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Print version ISSN 1413-3555
Rev. bras. fisioter. vol.14 no.5 São Carlos Sept./Oct. 2010
Natalia A. RicciI; Mayra C. ArataniII; Flávia DonáIII; Camila MacedoIV; Heloísa H. CaovillaIV; Fernando F. GanançaIV
IDepartment of Physical Therapy, Universidade Federal de São Carlos (UFSCar), São Carlos (SP), Brazil
IIPost-graduate Program in Otorhinolaringology and Surgery from the Neck and Head, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil
IIIPost-graduate Program in Vestibular Rehabilitation and Social Inclusion, Universidade Bandeirante de São Paulo (UNIBAN), São Paulo (SP), Brazil
IVDepartment of Otorhinolaringology and Surgery from the Neck and Head, EPM, UNIFESP
OBJECTIVE: To summarize the results of clinical trials on vestibular rehabilitation (VR) in middle-aged and elderly people with vestibular disorders.
METHODS: A search for relevant trials was performed in the databases LILACS, EMBASE, MEDLINE, SciELO, Cochrane, ISI Web of Knowledge and virtual libraries of theses and dissertations. Randomized controlled trials published in the last 10 years and written in English, Portuguese or Spanish were included. The methodological quality of the studies was assessed by the PEDro scale. Results from the included studies were analyzed through a critical review of content.
RESULTS: Nine studies were included in the review. Four studies reported on participants aged over 40 years (middle-aged and elderly) and five studies consisted exclusively of elderly subjects (over 60 years). Findings of vestibular dysfunction were diverse and the most common complaints were body imbalance or postural instability (3 studies), and vertigo or dizziness (3 studies). The Visual Analogue Scale (VAS) was the most commonly used instrument to assess subjective perception of symptoms of vestibular dysfunction (4 studies). According to the PEDro scale, four studies were considered to be of good quality. The most common experimental intervention was the Cawthorne & Cooksey protocol (4 studies). For most outcome measures, the studies comparing VR with another type of intervention showed no differences between the groups after the therapy.
CONCLUSION: The studies included in this review provide evidence for the positive effects of VR in elderly and middle-aged adults with vestibular disturbances.
Key words: vestibular diseases; rehabilitation; older adults.
The maintenance of body balance depends on the harmonious interaction among the information generated by the sensory systems (visual, somatosensory and vestibular), the central nervous system (CNS) processing, and the proper execution by the motor system (neuromuscular). The integration of the sensory information by the CNS triggers reflexes such as the vestibulo-ocular reflex (VOR) and the vestibulo-spinal reflex, which act on visual field stabilization and maintenance of the standing posture during body and cephalic movements. In situations of sensory information conflict, specially due to vestibular dysfunction, the signs and symptoms of body balance impairment become frequent1,2 .
The complaining of vertigo or other types of dizziness in subjects with vestibular dysfunction are generally expressed as postural instability, increase in postural sway, reduction in the limits of stability, gait impairments, falls, and reduction in functional capacity2,3.
Dizziness is the sensation of impairment in body balance, while vertigo is a sensation of rotary-type spatial disorientation. Vertigo and other dizziness from vestibular origin are present in 5% to 10% of the world's population, representing the most common symptoms after the age of 65 years-old, and affecting 80% of the older adults attending geriatric outpatient settings4.
The dizziness in older adults is considered a multi-factorial geriatric syndrome originated from changes inherent to the aging process and/or from pathological conditions, that result in instability and greater predisposition to falls4. After the age of 40 years, it is possible to observe microscopic synaptic changes in the vestibular nerve; at the age of 50 years, there is an increase in the degeneration of the vestibular receptors in the ampullary crest of semicircular canals and macular region of saccule and utricle; at the age of 60 years, among several alterations, there is an increase in friction among the fibers of the vestibular nerve and a decrease in conduction velocity of the electrical stimuli in the vestibular nerve4.
Vestibular rehabilitation (VR) is a therapeutic tool used in patients with body balance disorders of vestibular origin. Its proposed action is based on central mechanisms of neuroplasticity, known as adaptation, habituation and substitution, aiming a vestibular compensation5. The aim of VR exercises is to improve the vestibule-visual interaction during cephalic movement and to increase static and dynamic postural stability in conditions that produce conflicting sensory information.
