been tested.

METHODS

Our study investigated the recovery of DVA in 28 UVH patients whose unilateral deficit was attested by clinical history and video head impulse test (vHIT). Patients were tested under passive conditions before (pre-tests) and after (post-tests) being subjected to an active DVA rehabilitation protocol. The DVA protocol consisted in active gaze stabilization exercises with two training sessions per week, each lasting 30 min, during four weeks. Patients were sub-divided into three groups depending on the time delay between onset of acute UVH and beginning of VR. The early DVA group (N = 10) was composed of patients receiving the DVA protocol during the first 2 weeks after onset (mean = 8.9 days), the late group 1 (N = 9) between the 3rd and the 4th week (mean = 27.5 days after) and the late group 2 (N = 9) after the 1st month (mean: 82.5 days). We evaluated the DVA score, the angular aVOR gain, the directional preponderance and the percentage of compensatory saccades during the HIT, and the subjective perception of dizziness with the Dizziness Handicap Inventory (DHI). The pre- and post-VR tests were performed with passive head rotations done by the physiotherapist in the plane of the horizontal and vertical canals.

RESULTS

The results showed that patients submitted to an early DVA rehab improved significantly their DVA score by increasing their passive aVOR gain and decreasing the percentage of compensatory saccades, while the late 1 and late 2 DVA groups 1 and 2 showed less DVA improvement and an inverse pattern, with no change in the aVOR gain and an increase in the percentage of compensatory saccades. All groups of patients exhibited significant reductions of the DHI score, with higher improvement in subjective perception of dizziness handicap in the patients receiving the DVA rehab protocol in the first month.

CONCLUSION

Our data provide the first demonstration in UVH patients that earlier is better to improve DVA and passive aVOR gain. Gaze stabilization exercises would benefit from the plastic events occurring in brain structures during a sensitive period or opportunity time window to elaborate optimal functional reorganizations. This result is potentially very important for the VR programs to restore the aVOR gain instead of recruiting compensatory saccades assisting gaze stability.

Guided and unguided internet-based vestibular rehabilitation versus usual care for dizzy adults of 50 years and older: a protocol for a three-armed randomised trial

INTRODUCTION

Dizziness is a common symptom in general practice with a high prevalence among older adults. The most common cause of dizziness in general practice is peripheral vestibular disease. Vestibular rehabilitation (VR) is a safe and effective treatment for peripheral vestibular disease that entails specific exercises to maximise the central nervous system compensation for the effects of vestibular pathology. An internet-based VR intervention has recently been shown to be safe and effective. Online interventions are low cost and easily accessible, but prone to attrition and non-adherence. A combination of online and face-to-face therapy, known as blended care, may balance these advantages and disadvantages.

METHODS AND ANALYSIS

A single-blind, three-arm, randomised controlled trial among patients aged 50 years and over presenting with dizziness of vestibular origin in general practice will be performed. In this study, we will compare the clinical and cost-effectiveness of stand-alone internet-based VR and internet-based VR with physiotherapeutic support ('blended care') with usual care during 6 months of follow-up. We will use a translated Dutch version of a British online VR intervention. Randomisation will be stratified by dizziness severity. The primary outcome measure is the Vertigo Symptoms Scale-Short Form. Intention-to-treat analysis will be performed, adjusting for confounders. The economic evaluation will be conducted from a societal perspective. We will perform an additional analysis on the data to identify predictors of successful treatment in the same population to develop a clinical decision rule for general practitioners.

ETHICS AND DISSEMINATION

The ethical committee of the VU University Medical Center approved ethics and dissemination of the study protocol. The insights and results of this study will be widely disseminated through international peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

Pre-results, NTR5712.

Influence of asymmetry of vestibular caloric response and age on balance and perceived symptoms after acute unilateral vestibular loss

Objective: To evaluate the influence of asymmetry of vestibular caloric response and age on balance and perceived symptoms after acute unilateral vestibular loss.

Design: Prospective study.

Setting: Ear, nose and throat departments in three hospitals.

Subjects: Fifty-four patients (mean age 52 years) with acute unilateral vestibular loss participating in a randomized controlled training study were included.

Main measures: Electronystagmography testing was performed within one week after onset of symptoms and after 10 weeks. The outcome measures clinical static balance tests (sharpened Romberg's test with eyes closed, standing on foam with eyes closed, and standing on one leg with eyes open and closed) and subjective symptom ratings on a visual analogue scale were done after one week, 10 weeks and six months. The correlation between age and asymmetry of vestibular caloric response, respectively, and the outcome measures were analysed.

Results: Greater caloric asymmetry correlated with poorer performance at the sharpened Romberg's test and standing on one leg with eyes closed at all three follow-ups (rho=-0.31 to -0.54), and with higher symptom ratings at the 10-week and six-month follow-ups (rho=0.30-0.60). Higher age was associated with poorer performance on the sharpened Romberg's test and standing on one leg at all three follow-ups (rho=0.31-0.64), but did not change over time. Higher age was also associated with higher ratings of vertigo at the six-month follow-up, and less reduction of vertigo between the 10-week and six-month follow-ups (rho=0.29-0.48).

