Effects of vestibular rehabilitation in the elderly: a systematic review

Telerehabilitation: Vestibular Physiotherapy vs. Multicomponent Exercise for Functional Improvement in Older Adults: Randomized Clinical Trial

The loss of vestibular and motor function can occur naturally with aging. Vestibular physiotherapy exercises (VE) specifically address vestibular rehabilitation to reduce imbalances and improve physical condition, like therapeutic exercise (TE). During COVID-19, technology was used with the elderly for implementation. Objective: to determine if vestibular exercises are as effective as multicomponent exercises in improving functional capacity using technological tools. Methods: A randomized clinical trial compared two intervention groups of 21 subjects with functional limitations and frailty (average age 76.11 years). The intervention involved multicomponent exercise for the control group (Vivifrail protocol) and vestibular exercises for the experimental group (Cawthorne and Cooksey exercises) for 6 weeks with five sessions per week both groups. Two professionals implemented the exercises, and participants received tailored exercise videos. Primary outcomes were gait speed, dynamic balance, and physical capacity. Results: Both groups showed significant improvements. For physical function measured by SPPB (0-12 points), the multicomponent exercise group improved by 1.97 (0.91; 3.03), p < 0.001, and the vestibular exercise group improved by 1.63 (0.65; 2.60), p = 0.002. For dynamic balance measured by the Timed Up and Go (TUG) test, the multicomponent exercise group improved by -0.88 (-1.33; -0.42), p < 0.001, and the vestibular exercise group improved by -0.79 (-1.21; -0.37), p < 0.001. There were no significant differences between groups. Finally, regarding gait speed, there were no differences in either group between pretest and post-test (p > 0.05). Conclusions: Both multicomponent exercise and vestibular exercises improve functional capacities via telerehabilitation as measured by the SPPB, although vestibular physiotherapy does not show superior outcomes compared to the control group.

Effect of Vestibular Rehabilitation on Sleep Quality and Depression in the Elderly With Chronic Dizziness: A Prospective Study

BACKGROUND AND OBJECTIVES

Dizziness and the accompanying complaints, including sleep disorders and depression, are common among the elderly. This study investigated the effect of vestibular rehabilitation on complaints of dizziness, sleep problems, and the severity of depression in older people with chronic dizziness.

SUBJECTS AND METHODS

The study included 25 participants with chronic dizziness accompanied by comorbid sleep disturbance (Pittsburgh Sleep Quality Index [PSQI] global score >5). Participants completed the Dizziness Handicap Inventory (three sub-scales: physical, emotional, and functional), the PSQI, and the Persian version of the shortened Beck Depression Inventory (BDI-13) before and after the vestibular rehabilitation.

RESULTS

The findings showed that the handicap caused by dizziness, the severity of depression, and the quality of sleep in the study participants improved significantly after the intervention (p<0.05).

CONCLUSIONS

Vestibular rehabilitation is an effective intervention to reduce dizziness handicap, comorbid sleep disturbance, and depression.

Online vestibular rehabilitation for chronic vestibular syndrome: 36-month follow-up of a randomised controlled trial in general practice

BACKGROUND

Vestibular rehabilitation (VR) is the preferred treatment for chronic vestibular symptoms such as dizziness and vertigo. An internet-based programme was developed to increase uptake of VR. The authors have previously reported that internet-based VR resulted in a clinically relevant decrease of vestibular symptoms for up to 6 months, compared with usual care.

AIM

To evaluate long-term outcomes of internet-based VR in patients with chronic vestibular syndrome.

DESIGN AND SETTING

A randomised controlled trial was conducted in Dutch general practice involving 322 participants aged ≥50 years with chronic vestibular syndrome. Participants were randomised to stand-alone VR, blended VR (with physiotherapy support), and usual care. Usual care participants were allowed to cross over to stand-alone VR 6 months after randomisation.

METHOD

Participants were approached 36 months after randomisation. The primary outcome was the presence of vestibular symptoms as measured by the vertigo symptom scale-short form (VSS-SF). Secondary outcomes were dizziness-related impairment, anxiety, depressive symptoms, and healthcare utilisation.

