Effectiveness of Otolith Repositioning Maneuvers and Vestibular Rehabilitation exercises in elderly people with Benign Paroxysmal Positional Vertigo: a systematic review

Ribeiro, Karyna Figueiredo; Oliveira, Bruna Steffeni; Freitas, Raysa V.; Ferreira, Lidiane M.; Deshpande, Nandini; Guerra, Ricardo O.

doi:10.1016/j.bjorl.2017.06.003

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Brazilian Journal of Otorhinolaryngology

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Review articles • Braz. j. otorhinolaryngol. 84 (1) • Jan-Feb 2018 • https://doi.org/10.1016/j.bjorl.2017.06.003 copy

Effectiveness of Otolith Repositioning Maneuvers and Vestibular Rehabilitation exercises in elderly people with Benign Paroxysmal Positional Vertigo: a systematic review^☆ ☆ Please cite this article as: Ribeiro KF, Oliveira BS, Freitas RV, Ferreira LM, Deshpande N, Guerra RO. Effectiveness of Otolith Repositioning Maneuvers and Vestibular Rehabilitation exercises in elderly people with Benign Paroxysmal Positional Vertigo: a systematic review. Braz J Otorhinolaryngol. 2018;84:109-18.

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Abstract

Introduction

Benign Paroxysmal Positional Vertigo is highly prevalent in elderly people. This condition is related to vertigo, hearing loss, tinnitus, poor balance, gait disturbance, and an increase in risk of falls, leading to postural changes and quality of life decreasing.

Objective

To evaluate the outcomes obtained by clinical trials on the effectiveness of Otolith Repositioning Maneuver and Vestibular Rehabilitation exercises in the treatment of Benign Paroxysmal Positional Vertigo in elderly.

Methods

The literature research was performed using PubMed, Scopus, Web of Science and PEDro databases, and included randomized controlled clinical trials in English, Spanish and Portuguese, published during January 2000 to August 2016. The methodological quality of the studies was assessed by PEDro score and the outcomes analysis was done by critical revision of content.

Results

Six studies were fully reviewed. The average age of participants ranged between 67.2 and 74.5 years. The articles were classified from 2 to 7/10 through the PEDro score. The main outcome measures analyzed were vertigo, positional nystagmus and postural balance. Additionally, the number of maneuvers necessary for remission of the symptoms, the quality of life, and the functionality were also assessed. The majority of the clinical trials used Otolith Repositioning Maneuver (n = 5) and 3 articles performed Vestibular Rehabilitation exercises in addition to Otolith Repositioning Maneuver or pharmacotherapy. One study showed that the addition of movement restrictions after maneuver did not influence the outcomes.

Conclusion

There was a trend of improvement in Benign Paroxysmal Positional Vertigo symptomatology in elderly patients who underwent Otolith Repositioning Maneuver. There is sparse evidence from methodologically robust clinical trials that examined the effects of Otolith Repositioning Maneuver and Vestibular Rehabilitation exercises for treating Benign Paroxysmal Positional Vertigo in the elderly. Randomized controlled clinical trials with comprehensive assessment of symptoms, quality of life, function and long-term follow up are warranted.

KEYWORDS
Benign Paroxysmal Positional Vertigo; Elderly; Vertigo; Dizziness; Rehabilitation