Conclusions: A higher degree of asymmetry of vestibular caloric response and high age seem to be associated with poor outcome in balance and perceived symptoms after acute unilateral vestibular loss.

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.

Chulalongkorn vestibular balance exercise for rehabilitation in persons with various types of vestibular disorders

OBJECTIVE

To study the efficiency of Chulalongkorn vestibular balance exercise for rehabilitation in persons with various types of vestibular disorders.

MATERIAL AND METHOD

Fifty-eight patients with various types of vestibular disorder were identified by a retrospective chart review. Thirty of the 58 patients met the inclusion criteria of having dizziness and unsteadiness post vestibular diseases with complete record of neuro-otologic examination; vestibular tests and had been followed-up for at least 3 month. These patients were treated with Chulalongkorn vestibular balance exercise and were evaluated for dizziness symptoms and balance bedside test at the beginning of treatment, one month and three months after the exercise.

RESULTS

The average age of the patients was 50.34 ± 14.04 years. The average of duration of exercise program was 5.6 months. There were 6 cases of vestibular neuronitis; 5 cases of post acoustic neuroma removal; 4 cases of acute cochleovestibular loss; 3 cases of motion sickness; 2 cases of cerebellar atrophy; 3 cases of multisensory dizziness; 4 cases of post meningitis with deafness; and 3 cases of ototoxicity. After the exercise, improvement of dizziness symptoms could be found in all groups of the diseases at one month and three months. The objective of balance bedside test was improved in most cases except motion sickness, multisensory dizziness and cerebellar atrophy. The overall percentage of improvement of dizziness was statistically significant at one month and three months (p = 0.0373 and p < 0.001). However the overall balance bedside test was statistically improved at three months after the exercise (p = 0.034).

CONCLUSION

Chulalongkorn vestibular balance exercise gave significantly effective results in the treatment of dizziness and unsteadiness from various types of vestibular disorder. This study demonstrated improvement of dizziness symptom post-exercise at one month and three months with statistical significance. The balance bedside test was also statistically significant improved at three months post-exercise.

Vestibular rehabilitation in elderly patients with central vestibular dysfunction: a prospective, randomized pilot study

For the vestibular system, aging is associated with degenerated otoconia and loss of hair cells, vestibular afferents, and cells in the vestibular nuclei. Further neurodegenerative processes involve cortical, extrapyramidal motor, and cerebellar structures. Dizziness is quite common in the elderly, limiting their mobility and activities. The role of vestibular rehabilitation in these patients is controversial. The present prospective, randomized, preliminary investigation aimed to compare the effect of a 6-week posturography-assisted vestibular rehabilitation protocol (30 min a week) combined with a home-based exercise program (group A, 14 randomly assigned elderly patients) with the same home-based exercise program alone (group B, 14 randomly assigned elderly patients) for treating dizziness due to central vestibular dysfunction in elderly patients. The outcomes were analyzed using the 25-item Dizziness Handicap Inventory (DHI) and computerized posturography. After rehabilitation, group A scored significantly better in the DHI for the functional (p = 0.0016) and emotional (p = 0.01) domains and total score (p = 0.001); only the emotional domain improved significantly in group B (p = 0.038). Group A improved significantly in some posturographic parameters in the motor tests (reaction time, movement velocity, and endpoint excursion), while group B experienced more limited improvements. Our preliminary results with a program of posturography-assisted vestibular rehabilitation, and home-based exercises are more promising than with home-based exercises alone. A new study on a larger series of elderly patients with central vestibular dysfunctions is currently underway at Padova University, considering the effect of a protocol involving rehabilitation with computerized posturography alone and the relationship between outcomes and the duration of rehabilitation programs.

Ocular VEMPs indicate repositioning of otoconia to the utricle after successful liberatory maneuvers in benign paroxysmal positioning vertigo

CONCLUSIONS

This study showed a transient increase of ocular vestibular evoked myogenic potential (oVEMP) amplitudes in the affected ear after successful liberatory maneuvers and no changes in cervical VEMP (cVEMP) amplitudes. These findings support the hypothesis that successful liberatory maneuvers can lead to a repositioning of otoconia to the utricle.

OBJECTIVES

To evaluate whether oVEMP amplitudes increase after successful liberatory maneuvers in patients with posterior semicircular canal benign paroxysmal positioning vertigo (pc-BPPV), while cVEMP amplitudes do not change. These findings may indicate a successful repositioning of dislodged otoconia to the utricular macula, but not to the saccular macula.

METHODS

Thirty patients with unilateral pc-BPPV were prospectively examined with bone-conducted oVEMP and air-conducted cVEMP at four time points: before, after, 1 week after, and 1 month after the liberatory maneuvers (Sémont maneuvers).