RESULTS

At 36-month follow-up, 65% of participants filled in the VSS-SF. In the usual care group, 38% of participants had crossed over to VR at 6 months. There were no significant differences in vestibular symptoms between VR groups and usual care (mean difference = -0.8 points, 95% confidence interval [CI] = -2.8 to 1.2, for stand-alone VR; -0.3, 95% CI = -2.2 to 1.7, for blended VR). In VR groups, clinically relevant improvement compared with baseline was maintained over time.

CONCLUSION

Internet-based VR provides a maintained improvement of vestibular symptoms for up to 36 months in patients with chronic vestibular syndrome.

Vestibular rehabilitation therapy on balance and gait in patients after stroke: a systematic review and meta-analysis

BACKGROUND

There is limited evidence to support the use of vestibular rehabilitation therapy (VRT) on improving balance and gait in patients after stroke. This systematic review aimed to evaluate the effects of VRT in addition to usual rehabilitation compared with usual rehabilitation on improving balance and gait for patients after stroke.

METHODS

This review followed the Preferred Reporting Items for Systematic reviews and Meta-Analysis statement guidelines. Ten electronic databases were searched up to 1 June 2023 without restrictions in language and publication status. The PEDro scale and the Grading of Recommendations Assessment Development, and Evaluation were used to evaluate the risk of bias and the certainty of evidence. The meta-analysis was conducted with Review Manager 5.3.

RESULTS

Fifteen randomised controlled trials with 769 participants were included. PEDro scale was used to assess the risk of bias with a mean score of 5.9 (0.7). VRT was effective in improving balance for patients after stroke (SMD = 0.59, 95% CI (0.40, 0.78), p < 0.00001), particularly for patients after stroke that occurred within 6 months (SMD = 0.56, 95% CI (0.33, 0.79), p < 0.00001) with moderate certainty of evidence. Subgroup analysis showed that VRT provided as gaze stability exercises combined with swivel chair training (SMD = 0.85, 95% CI (0.48, 1.22), p < 0.00001) and head movements (SMD = 0.75, 95% CI (0.43, 1.07), p < 0.00001) could significantly improve balance. Four-week VRT had better effect on balance improvement (SMD = 0.64, 95% CI (0.40, 0.89), p < 0.00001) than the less than 4-week VRT. The pooled mean difference of values of Timed Up-and-Go test showed that VRT could significantly improve gait function for patients after stroke (MD =  -4.32, 95% CI (-6.65, -1.99), p = 0.0003), particularly for patients after stroke that occurred within 6 months (MD =  -3.92, 95% CI (-6.83, -1.00), p = 0.008) with moderate certainty of evidence.

CONCLUSIONS

There is moderate certainty of evidence supporting the positive effect of VRT in improving balance and gait of patients after stroke.

TRIAL REGISTRATION

PROSPERO CRD42023434304.

Comparison of the Efficacy of Vestibular Rehabilitation and Pharmacological Treatment in Benign Paroxysmal Positional Vertigo

Aim: The aim of the study is to compare the effects of vestibular rehabilitation and pharmacological treatment in benign paroxysmal positional vertigo (BPPV). Materials and methods: Thirty patients (40.93 ± 8.66 years old) diagnosed with BPPV were recruited. Patients were equally divided into pharmacological control group and vestibular rehabilitation group. The pharmacological control group was further divided into Group A (n = 8, 2 doses/day, 24 mg betahistine) and Group B (n = 7, 1 dose/day, 50 mg dimenhydrinate in addition to betahistine). Patients in the rehabilitation group underwent repeated head and eye movements, and Epley or Barbecue Roll Maneuvers were applied for 4 weeks. Subjective assessment of vertigo was measured with the visual analog scale. Static balance parameters were measured with the tandem, one-legged stance, and Romberg tests. Dynamic visual acuity was measured with a Snellen chart, and vestibular dysfunction was measured with the Unterberger (Fukuda stepping) test. All parameters were evaluated before and after treatment. Results: Vestibular rehabilitation resulted in greater improvement in severity of vertigo, balance parameters except Romberg test, and vestibular dysfunction than pharmacological therapy (p < 0,001). There was no significant difference in dynamic visual acuity between groups (p = 0,24). The effects of medication with the active ingredients betahistine and dimenhydrinate were similar (p > 0,05). Conclusion: The vestibular rehabilitation method can positively change the severity of vertigo, balance ability, and vestibular dysfunction compared to pharmacological therapy. Dimenhydrinate administered in combination with betahistine was not superior to betahistine alone but can be recommended for its antiemetic effect.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-03598-4.