Author Year Country	Sample	Age (mean-median) in years	Outcome measures	Intervention	Results
Angeli et al. (2003) United States^(PEDro: ^4/10)	EG: 28 CG: 19 PC-BPPV	EG: 74.5 ± 4.5 CG: 74.2 ± 3.4	(1) Vertigo: - Reported during Dix-Hallpike test (2) Positional nystagmus: - Electronystagmo-graphy during Dix-Hallpike test.	1st Phase: - EG: ORM (Epley maneuver); CG: no intervention. Number of maneuvers: 1-3. Follow-up: 1 month. 2nd Phase: - CG: Participants in CG who did not achieve spontaneous remission of symptoms received ORM (after 1 month). - The participants from both groups who did not get remission of symptoms, underwent a supervised VR exercises program. VR frequency: 2 or 3 times a week. Follow-up: 4-6 weeks.	1st Phase: - 64% of patients from EG obtained negative Dix-Hallpike test (no vertigo or nystagmus) compared to only 5% in CG (p < 0.001). There was no difference in cure rate between the CG subgroup and the experimental group after maneuver performance (p = 0.553). 2nd Phase: - 18 patients received personalized VR. Seven patients had total remission of symptoms and/or nystagmus (negative Dix-Hallpike), 6 continued to present a positive test and 5 did not conclude the study. - At the end, 77% of patients obtained success in treatment.
Resende et al. (2003) Brazil^(PEDro: ^4/10)	EG: 8 CG: 8 Did not specify the canal	EG: 70.5 (61-82) CG: 69.3 (60-78)	(1) Functionality (VDADL)	EG: Cawthorne and Cooksey exercises protocol and pharmacotherapy (Gingko-Biloba-40 mg de 12/12 h); VR frequency: 2 sessions a week, during 5 weeks. CG: Pharmacotherapy. Follow-up: 5 weeks (EG) and 30 days (CG).	Significant decrease in VDADL scores in EG (p < 0.01). There were no differences in the final score of VDADL in CG compared to pre-treatment phase. Significant benefit to EG compared to CG (p < 0.009).
Salvinelli et al. (2004) United Kingdom^(PEDro: ^4/10)	G1: 52 G2: 52 G3: 52 PC-BPPV	G1: 73 (70-78) G2: 74.5 (71-80) G3: 75 (72-79)	(1) Vertigo: - Reported during Dix-Hallpike test (2) Functionality (VDADL)	- G1: ORM (SLM). Number of maneuvers: 1-3 consecutive maneuvers per week until symptom resolution. - G2: Calcium antagonists (10 mg/d of Flunarizine before sleeping for 60 days); - G3: no treatment. Follow-up: 6 months after the end of each treatment.	- G1: 94.2% of vertigo remission after 3 maneuvers and 3.8% of recurrence in 6 months. - G2: 57.7% of symptoms remission; 5.8% of recurrence in 6 months; - G3: 34.6% had spontaneous remission of symptoms; 21.1% of recurrence in 6 months; - A statistically significant post-treatment improvement in activities of daily living and in quality of life was noticed (p < 0.001).
André et al. (2010) Brazil^(PEDro: ^2/10)	G1: 23 G2: 15 G3: 15 PC-BPPV Ductolithiasis	67.2 (60-91) Authors did not provide the median age by group	(1) Dix-Hallpike test; (2) Clinical aspects and symptoms: referred by Brazilian DHI questionnaire.	- G1: ORM (Epley maneuver) + neck brace + Postural restrictions for 48 hours after maneuver; - G2: ORM (Epley maneuver); - G3: ORM (Epley maneuver) + Mini vibrator Number of maneuvers: one per session until complete remission of vertigo. Follow up: time between evaluations was not informed.	- Number of maneuvers ranged from 1 to 3 in all groups. No difference was found between groups; - Statistically significant difference was observed in all aspects evaluated by DHI after treatment in all groups; - Significant improvement on physical aspects of G1 after treatment when compared to G2 (p = 0.009); - Independent of the procedure after maneuver the ORM was effective based on DHI score.
Ribeiro et al. (2016) Brazil ^(PEDro: ^7/10)	EG: 7 CG: 7 PC-BPPV	EG: 69 (65-78) CG: 73 (65-76)	(1) Dix-Hallpike test; (2) Vertigo-evaluated by VAS; (3) Number of maneuvers.	EG: ORM (Epley maneuver) + VR CG: ORM (Epley maneuver) Number of maneuvers: 1 to 3 per session. VR frequency: 2 times a week. Follow-up: 13 weeks	- The median for the number of comorbidities in the EG was 4 (3-6) and 4 (2-6) in the CG, while the median number of drugs used was 3 (1-6) in the EG and 3 (3-7) in the CG. - The Dix-Hallpike test was negative for all seniors in the EG after 13 weeks, while the CG showed treatment failure in 28.6% patients. - There was significant improvement gradient, with a progressive decrease in the number of maneuvers necessary for the treatment in EG (p < 0.001). - The recurrence rate was higher, yet not statistically significant, in the CG in the 13 week period.
Ribeiro et al. (2016) Brazil^(PEDro: ^7/10)	EG: 7 CG: 7 Did not specify the canal	EG: 69 (65-78) CG: 73.5 (72-76)	(1) Postural balance-evaluated by computadorized posturography and DGI; (2) Vertigo-evaluated by VAS; (3) Quality of life-evaluated by DHI.	EG: ORM (Epley maneuver) + balance VR CG: ORM (Epley maneuver) Number of maneuvers: 1-3 per session. VR frequency: 2 times a week. Follow-up: 13 weeks	- No differences between groups were found regarding all standing balance aspects. However, there was a within group improvement in standing balance in all tests in experimental group. - Concerning dynamic balance, there were significant differences between groups in the majority of the tests. In within group comparisons, the experimental group's all dynamic balance parameters significantly improved. Conversely, no significant differences were found regarding dynamic balance in the control group. - There were no significant differences in dizziness symptoms and quality of life between groups. However, both groups showed intragroup significant improvement for both outcome measures.

	Angeli et al. 2003	Resende et al. 2003	Salvinelli et al. 2004	André et al. 2010	Ribeiro et al. 2016	Ribeiro et al. 2016
1. Eligibility criteria were specified	Yes	Yes	Yes	Yes	Yes	Yes
2. Subjects were randomly allocated to groups	Yes	Yes	No	Yes	Yes	Yes
3. Allocation was concealed	No	No	No	No	Yes	Yes
4. The groups were similar at baseline regarding the most important prognostic indicators	Yes	Yes	No	No	Yes	Yes
5. There was blinding of all subjects	No	No	No	No	No	No
6. There was blinding of all therapists who administered the therapy	No	No	No	No	No	No
7. There was blinding of all assessors who measured at least one key outcome	No	No	No	No	Yes	Yes
8. Measures of at least one key outcome were obtained from more than 85% of the subjects initially allocated to groups	Yes	No	Yes	No	Yes	Yes
9. All subjects for whom outcome measures were available received the treatment or control condition as allocated or, where this was not the case, data for at least one key outcome was analyzed by "intention to treat"	No	No	No	No	No	No
10. The results of between-group statistical comparisons are reported for at least one key outcome	Yes	Yes	Yes	Yes	Yes	Yes
11. The study provides both point measures and measures of variability for at least one key outcome	No	Yes	Yes	No	Yes	Yes
Score	4/10	4/10	3/10	2/10	7/10	7/10

Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Sede da Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico Facial, Av. Indianópolia, 1287, 04063-002 São Paulo/SP Brasil, Tel.: (0xx11) 5053-7500, Fax: (0xx11) 5053-7512 - São Paulo - SP - Brazil
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[1] * Corresponding author. E-mail:karynamy@hotmail.com (K.F. Ribeiro).