RESULTS

At the 1-week follow-up, 20 of 30 patients were asymptomatic (responders); BPPV could still be induced in the other 10 (non-responders). In responders the mean n10 amplitude on the affected side increased from 12 ± 6.5 µV at baseline (before the treatment) to 15.9 ± 7.1 µV at 1 week after treatment; this increase was significantly (p = 0.001) higher in responders than in non-responders. cVEMP did not differ significantly.

[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.

An update on vestibular physical therapy

Vestibular physical therapy is a specialized exercise based intervention for management of symptoms associated with vestibular dysfunction that manifests itself as dizziness and imbalance related to position or movement of the body. The aim of this review is to evaluate and summarize the efficacy of vestibular physical therapy for the treatment of vestibular disorders. A literature review was conducted to identify references related to vestibular disorders plus rehabilitation. Articles ranged from descriptions of vestibular dysfunction, its diagnosis, treatment, and rehabilitation in various populations. Case studies, case series with no controls, and controlled studies support the use of vestibular rehabilitation physical therapy for persons with peripheral vestibular disorders. There are emerging data that support vestibular rehabilitation physical therapy for persons with central vestibular disorders.

Falls and dizziness in the elderly

The complaint of dizziness is one of the most common reasons that older adults feel constrained to visit the doctor's office. Because of a growing number of older people in the industrial society the problem grows. Therapeutic process of elderly people with vertigo and dizziness needs more than vestibular diagnostics. In addition to sufficient anamnesis, presence of visual deficits, extrasensory changes and even psychological circumstances are necessary. Frequently the indication and the encouragement of vestibular rehabilitation have significant value. The initiation of fall prevention may also be essential.

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 the canalith repositioning procedure on subjective visual horizontal in patients with posterior canal benign paroxysmal positional vertigo

CONCLUSION

Substantial numbers of patients with posterior canal benign paroxysmal positional vertigo (p-BPPV) have signs of utricular dysfunction at baseline. This improves after performing the canalith repositioning procedure.

OBJECTIVE

To evaluate the changes of subjective visual horizontal (SVH) in patients with p-BPPV before and after treatment with the canalith repositioning procedure.

METHODS

Twenty-six patients with p-BPPV were treated with the canalith repositioning procedure, Epley's maneuver, according to the affected side. Baseline SVH measurements were taken before performing the Dix-Hallpike maneuver and Epley's maneuver, for comparison with measurements taken just after Epley's maneuver, and 2 weeks after Epley's maneuver.

RESULTS

Among 26 patients with p-BPPV, 11 (42%) showed abnormal deviation of SVH at baseline. Just after performing Epley's maneuver, the number of patients who showed an abnormal deviation of SVH decreased significantly to 15% (4 of 26 patients; p < 0.05). Two weeks after performing Epley's maneuver, only two patients (8%) showed an abnormal deviation of SVH (p < 0.001).

Positional nystagmus of horizontal canalolithiasis

CONCLUSION

Vertical and torsional components occur from the horizontal semicircular canal, and the response to ampullopetal flow is greater than that to ampullofugal flow in every component.

OBJECTIVES

To clarify whether positional nystagmus of horizontal canalolithiasis contains vertical and torsional components, and to quantify the asymmetry of nystagmus.

METHODS

Twenty patients with transient direction-changing geotropic positional nystagmus were examined, and we performed three-dimensional video-oculography and measured the maximum slow-phase velocity (MSV) of three components.

RESULTS

Positional nystagmus was not purely horizontal. Fifteen (75%) patients revealed a vertical component and 19 (95%) patients had a torsional component. The mean value of MSV of the horizontal component in the affected-ear-down position was 51.5°/s and that in the healthy-ear-down position was 19.1°/s. The mean value of MSV of the vertical component in the affected-ear-down position was 8.7°/s and that in the healthy-ear-down position was 3.0°/s. The mean value of MSV of the torsional component in the affected-ear-down position was 12.8°/s and that in the healthy-ear-down position was 6.5°/s. For every component, MSV in the affected-ear-down position was significantly greater than that in the healthy-ear-down position (p < 0.01).