VR has a positive effect in improving static and dynamic balance, gait, self-confidence, quality of life, and in reducing symptoms of dizziness, anxiety and depression4,5. VR can promote complete healing in 30% of patients and improvement of different degrees in 85% of patients6. There are several protocols of VR described in the literature, and the most frequently used ones are those of Cawthorne & Cooksey, Herdman, Italian Association of Neuro-Otology, and Norré39. However, there is a paucity of information on the effectiveness of the various VR protocols in middle-aged and elderly adults, given the peculiarities of vestibular disorders in this population.
This systematic review aims to provide a summary of the evidence on the effects of VR in middle-aged and elderly people with vestibular disorders.
A literature search was conducted on November 2008 in the electronic databases LILACS, EMBASE, MEDLINE, SciELO, Cochrane Library, ISI Web of Knowledge, and in three virtual libraries of theses and dissertations (Universidade de São Paulo (USP), Universidade Estadual de Campinas (UNICAMP) e Universidade Estadual Paulista (UNESP). Potentially relevant studies were identified by the following search strategy: ("aged" OR "elderly" OR "middle aged" OR "older people") AND ("vestibular diseases" OR "vestibular disorder") AND ("vestibular rehabilitation" OR "exercises" OR "balance training" OR "balance exercises" OR "virtual reality rehabilitation" OR "rehabilitation"). The search was limited by language (English, Portuguese or Spanish) and by date of publication (from November 1998 to November 2008).
The records retrieved from the search strategy had their titles and abstracts screened for eligibility by two independent reviewers, according to the following inclusion criteria: (1) sample aged over 40 years; (2) participants with vestibular dysfunction; (3) random sampling; (4) experimental group consisting of VR and control group with no treatment/placebo or another type of active intervention; and (5) experimental intervention defined as stimulation exercises for restoration of vestibular and body balance function, through vestibular neuroplasticity. Studies not specifying the exact age range of the participants were excluded, as were studies investigating pharmacological interventions, or electrophysiological or repositioning maneuvers not associated with vestibular exercises.
After the screening of titles and abstracts, the full texts of potentially eligible studies were screened, and those meeting the inclusion criteria had the relevant data extracted using a standardized form that included the following items: sample characteristics, primary and secondary outcomes, trial design, characteristics of the interventions and effects of the interventions.
The primary outcomes were selected according to the practicality and clinical relevance in outpatient clinics and rehabilitation centers; these included the subjective evaluation of the intensity of dizziness and body imbalance, clinical tests to assess balance and gait, and questionnaires and/or scales for measuring the impact of vestibular disorders in activities of daily living. The secondary measures chosen were laboratory tests assessing body balance, gait and visual acuity, doppler ultrasound and scales used to assess symptoms secondary to vestibular disorders (e.g. depression and anxiety).
The PEDro scale was used to assess the methodological quality of the included studies. The PEDro scale consists of a list of 11 criteria on validity and interpretation of results of controlled trials7. The rating of the methodological quality is done by assigning one point for each criterion of quality that is fulfilled; the first criterion, which refers to the sample eligibility criteria, is not scored. The higher the score on the PEDro scale, the most appropriate the study design, and the greater the possibility of reproducing the data presented. PEDro's website lists the quality ratings of the trials included in their database.
The disagreements between reviewers in the early stages of selection and assessment of the studies were solved by consensus, with divergent issues resolved by a third reviewer. Results of the included studies were analyzed by critical review of content and confrontation with those of other publications on the subject.
One hundred and five studies were retrieved from the initial search strategy. After the title and abstract screening, 28 studies were identified as potentially eligible. However, after full text screening, 19 studies were excluded due to the following reasons: sample outside the pre-specified age range (n=14)8-21, lack of randomization (n=4)22-25, and sample with no complaints or vestibular disorders (n=1)26. Thus, nine randomized controlled trials were eligible for inclusion in this review and had their content critically analyzed. A synopsis of the main study characteristics and results of the included trials is shown on Table 1.
The sample sizes ranged from 1427 to 21528 subjects randomized to either VR or the control intervention. In four studies, participants aged over 40 years (middle-aged and elderly)27,29-31; in five studies, samples consisted exclusively of elderly subjects (over 60 years)28, 32-35. The samples were composed of participants from both genders, but with a predominance of women28,29,31,33-35. The data on vestibular dysfunction were variable among the studies, with the most common complaints being body imbalance or postural instability28,32,35, and dizziness or vertigo31,33,35. The topography of the vestibular dysfunction was rarely reported, with the most common being vestibular hypofunction27,29. To obtain the topographic diagnosis of the vestibular syndrome, studies employed electronystagmography29,30,32 and other tests such as tone threshold audiometry28,32 , rotatory chair test27,29,33, and the investigation of the brainstem electric response audiometry28. Diet was not controlled in any of the studies, and only one study27 restricted the use of anti-vertigo drugs during treatment with VR.