Effects of Neuromuscular Training on Physical Performance in Older People: A Systematic Review

This systematic review aimed to assess the available evidence on the effects of neuromuscular training on physical performance in older adults. A literature search was conducted across four databases (Psychology and Behavioral (EBSCO), Scopus, Web of Science and PubMed). The PRISMA guidelines were followed. The PEDro scale and Cochrane risk of bias tool were used to assess the quality of and risk of bias in the studies, respectively. The protocol was registered in PROSPERO (code: CRD42022319239). The outcomes were muscle strength, cardiorespiratory fitness, postural balance and gait speed. From 610 records initially found, 10 were finally included in the systematic review, involving 354 older people with a mean age of 67.3 years. Nine of them reported significant changes in at least one variable related to physical performance in the intervention compared to the control groups. The neuromuscular training caused significant improvements in postural balance, flexibility, cardiorespiratory fitness, strength power of the upper and lower limbs and autonomy. The available evidence indicates that neuromuscular training has a positive effect on some variables of physical performance, especially in postural balance; however, the methodological quality and certainty of the evidence in the available literature are limited. Therefore, a greater number of high-quality studies are required to draw definitive conclusions.

Effectiveness of an evidence-based care pathway to improve mobility and participation in older patients with vertigo and balance disorders in primary care (MobilE-PHY2): study protocol for a multicentre cluster-randomised controlled trial

BACKGROUND

Vertigo, dizziness or balance disorders (VDB) are common leading symptoms in older people, which can have a negative impact on their mobility and participation in daily live, yet, diagnosis is challenging and specific treatment is often insufficient. An evidence-based, multidisciplinary care pathway (CPW) in primary care was developed and pilot tested in a previous study. The aim of the present study is to evaluate the effectiveness and safety of the CPW in terms of improving mobility and participation in community-dwelling older people with VDB in primary care.

METHODS

For this multicentre cluster randomised controlled clinic trial, general practitioners (GP) will be recruited in two regions of Germany. A total of 120 patients over 60 years old with VDB will be included. The intervention is an algorithmized CPW. GPs receive a checklist for standardise clinical decision making regarding diagnostic screening and treatment of VDB. Physiotherapists (PT) receive a decision tree for evidence-based physiotherapeutic clinical reasoning and treatment of VDB. Implementation strategies comprises educational trainings as well as a workshop to give a platform for exchange for the GPs and PTs, an information meeting and a pocket card for home care nurses and informal caregivers and telephone peer counselling to give all participants the capability, opportunity and the motivation to apply the intervention. In order to ensure an optimised usual care in the control group, GPs get an information meeting addressing the national guideline. The primary outcome is the impact of VDB on participation and mobility of patients after 6 month follow-up, assessed using the Dizziness Handicap Inventory (DHI) questionnaire. Secondary outcomes are physical activity, static and dynamic balance, falls and fear of falling as well as quality of life. We will also evaluate safety and health economic aspects of the intervention. Behavioural changes of the participants as well as barriers, facilitating factors and mechanisms of impact of the implementation will be investigated with a comprehensive process evaluation in a mixed-methods design.

DISCUSSION

With our results, we aim to improve evidence-based health care of community-dwelling older people with VDB in primary care.

TRIAL REGISTRATION

DRKS, DRKS00028524 retrospectively registered on March 24, 2022.