[Computerized methods for therapy and rehabilitation of patients suffering dizziness and balance disorder]

A new computerized method is proposed for correction and inhibition of unfavorable illusory (vertigo), vestibular-oculomotor (nystagmus), and vestibular-postural (balance) responses. This method allows to teach the subject to block generalization of an afferent signal to effector mechanisms of the central nervous system by developing a fixational reflex, utilizing a delayed biofeedback. Three variant ofthis method were employed, depending on the kind of stimulation programs aimed at inducing abnormal responses of a certain sensory modality (visual, vestibular or combined). The study involved 36 subjects divided into 3 equal groups one of which had been taught by a visual or vestibular technique, and the last one by a combined. Each group included approximately equal numbers of subjects with vestibulopathies of an organic (peripheral or central) or psychogenic origin. It was demonstrated that the method proposed allows, with the help of computerized stimulation programs, to provoce abnormal illusory and vestibular-optooculomotor responses in the subject, and inhibit them with the help of development of a fixational reflex. Patients were taught using three various variants of the method. A subsequent comparative analysis of results obtained has shown dependence of their effectiveness on the level of disturbance in the vestibular system: the visual variant of correction was the most effective for subjects with peripheral vestibulopathia; for subjects with central vestibulopathia, the vestibular variant was more effective; the combined variant of correction was the most effective for subjects with psychogenic vestibulopathia.

[Clinical value of dynamic posturography in the evaluation and rehabilitation of vestibular function of patients with benign paroxysmal positional vertigo]

OBJECTIVE

To explore the clinical value of dynamic posturography in the evaluation and rehabilitation of vestibular function of patients with benign paroxysmal positional vertigo (BPPV).

METHODS

A total of 48 patients with BPPV of posterior semicircular canal in vertigo clinic of our hospital from May 2007 to December 2008 were retrospectively analyzed in this study. All patients underwent the inspection of caloric test, static posturography, and dynamic posturography. The vestibular tests were performed at two different time points: at onset when patients had typical nystagmus provoked by the Dix-Hallpike maneuver before treatment with the Epley maneuver (canalith repositioning maneuver, CRM), and at one week after treatment with CRM as their nystagmus disappeared. And results at theses two time points were compared. Eight patients whose dynamic balances were still abnormal after CRM accepted vestibular rehabilitation exercise using dynamic posturography, and re-examined 3 weeks later with dynamic posturography.

RESULTS

Among 48 cases of BPPV, the abnormal rates of caloric test, static posturography, and dynamic posturography before CRM were 25.0%, 33.3% and 70.8%, respectively. The abnormal rate of dynamic posturography was much higher than that of caloric test or static posturography, and the differences were statistically significant (χ² = 4.84, 7.88; P < 0.05). After CRM, the abnormal rates of caloric test, static posturography, and dynamic posturography were 14.6%, 8.3% and 16.7%, respectively. After CRM, the abnormal rate of static and dynamic posturography showed significant reduction (χ² = 24.04, 10.08; P < 0.05), however, the results of caloric test showed no significant change (χ² = 3.20, P > 0.05). Eight patients whose dynamic balances were still abnormal after CRM, accepted vestibular rehabilitation exercise lasting 3 weeks using dynamic posturography. The dynamic balances were all improved to normal after vestibular rehabilitation.

CONCLUSIONS

Dynamic posturography can quantitatively analyze postural balance, and is helpful in comprehensive evaluation of the vestibular function of BPPV patients. Impaired balance often presents in patients with BPPV. Treatment of BPPV using the canalith repositioning maneuver results in improved postural stability in static and dynamic posturography. However, not all patients have normal dynamic stability after successful CRM. The vestibular rehabilitation exercise using dynamic posturography is a helpful adjunct to the treatment for these patients.

Assessing vestibular dysfunction. Exploring treatments of a complex condition

In summary, patients with BPPV can be treated with the canalith repositioning maneuver. Patients with unilateral vestibular hypofunction can be treated using adaptation, substitution, and/or habituation exercises. Patients with motion sensitivity can demonstrate improved tolerance to motion after performing habituation exercises. Patients with bilateral vestibular loss will benefit from substitution and adaptation exercises. Each patient requires a treatment regime that is individualized and appropriate to address their impairments. Often the treatment is determined through the evaluation process. The task that causes the patient's complaints, whether it be dizziness, imbalance, and/or issues with eye-head coordination, often becomes the treatment of choice, gradually increasing difficulty as appropriate and safe. Patients with TBI who have concomitant vestibular dysfunction are a challenging population to treat. One has to be cognizant of cognitive deficits that may interfere with or prolong treatment as well as the many other neurological deficits that may be present because of the brain injury. For example, attempting to perform the canalith repositioning maneuver on a patient status post TBI when they are not able to comprehend the reasoning behind the treatment can lead to agitation or behavioral issues. Communication with the patient's primary doctor is a necessity so that the team is always on the same page about the approach to treatment. Vestibular evaluation and rehabilitation are a necessity for patients who have experienced a TBI. The sooner the problems are identified, the sooner treatment can be initiated with the goal of helping patients recover their maximal functional level of independence and safety. Also, treating patients with TBI and vestibular impairments can require increased treatment time in comparison to treatment of a patient with only vestibular dysfunction, so the sooner the treatment for vestibular dysfunction can be started, the better for the patient with TBI.