Primary outcomes: The subjective perception of vestibular dysfunction symptoms was assessed in the majority of the studies27,28,30-33,35, and the Visual Analogue Scale (VAS)27,31,32,35 was the instrument most commonly used for this purpose. Other frequently used outcomes included static28,30-33,35 and dynamic30,31,33,35 body balance. Functional scales that evaluate the impact of dizziness in activities of daily living and in quality of life were applied in four studies30,32-34, with the Dizziness Handicap Inventory (DHI) being the most commonly used30,33.
Secondary outcomes: The laboratory tests used in the studies were computerized posturography28,32,35 force platform for the assessment of gait29, computerized test of visual acuity27, and intracranial ultrasonography with doppler mapping28.
Trial design and methodological quality
All studies were clinical controlled trials, with random allocation of participants to study groups. The effectiveness of VR was analyzed by the change in outcomes (pre- to post-treatment) between the VR group and the no treatment or placebo groups27,28,30,31,33-35, or between the VR group and the other active treatment group29,32 . The studies from Vereecke et al.30 and from Hansson, Mansson and Håkansson31 conducted a follow-up analysis after the intervention period.
The assessment of the quality revealed that four studies (44%)27,30,33,35 were of good quality, and consequently yielded scientific evidence of higher level (Table 2).
The experimental intervention most commonly used was the VR protocol from Cawthorne & Cooksey28,32-34. In most studies, participants were instructed to perform home exercises, which were assisted by information leaflets27-30,33. In three studies27,28,30, the exercises were performed exclusively at home, from three30 to five27 times a day, and visits to guide the progression of treatment were made to the therapist weekly27, or every three weeks30. In the other studies28,29,33, home exercises complemented the therapy performed in the rehabilitation center. In most studies, exercises were performed in groups29,31,33-35 and were administered weekly29,33 or twice a week31,34,35. The total treatment duration varied between the minimum of five34 to the maximum of 20 weeks28,30.
Most studies compared the VR protocol with a control group formed by participants who did not perform any type of exercise28,30,31,33-35, or who performed placebo exercises27. In the study of McGibbon et al.29, the control group performed Tai Chi Chuan, and in the study of Simoceli, Bittar and Sznifer32 , the protocol of Tusa and Herdman was used for comparison with traditional VR.
Effects of Intervention
The studies that compared VR with other type of active intervention29,32 showed no difference between groups in most outcome measures after therapy. In the study of Simoceli, Bittar and Sznifer32 , the group that performed the protocol of Cawthorne & Cooksey (experimental) and the group that performed the protocol of Tusa and Herdman (control) for adaptation of the VOR showed improvements in VAS and in the functional scale, but no difference was found in the limits of stability measured by dynamic posturography after the interventions. In the study comparing VR exercises with Tai Chi Chuan29, there was also no evidence of significant between-group differences in the parameters of neuromuscular function and trunk stability after the interventions.
Considering the control group, the proposed intervention through home exercises27,30 showed higher gains in dynamic visual acuity27, Timed-Up-and-Go Test (TUGT)30 and Dynamic Gait Index (DGI)30, but no significant difference was found for the stabilization of VOR27, tandem gait30, static balance30 and DHI30.
In the study by Hansson, Mansson, and Håkansson31, in the follow-up period of three months, the intervention group remained with a significant improvement in the one leg stance test in comparison to the control group. Another study30 that examined the effects of VR six months and one year after the intervention found that both groups (experimental and control) reached their previous functional levels and maintained the gains obtained in the period. In the same study, the control group, which did not perform any exercise, showed functional values similar to those of the VR group after surgery for removal of acoustic neuroma. However, in the early stages, the recovery of elderly participants in the VR group was superior to that of participants in the control group.
Among the studies that used the protocol of Cawtorne & Cooksey, there was a significant improvement in the experimental group in DHI33, gait speed33, in the number of abnormal cases in posturography28, and in the scale of activities of daily living and vestibular disorders34. However, after the intervention, no between-group differences were found in the limits of stability32 , functional scale32 , VAS32 , doppler ultrasound of the internal carotid arteries28, tandem position33, or in the psycho-cognitive scales Vertigo Symptom Scale (VSS), Spielberger's Trait Anxiety Inventory (STAI- t) and Beck Depression Inventory (BDI)33.