The Effects of Vestibular Rehabilitation on Kinesiophobia and Balance with Individuals Who has Vestibular Hypofunction

 The study aimed to examine the effects of vestibular rehabilitation on kinesiophobia, quality of life, dynamic visual acuity, and balance. Thirty vestibular hypofunction patients aged 18-65 years who were diagnosed by videonystagmography (VNG) voluntarily participated in the study. Before and after treatment Tampa Kinesiophobia Scale, World Health Organization Quality of Life Scale-Turkish Short Form, Tandem Stance Test, Dynamic Visual Acuity, Visual Analog Scale to measure dizziness, Subjective Visual Vertical and Subjective for verticality and horizontality perception Visual Horizontal tests were applied. The exercise program was applied for 8 weeks. Patients were observed in the hospital every two weeks. The exercises given in the session were given as home exercises, 3 times a day, for 10 repetitions. As a result of the study, statistical correlations were found tandem stance test, subjective visual vertical and subjective visual horizontal tests for the perception of verticality and horizontality, visual analog scale to measure the severity of dizziness, dynamic visual acuity, quality of life and tampa kinesiophobia scales (p < 0.05). It can be said that vestibular rehabilitation improves the quality of life, balance, dynamic visual acuity, and overcomes kinesiophobia in patients. Trial registration number: NCT05070936, Date of registration:10/06/2021 (Retrospectively registered).

Age- and gender-specific normative data on computerized dynamic posturography in a cohort of Danish adults

PURPOSE

Balance performance can be measured with a computerized dynamic posturography (CDP). Frequently used CDP protocols include the sensory organization test (SOT), motor control test (MCT) and adaptation test (ADT). The primary aim of this study was to produce normative data using the Bertec^® Balance Advantage CDP on a cohort of healthy adults aged 20-79 years for the SOT, MCT and ADT. The secondary aim was to determine age- and gender-related differences.

METHODS

The study population of 120 participants were divided into age groups of 20-29, 30-39 years, etc., with an equal number of men and women in each group. Using the Bertec^® CDP, the SOT, MCT and ADT protocols were performed.

RESULTS

SOT found that the 70-79 age group and men scored lower equilibrium scores (ES) on SOT4, and SOT6. Women had higher ES on SOT1. For the MCT, backward translation_. latencies were higher for the 60 s and 70 s age groups. The 60 s age group had higher forward translation latencies. Women had lower latencies on all MCTs. For the ADT toes up test, the 70-79 age group scored higher sway energy. On the toes down test, higher sway energy was registered for the 50-79 age groups. Women had lower sway energy for both ADT's.

CONCLUSION

We have produced normative data for healthy adults aged 20-79 years for the SOT, MCT and ADT protocols using the Bertec® Balance Advantage CDP. Balance performance differences might be due to decline in visual acuity, presbyvestibulopathy and differences in body composition.

Factors affecting the outcome of vestibular rehabilitation in patients with peripheral vestibular disorders

OBJECTIVE

Previous studies have reported that developmental, environmental, medical, psychological, visual, and other sensory-related factors can influence the outcome of vestibular rehabilitation. However, only a few studies have used patient's daily lives as the main outcome. In addition, in some studies, rehabilitation was not supervised by a physical therapist. This study aimed to determine the factors associated with the outcome of physical-therapist-supervised vestibular rehabilitation in patients with peripheral vestibular disorders, with the impact of dizziness on quality of life as the main outcome.

METHODS

This retrospective cohort study included 47 patients with peripheral vestibular disorders. A physical therapist provided 40 min of vestibular rehabilitation once a week for 4 weeks. Age, sex, disease duration, Dizziness Handicap Inventory (DHI), Timed Up-and-Go test (TUG), Dynamic Gait Index (DGI), Functional Gait Assessment (FGA), Activity-Specific Balance Confidence Scale (ABC scale), and Hospital Anxiety and Depression Scale (HADS) were investigated. Multiple regression analysis was performed, with the DHI rate of change before and after the intervention as the objective variable.

RESULTS

Vestibular rehabilitation improved all outcomes. In the multiple regression analysis, the ABC scale was identified as a factor that significantly influenced the DHI rate of change (β = -0.428, p < 0.01).

CONCLUSION

A higher ABC scale score was associated with a lower DHI rate of change (i.e., better improvement). Therefore, it may be important to assess psychological aspects, especially confidence in balance, when implementing vestibular rehabilitation in patients with peripheral vestibular disorders.