Does vertigo disappear only by rolling over? Rehabilitation for benign paroxysmal positional vertigo

CONCLUSION

We propose that the rolling-over maneuver (ROM) is as effective as the canalith repositioning maneuver (CRP) for the treatment of benign paroxysmal positional vertigo (BPPV). ROM involves easy movements, with only a small load. This therapy is suitable for most BPPV patients, even for those without an indication for CRP.

OBJECTIVES

BPPV is a common vestibular disorder. CRP is known to be an effective therapy for the treatment of BPPV. Because of its various movements of the head and body, it is impossible to perform CRP in BPPV patients with orthopedic impairments or in the elderly. For these patients, we perform a maneuver called ROM, which involves easy movements. In this study, we compared the efficacy of ROM with that of CRP in patients with posterior semicircular canal-type BPPV.

PATIENTS AND METHODS

The study included 22 patients with BPPV who were randomized and divided into the following 2 groups: 1) those treated by the modified Epley maneuver as CRP; and 2) those treated by ROM.

RESULTS

We found no significant difference between the two groups in the number of days from onset to remission of both nystagmus and vertigo.

Clinical benefits to vestibular rehabilitation in multiple sclerosis. Report of 4 cases

BACKGROUND

Balance difficulties are common among multiple sclerosis patients.

OBJECTIVE

To evaluate the effectiveness of the Cawthorne and Cooksey protocol of vestibular rehabilitation (VR) exercises in reducing the physical, functional and emotional impact of multiple sclerosis among individuals who complained of vertigo.

METHODS

Four patients with remittent-recurrent multiple sclerosis underwent an interview, otorhinolaryngological and vestibular evaluation, VR exercises and the Dizziness Handicap Inventory pre- and post-intervention.

RESULTS

There was significant improvement in the physical, functional and emotional aspects of the DHI after the completion of the VR.

CONCLUSION

The VR exercises appeared useful in reducing subjective complaints of the study participants.

Benign paroxysmal positional vertigo recurrence and persistence

Aim

Study design

Materials and Methods

Results

[Vertigo and falls in the elderly: Part 2: Fall diagnostics, prophylaxis and therapy]

In many acute or chronic vestibular diseases in old age, the risk of falling is increased. A fear of falling often develops together with further limitations to physical activity and subsequent physical and psychological consequences. Falls represent a substantial health-related risk factor. A regular balance, walking and muscle training is an effective prophylaxis. Components of the treatment of vestibular diseases in old age are counselling and encouragement (psychotherapy), treatment of the specific organic disease, specific vestibular rehabilitation and a symptomatic medication therapy. Vertigo in old age is a multifactorial process. The differential diagnosis of disorders of the equilibrium function in old age represents a challenge which can only be overcome by interdisciplinary cooperation.

Vertigo - part 2 - management in general practice

BACKGROUND

Vertigo is a common clinical problem managed by general practitioners.

OBJECTIVE

This article focuses on the acute management of a vertigo attack, specific management of conditions causing vertigo, and the long term management issues associated with chronic vertigo.

DISCUSSION

Supportive treatment, antiemetic and vestibular blocking agents help relieve an acute vertigo attack, however the prolonged use of such medications is not recommended. Specific treatments for various conditions causing vertigo are available, however, the majority of patients are managed symptomatically. The patient's ability to drive safely should be carefully assessed according to Austroads guidelines and advice from an ear, nose and throat surgeon should be sought when in doubt. There is evidence to support the efficacy of vestibular rehabilitation programs for unilateral peripheral vestibular disorder and these programs should be considered. A simple program including patient education and home based exercises can be sufficient.

[Vestibular rehabilitation of vertigo and dizziness]

THE AIM OF THE STUDY was to assess the effectiveness of kinesitherapy in vertigo and dizziness.

MATERIAL AND METHODS

One hundred thirty two patients with vertigo and dizziness, aged 19-71, treated by kinesitherapy and pharmacotherapy were examined. The control group consisted of 126 patients treated by pharmacotherapy alone. The effects of therapy were assessed by patients' self-control cards and electronystagmography (ENG) examinations.

CONCLUSION

Kinesitherapy is an effective complementary method of treating patients with vertigo and dizziness.

Vestibular rehabilitation outcomes in chronic vertiginous patients through computerized dynamic visual acuity and Gaze stabilization test

OBJECTIVE

To evaluate the efficiency of the rehabilitative protocols in patients with labyrinthine hypofunction, focusing on computerized dynamic visual acuity test (DVAt) and Gaze stabilization test (GST) specifically evaluating the vestibulo-oculomotor reflex (VOR) changes due to vestibular rehabilitation.

DESIGN

Consecutive sample study.

SETTING

Day hospital in Ears, Nose, and Throat Rehabilitation Unit.

SUBJECTS

Thirty-two patients with chronic dizziness with a mean age of 60.74 years.

INTERVENTION

Patients performed one cycle of 12 daily rehabilitation sessions (2 h each) consisting of exercises aimed at improving VOR gain. The rehabilitation program included substitutional and/or habitudinal exercises, exercises on a stability platform, and exercises on a moving footpath with rehabilitative software.