Of the four studies27,31,32,35 that evaluated the symptoms of dizziness through the VAS, two32,35 found a significant improvement after intervention. Regarding static balance, there was an improvement in two31, 35 of the six studies28, 30-33,35 that examined this outcome; similarly, only two studies33,35 showed results favoring the experimental intervention in terms of gait29-31,33,35.
None of the studies included in this review reported adverse effects related to VR.
Randomized controlled trials evaluating the effects of VR are scarce in the literature, particularly in the middle-aged and elderly population. However, despite the shortage in numbers, the studies included in this review showed positive results in favor of VR regarding the outcomes postural control, functional capacity and quality of life in elderly and middle-aged adults with complaints or diagnosis of vestibular syndrome. However, the methodological differences among the included studies made it difficult to establish what is the best protocol, time of intervention, or other ideal parameters.
While four studies were found to be of adequate quality according to the PEDro scale, they did not present allocation concealment or blinding of participants, therapists and assessors. This can sometimes lead to biased results and thus the strength of the evidence coming from these studies is decreased. The study of Simoceli, Bittar and Sznifer32 had not been rated for quality at PEDro's website by the time this review was conducted, but the study shows methodological problems similar to those of the other included studies. Moreover, the sample size of some studies27,32,33,35 may have been insufficient to ensure the external validity of the results found. Due to the variability in assessments and interventions, it was not possible to perform a meta-analysis of the results.
The included studies generally reported on both middle-aged and elderly adults in order to enable a broader discussion on the effects of VR, since the structural and physiological changes in the vestibular system begin to emerge at the age of 40 years4. Several studies were excluded from this review because their samples consisted of a combination of youth, adult and senior participants. This fact reinforces the necessity of future studies with homogeneous samples, involving exclusively the elderly population, because this is a group with peculiar physical and functional characteristics.
The diversity of the inclusion criteria among the studies had limited their comparison. Grouping subjects by the topography of the vestibular syndrome can be uncertain, since elderly subjects may present normal caloric test, even in the presence of vestibular symptoms6. Additional tests, such as those assessing the brainstem electric response audiometry and tone threshold audiometry, do not characterize the vestibular disorders according to the functional aspects of body balance. Thus, these tests have little significance for clinical monitoring in the elderly population. In the other hand, the computerized posturography is used to quantify the postural control in upright stance in either static or dynamic. Thus, grouping elderly subjects according to a single cause of vestibular dysfunction can be challenging, since many of them may present multiple conditions leading to the manifestation of dizziness6. Despite these difficulties, working with homogeneous samples allows greater control of confounding factors that interfere with the evaluation of VR effectiveness. The proper identification of vestibular dysfunction and its causes is essential to implement the best type of treatment6.
It is estimated that in 20% of the elderly patients the vestibular dysfunction is due to vascular problems36. The main circulatory disorders that can cause impairment of the peripheral or central auditory and vestibular systems are hyper- or hypotension, heart failure, myocardial infarction, arrhythmia, hypersensitivity of the carotid sinus reflex, aortic stenosis and atherosclerosis36. One of the included studies28 used intracranial doppler ultrasound mapping and found a reduction in the blood flow of the internal carotid, ophthalmic and basilar arteries in elderly patients with complaints of chronic dizziness and body imbalance. The authors observed a significant increase in blood flow in the carotid artery after eight weeks of VR.
Among the outcomes investigated, the VAS was the instrument most commonly used to assess the subjective perception of patients regarding the intensity of dizziness31,35, oscillopsia27, postural instability35 and/or body imbalance27,28,32 . Other subjective instruments used to measure the impact of dizziness on quality of life and on activities of daily living in elderly people were the DHI30,33, Disability Index32 , VSS33 and the Vestibular Disorders Activities of Daily Living Scale34. The objective measures, such as balance tests, can reveal major limitations in performance. However, subjective measures consider the perception of the individual regarding the impact of symptoms that are difficult to quantify objectively, such as the impact of dizziness on everyday life.