Efficacy of Vestibular Rehabilitation in Patients With Neurologic Disorders: A Systematic Review

OBJECTIVE

The aim of this systematic review is to critically assess the effectiveness of vestibular rehabilitation (VR) administered either alone or in combination with other neurorehabilitation strategies in patients with neurologic disorders.

DATA SOURCES

An electronic search was conducted by 2 independent reviewers in the following databases: MEDLINE (PubMed), the Physiotherapy Evidence Database, and the Cochrane Database of Systematic Reviews.

STUDY SELECTION

All clinical studies carried out on adult patients with a diagnosis of neurologic disorders who performed VR provided alone or in combination with other therapies were included.

DATA EXTRACTION

Screening of titles, abstracts, and full texts and data extraction were undertaken independently by pairs of reviewers. Included studies were quality appraised using a modified version of the Newcastle-Ottawa Scale.

DATA SYNTHESIS

The summary of results was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Twelve studies were included in the review. All the included studies, with 1 exception, report that improvements provided by customized VR in subject affected by a central nervous system diseases are greater than traditional rehabilitation programs alone.

CONCLUSIONS

Because of the lack of high-quality studies and heterogeneity of treatments protocols, clinical practice recommendations on the efficacy of VR cannot be made. Results show that VR programs are safe and could easily be implemented with standard neurorehabilitation protocols in patients affected by neurologic disorders. Hence, more high-quality randomized controlled trials of VR in patients with neurologic disorders are needed.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effectiveness of Vestibular Training for Balance and Dizziness Rehabilitation in People with Multiple Sclerosis: A Systematic Review and Meta-Analysis

Postural instability and dizziness are commonly observed in people with multiple sclerosis (PwMS). The aim of this systematic review was to evaluate the evidence for the use of vestibular rehabilitation, in comparison with other exercise interventions or no intervention, to treat balance impairments and dizziness in PwMS. An electronic search was conducted by two independent reviewers in the following databases: MEDLINE (Pubmed), Scopus, the Physiotherapy Evidence Database (PEDro), Web of Science (WOS), Lilacs, CINHAL and the Cochrane Database of Systematic Reviews (CDSR). A quality assessment was performed using the PEDro scale and the Cochrane Risk of Bias Tool. When possible, the data were pooled in a meta-analysis (95%CI). This systematic review followed the PRISMA guideline statement and was registered in the PROSPERO database (CRD42019134230). Seven studies were included, with a total of 321 participants analysed. Compared with no intervention, vestibular rehabilitation was more effective for balance development (SMD = 2.12; 95% CI = 0.49, 3.75; p = 0.01; I² = 89%) and dizziness symptoms improvement (SMD = −17.43; 95% CI = −29.99, −4.87; p= 0.007; I²= 66%). Compared with other exercise interventions, improvements in favour of the experimental group were observed, but statistical significance for the differences between groups was not reached.

Effectiveness of Mechanical Horse-Riding Simulators on Postural Balance in Neurological Rehabilitation: Systematic Review and Meta-Analysis

Mechanical horse-riding simulators consist of a device that mimics the movement of a real horse, generating between 50 and 100 three-dimensional physical movements (forward and back, left and right, up and down). The main objective of this study is to analyze the effectiveness of mechanical horse-riding simulators to improve postural balance in subjects with neurological disorders. The search was conducted during January-March 2019 in PubMed, Physiotherapy Evidence Database (PEDro), Cochrane, Web of Science, CINAHL, and Scopus. The methodological quality of the studies was evaluated through the PEDro scale. A total of seven articles were included in this systematic review, of which four contributed information to the meta-analysis. Statistical analysis showed favorable results for balance in stroke patients, measured by the Berg Balance Scale (standardized mean difference (SMD) = 3.24; 95%; confidence interval (CI): 1.66-4.83). Not conclusive results were found in sitting postural balance, measured using the Gross Motor Function Measure-66 (GMFM-66) Sitting Dimension, in patients with cerebral palsy. Most studies have shown beneficial effects on postural balance compared with conventional physical therapy. However, due to the limited number of articles and their low methodological quality, no solid conclusions can be drawn about the effectiveness of this therapy.