MAIN MEASURES

Dizziness Handicap Inventory and Activities-specific Balance Confidence Scale. Computerized dynamic posturography, computerized DVAt, and GST.

RESULTS

The patients significantly improved in all the tests.

CONCLUSION

Vestibular rehabilitation improved the quality of life by reducing the handicap index and improving the ability in everyday tasks. The recovery of the vestibular-ocular reflex and vestibular-spinal reflex efficiency was objectively proven by instrumental testing. The DVAt and the GST allow to objectively quantify the fixation ability at higher frequencies and speeds (main VOR function). Moreover, these new parameters permit to completely evaluate vestibular rehabilitation outcomes, adding new information to the generally used tests that only assess vestibulospinal reflex.

Body balance in patients with systemic vertigo after rehabilitation exercise

The aim of this paper was to characterize structural balance of the body in people with systemic vertigo after applying rehabilitation exercise, such as motor-visual coordination on a posturographic platform and balance exercise. Physiotherapeutic procedures were carried out in a group of 12 people, aged 25-60 years suffering from vertigo. The evaluation of body balance in the standing position was performed by means of recording of postural sways based on force-plate posturography. The examination was performed before and after the rehabilitation program. Standard tests were done, with eyes open, eyes closed, and with conscious visual control-biofeedback. Patients with vertigo underwent a month-long therapy, which included: exercise of motor-visual coordination on a posturographic platform and balance exercise, which consisted of repeated visual, vestibular, and somatosensory stimulation for conscious postural control. The rehabilitation program resulted in a decrease of the range of sways, improved visuomotor coordination and thus also improved balance.

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 Exercises in Acute Vertigo

OBJECTIVES/HYPOTHESIS

To evaluate the effect of vestibular rehabilitation exercises in the early stages of peripheral vestibular disorders.

STUDY DESIGN

Prospective, randomized trial. Patients were blinded to assignment groups.

METHODS

The study group (45 patients) performed exercises for adaptation of the vestibulo-ocular reflex; the control group (42 patients) performed placebo exercises. Both groups were instructed to use dimenhydrinate (up to 150 mg/d) if symptomatic, irrespective of exercises. Patients were evaluated by visual analogue scale, physical examination, and need to use the medication. All patients were adults and symptomatic for less than 5 days.

RESULTS

The study and control groups were comparable in terms of demographics data and duration and intensity of symptoms. Study group patients recovered faster than controls and used less medication. By 10 to 14 days after the intervention, 43% of study group and 5% of control group patients had no significant symptoms (P < .001), and 67% of study group and 3% of control group patients needed no medication (P < .001). Although both groups had no significant symptoms by the end of the follow-up period (21 days), 14% of the study group patients were still using medication, compared with 83% of the placebo group patients (P < .001).

CONCLUSIONS

Vestibular exercises are effective in reducing the duration of symptoms and the need of medication of patients in the early stages of peripheral vestibular disorders.

The effectiveness of wedge shoes in patients with insufficient vestibular compensation

OBJECTIVES

Patients who fail to achieve sufficient vestibular compensation after acute vestibular deafferentation show a tendency to deviate toward the affected side. This study evaluated the effectiveness of wedge shoes specially manufactured with a 4mm inclination on the affected side to patients with chronic vestibular insufficiency.

METHODS

Subjects comprised 13 patients with chronic vestibular insufficiency for >6 months after acute unilateral vestibular dysfunction and 9 healthy volunteers. Subjects underwent vestibular tests wearing wedge shoes and regular shoes. Differences in results were compared.

RESULTS

Patients showed significant improvements in the straight gait test (p<0.01), Unterberger-Fukuda stepping test (p<0.01) and posturography test (p=0.015) when wearing wedge shoes compared with wearing regular shoes.

CONCLUSION

Our results suggested that raising the lateral sole of shoes on the affected side could effectively ameliorate the effects of chronic vestibular insufficiency.

Implementation of nurse-delivered vestibular rehabilitation in primary care: a qualitative study of nurses? views on involvement in an innovative service

AIM

To explore practice nurses' perceptions of vestibular rehabilitation and its place in relation to their general role development.

BACKGROUND

Vestibular rehabilitation has been known for a long time to be effective for chronically dizzy patients in secondary care, but its use in primary care has been limited. A recent pragmatic trial of vestibular rehabilitation delivered by practice nurses in primary care has confirmed its utility in a community setting. This type of role is increasingly common for practice nurses, but few studies explore the nurses' perspective.

METHODS

A qualitative study was undertaken; 19 nurses took part in focus group sessions. Participants discussed their views on vestibular rehabilitation and its potential for integration with their existing role. A thematic analysis of the data was undertaken.