The postural control was assessed through tests of static30,31,33,35 and dynamic30,31 balance, functional scales30, and computerized posturography28,32-35. The static balance tests (Romberg and its higher sensibility versions) are practical and can be easily applied, but they do not evaluate the functional aspects of body balance and mobility. The dynamic and functional tests, such as DGI and TUGT, were used in one of the studies30 and they evaluate the individual performance in tasks based on the basic and instrumental activities of daily living, as well as on characteristics of balance, gait and mobility. Although functional tests are useful for the delineation of functional prognosis, they have a limited role in determining muscle shortening or weakness, or lack of motor coordination, which are important signs for the planning of a personalized treatment. On the other hand, these signs can be assessed by computerized posturography performed during the laboratory evaluation of body balance. Among the outcomes evaluated in three studies28,32,35 using computerized posturography, stood out the limits of stability32 , the latency until the beginning of movement32 , the displacement of the center of pressure28,35 and the influence of sensory interaction on body balance28,35. The computerized posturography complements the conventional tests for the diagnosis of vestibular disorders, and it is important for an adequate clinical management, documentation and monitoring of treatments concerning body balance disorders30.
The literature is consistent in stating that individualized or group VR exercises, performed at the clinic and daily at home, minimize the sensory conflict in elderly patients with dizziness and body imbalance27-35. Age is not considered a limiting factor for the final response to treatment. A retrospective study observed a similarity in the effectiveness of individualized VR performed in young and elderly participants on the symptoms and quality of life37.
In the included studies, there was no comparison of effectiveness between individualized and group VR, or between home-based and clinic-based exercises. However, the most commonly used form of VR was the group VR28,29,31,33-35 and home exercises27-30,33. These strategies appear to be appropriate given the high demand and costs of providing health care to the elderly population. In a systematic review on the effects of VR in adults with unilateral peripheral vestibular dysfunction, rehabilitation protocols focusing on education and home-based exercises showed satisfactory results38. However, according to Herdman39, individualized VR exercises lead to the remission of symptoms in 85% of patients with vestibular disorders, while generic exercises lead to the complete resolution of symptoms in 64% of the cases.
The interventions used in most studies were the protocol of Cawthorne & Cooksey28,32-34, the adaptation exercises of Herdman39 and static and dynamic body balance exercises27,29-31,35. These interventions aim to promote visual stabilization during cephalic movements, to improve postural stability in situations where sensory conflicts arise, to minimize sensory sensitivity to cephalic movements, and to improve static and dynamic body balance. Among the studies that used the protocol of Cawthorne & Cooksey28,32 -34, there was a significant improvement in dynamic balance in relation to the control group, as observed in the posturography and in the scale of activities of daily living. No between-group differences were found in the outcomes limits of stability, tandem position, and psycho-cognitive scales or VAS. These results may be due to the fact that the Cawthorne & Cooksey protocol does not include exercises that address the proprioceptive information together with visual information, or the modification of the base of support and other sensorimotor components.
The duration and frequency of the exercise protocols were largely variable among the studies, precluding the elucidation of the optimal procedures for an effective VR protocol. However, after VR, most authors showed a reduction or remission of the symptoms of dizziness, oscillopsia or postural instability, and a gradual disappearance of the static and dynamic body imbalance.
The Tai Chi exercises used in McGibbon's study29 were effective according to the laboratory evaluation of gait in elderly people with vestibular hypofunction, when compared to VR. Tai Chi is a form of Chinese gymnastic of high adherence among the elderly, which is capable of increasing the gains in fitness, strength and balance, and of preventing falls in this population40, 41.
The somato-psychic consequences of dizziness caused by vestibular disorders may include anguish, anxiety and panic attacks, fear of going out alone, interference with daily life activities and feelings of being out of reality, depersonalization and depressive humor42 . One of the included studies showed that cognitive-behavioral therapy associated with VR significantly reduced the dizziness and improved quality of life in elderly participants with vestibular diseases, when compared to participants managed with VR only33.
This systematic review summarizes the evidence on the effects of VR for balance disorders and on the assessment tools that can contribute to support the clinical actions of health professionals working in this area. The studies presented here support the use of simple and costless protocols for the management of vestibular disorders in middle-aged and elderly people. However, further high-quality studies are still needed to clarify some doubts regarding the effects of VR for certain diseases, the optimal treatment duration necessary to avoid recurrence of symptoms, and the comparison with protocols of multi-components of postural control.
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Correspondence to: Received: 19/05/2009 – Revised: 13/10/2009 – Accepted: 12/12/2009
Natalia Aquaroni Ricci
Rua Pacaembu, 257 apto 602, Jardim Paulistano
CEP 18040-710, Sorocaba (SP), Brazil
Received: 19/05/2009 – Revised: 13/10/2009 – Accepted: 12/12/2009