FINDINGS

Four main themes were identified: creating a unique nursing role; the therapeutic role; responsibility and role boundaries; and time. Nurses were positive about developing extended roles, but sought ways to achieve this without eroding fundamental nursing skills. Vestibular rehabilitation was seen as fulfilling both the need for a distinct nursing identity and professional development. Concerns over responsibility for patient assessment and time management constraints are potential obstacles to overcome in the wider development of this therapy in primary care.

CONCLUSIONS

Understanding the perspective of nurses will be vital in future development of chronic disease management within primary care. Whilst nurses may be positive about such role expansion, the implementation of services of this type will require clarity about nurses' responsibilities and flexibility in managing workload.

RELEVANCE TO CLINICAL PRACTICE

Vestibular rehabilitation is simple, low-tech and appropriate for widespread development in primary care. Nurses wishing to provide vestibular rehabilitation or similar chronic disease management activities will need to work with medical colleagues to define role boundaries.

Laboratory-free measurement of gait rhythmicity in the assessment of the degree of impairment and the effectiveness of rehabilitation in patients with vertigo resulting from vestibular hypofunction

A portable system for measurement of stride time rhythmicity was developed using the technique of Hausdorff et al (2001a Arch. Phys. Med. Rehabil. 82 1050-6). Measurement was performed for an extended period of walking of 256 steps for each foot outside of the laboratory on 18 normal individuals and 20 patients referred with symptomatic vestibular impairment. Ten of the patients were reassessed following vestibular therapy. Gait rhythmicity measured by standard deviation (SD) stride time was found to be significantly higher in patients with vestibular impairment than in normal volunteers (mean +/- SD 60.3 +/- 39.8 ms versus 21.9 +/- 4.9 ms respectively, P < 0.001, t-test). The ten patients who returned following a course of vestibular rehabilitation displayed significant improvement in SD stride time following therapy (mean +/- SD 57.3 +/- 44.6 ms prior to and 40.9 +/- 23 ms following therapy, P = 0.01, Wilcoxon signed rank test). Gait rhythmicity measurement, specifically measurement of stride time variability, appears to be a powerful assessment tool for objective measurement of extent of impairment and response to therapy in patients with vestibular hypofunction.

[Vertigo and dizziness]

Dizziness ranks among the most common complaints in medicine, affecting approximately 20% to 30% of the general population. However, the term dizziness encompasses a variety of different sensations each points in distinct diagnostic direction: rotational vertigo or other illusory sensation of motion indicates vestibular origin, whereas a sensation of light-headedness, giddiness, unsteadiness, drowsiness, or impending faint implies nonvestibular origin. Of patients older than 60 years, 20% have experienced dizziness severe enough to affect their daily activities. This article gives an overview of the historical and physical findings that help guiding to more specific diagnosis of vertigo and dizziness.

Diagnosing and treating benign paroxysmal positional vertigo

Gerontological nurses play a critical role in the early recognition of benign paroxysmal positional vertigo (BPPV), a condition that accounts for approximately 50% of vertigo in older adults. BPPV results in vertigo when debris collects in one or more of the semicircular canals, most typically the posterior canal. It may be differentiated from other forms of vertigo because it results in dizziness when recumbent or with head position changes. BPPV may be successfully treated with repositioning therapy, such as the Epley maneuver. Nurses working in medical offices, longterm care facilities, and assisted living may be called on to perform this maneuver. Gerontological nurses play a key role in assessing and treating BPPV, therefore minimizing unnecessary testing and medication and reducing the suffering and expense for patients with this condition.

Posttraumatic balance disorders

Head trauma is being more frequently recognized as a causative agent in balance disorders. Most of the published literature examining traumatic brain injury (TBI) after head trauma has focused on short-term prognostic indicators and neurocognitive disorders. Few data are available to guide those individuals who see patients with balance disorders secondary to TBI. Our group has previously examined balance disorders after mild head trauma. In this study, we study all classes of head trauma. We provide a classification system that is useful in the diagnosis and management of balance disorders after head trauma and we examine treatment outcomes. As dizziness is one of the most common outcomes of TBI, it is essential that those who study and treat dizziness be familiar with this subject.

Benign Paroxysmal Positioning Vertigo: A Disease Explainable by Inner Ear Mechanics

Many arguments give evidence that benign paroxysmal positioning vertigo, one of the most frequent kinds of vertigo, can be reduced to mechanical processes in the vestibular part of the labyrinth. Based on the assumption that otoliths have departed from their normally fixed position in the otolithic membrane and travel in the semicircular canals, clinical observations find their explanation. Latency between the onset of a head movement and the beginning of the vertiginous sensation, its duration and the nystagmic pattern provoked by specific head movements are in good correlation with the canalith hypothesis. Further arguments are the successful treatment by liberatory maneuvers, the relatively high number of recurrences and the change of the affected canal.

Evaluation of booklet-based self-management of symptoms in Ménière disease: a randomized controlled trial

OBJECTIVE

This study examined the effectiveness of booklet-based education in vestibular rehabilitation (VR) and symptom control (SC) techniques to manage vertigo and dizziness in Ménière disease.

METHODS

Participants (n = 360) were randomized to a waiting list control group or to receive either a VR or an SC self-management booklet. VR involved provoking dizziness in a controlled manner by making repeated head movements in order to promote neurological and psychological habituation. SC involved using applied relaxation, challenging negative beliefs, and lifestyle modification to reduce amplification of dizziness by anxiety. Subjective improvement in health, enablement (ability to understand and cope with symptoms), and adherence were measured at 3 and 6 months. Symptoms, handicap, anxiety and depression, and negative beliefs about symptoms were assessed pretreatment and at 3 and 6 months.

RESULTS

At 6-month follow-up, 45 (37.5%) of the VR group and 47 (39.2%) of the SC group reported improvement compared with 19 (15.8%) controls; the relative probability of improvement compared with controls was 2.37 (95% confidence interval [CI], 1.48-3.80) for VR and 2.47 (95% CI, 1.55-3.95) for SC. Both intervention groups reported greater enablement than controls (p < .001, d > 0.70). At 3 months, the VR group had reduced symptoms, anxiety, handicap, and negative beliefs about dizziness; the SC group had reduced handicap; but the control group showed no improvement. Reported adherence levels were low and strongly related to outcome.

CONCLUSIONS

Self-management booklets offer an inexpensive and easily disseminated means of helping people with Ménière disease to cope with dizziness symptoms.

Efficacy of Postural Restriction in Treating Benign Paroxysmal Positional Vertigo

OBJECTIVE

To investigate the efficacy of postural restriction after canalith repositioning in treating benign paroxysmal positional vertigo (BPPV).

DESIGN

Prospective trial of patients with postural restriction vs those without postural restriction after treatment.

PATIENTS

Patients with classic BPPV and with BPPV without nystagmus were treated using the modified Epley canalith repositioning procedure. Patients were randomly separated into 2 groups. The first group was instructed to wear a cervical collar and to maintain an upright head position for 2 days. The second group had no motion restriction. After 5 days, the patients were followed up and evaluated using the Dix-Hallpike test.

RESULTS

In the first group, 56 of 62 ears healed after the first maneuver, and the remaining ears healed after the second. In the second group, 45 of 57 ears healed after the first maneuver, 6 after the second, and 5 (with subsequent postural restriction) after the third (1 ear did not improve). Five patients in the first group and 3 patients in the second group had BPPV without nystagmus; all of these patients healed after a single maneuver. The difference between the 2 groups in the number of maneuvers required for treatment was statistically significant (P<.05). The number of patients who required a third maneuver was significantly higher in the second group (P<.05).

CONCLUSIONS

Postural restriction enhances the therapeutic effect of canalith repositioning in the treatment of posterior semicircular canal BPPV. The long-term efficacy of postural restriction in preventing BPPV recurrence has not been demonstrated.

Rehabilitation exercise for treatment of vestibular disorder: a case study

Vertigo and dizziness are common symptoms in the general population. While the clinical picture is well known and widely described, there are different interpretations of Benign Paroxysmal Positional Vertigo. The purpose of this case report was to describe the treatment of a 56 year old woman with complains of positional vertigo for 35 consecutive years. She suffered from a sudden onset of rotatory, unilateral horizontal canal type benign paroxysmal positional vertigo (BPPV). The symtoms started a day after falling from a bus, where she injured her head. Otherwise her medical history was unremarkable. She was treated with an individualized home exercise program of eye movement exercises, Brandt/Daroff exercises, and general conditioning exercises (i.e., laying on the left side from sitting on the bed, while the head rotated 45 degrees to the right, waiting for about one minue; twice a day on gradual basis, not laying on the side all the way, but to use enough pillows to lay about at 60 degrees). Four weeks from the start of physical therapy, the patient was free of symptoms, even when her neck was in the extended position.

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.

Improvement of postural control in patients with peripheral vestibulopathy

We present here the results of a short-term prospective study on a group of 37 patients with persistent unsteadiness. The treatment of these patients was customized according to the results of the Sensory Organization Test carried out using computerized dynamic posturography. A 5-week period of instrumental rehabilitation was established involving visual biofeedback-based computerized balance intervention that manipulated the individuals' capacities, the goals of the tasks and the environmental context. Exercises were performed twice weekly. This adaptation of the treatment was based on the hypothesis that it would reduce the level of disability and handicap associated with the unsteadiness suffered by these patients. Of the patients, 73% improved their status according to the DHI results. Furthermore, in the group of patients that showed an improvement in the DHI, their SOT composite score increased significantly, their reaction time reduced and their sway velocity, endpoint excursion, maximum excursion and directional control all increased. However, for those patients who did not experience a significant improvement or who recorded an increase in the total DHI score, the modifications in the SOT and LOS tests were not significant.