Internet-Based Interventions for Adults With Hearing Loss, Tinnitus, and Vestibular Disorders: A Systematic Review and Meta-Analysis

Internet-based interventions have been developed to improve access to audiovestibular health care. This review aimed to identify outcomes of Internet interventions for adults with hearing loss, tinnitus, and vestibular disorders. Electronic databases and manual searches were performed to identify studies meeting eligibility for inclusion. Fifteen studies (1,811 participants) met the inclusion criteria, with nine studies targeting tinnitus distress, five considering hearing loss, and one for vestibular difficulties. Only the tinnitus and hearing loss Internet intervention studies were eligible for data synthesis. Internet-based interventions for hearing loss were diverse. Overall, they showed no significant effects, although a statistically significant moderate effect (d = 0.59) was found after removing the study with the highest risk of bias (as a result of high attrition). Most Internet-based interventions for tinnitus provided cognitive behavioural therapy. They yielded statistically significant mean effect sizes for reducing tinnitus distress compared with both inactive (d = 0.59) and active controls (d = 0.32). Significant effects were also present for the secondary outcomes of anxiety, depression, insomnia, and quality of life (combined effect d = 0.28). Only Internet-based interventions for tinnitus evaluated the 1-year postintervention effects indicated that results were maintained long term (d = 0.45). Scientific study quality was appraised using the Grading of Recommendations Assessment, Development and Evaluation approach and found to vary from very low to moderate. This review indicates the potential of Internet interventions for tinnitus to provide evidence-based accessible care. There is a need for additional high-quality evidence before conclusive results can be established regarding the effects of audiovestibular Internet interventions.

The Vestibular System and Ageing

The world's population is ageing due to increased hygiene and improved medical care. Dizziness and imbalance frequently affect the elderly and is most common among individuals over the age of 60. In this age group approximately 30% of the population experience these debilitating symptoms at some point. They contribute to falls and frailty, which often result in hospitalization causing tremendous cost for the health care systems, and increased mortality. To make the matters worse balance disorders are often complex. Physicians face the difficulty of diagnosing the patient with the exact disorder especially since each disorder may manifest differently in each patient. In addition, several treatment options exist, however, with a low level of evidence. This chapter summarizes the underlying degenerative processes of the peripheral as well as the central vestibular system, diagnostic tools, the most common balance disorders in the elderly, and possible treatment options of these disorders.

Vestibular rehabilitation in elderly patients with postural instability: reducing the number of falls-a randomized clinical trial

BACKGROUND

Our previous study had shown the effectiveness of vestibular rehabilitation (VR) in improving balance in elderly patients, assessed immediately afterwards.

AIMS

The main goal of the present study is to consider whether this improvement in balance assessment turns out in a reduction of the number of falls.

METHODS

139 elderly patients with high risk of falls were included and randomized to one of the following study arms: computerized dynamic posturography (CDP) training, optokinetic stimulus, exercises at home or control group. Patients were assessed with objective outcome measures (sensorial organization test and limits of stability of CDP, number of falls and number of hospital admissions due to falls) and subjective outcome measures (dizziness handicap inventory and short falls efficacy scale-international) during a 12-month follow-up period.

RESULTS

Average number of falls significantly declined from 10.96 (before VR) to 3.03 (12-month follow-up) in the intervention group (p < 0.001); meanwhile, in the control group, the average number of falls changed from 3.36 to 2.61 during a 12-month follow-up period (p = 0.166).

DISCUSSION

The present study provides evidence that VR can decisively improve balance in elderly patients with instability, which can lead in turn to a significant reduction of falls.

CONCLUSION

We recommend performing VR in any older person with high risk of falls.

In Older Patients Treated for Dizziness and Vertigo in Multimodal Rehabilitation Somatic Deficits Prevail While Anxiety Plays a Minor Role Compared to Young and Middle Aged Patients

Objective: Many patients with dizziness and vertigo are of older age. It is still unclear which age-associated factors play a role in the treatment of dizziness and vertigo. Therefore, age-associated characteristics of patients subjected to an interdisciplinary day care approach for chronic vertigo and dizziness were analyzed.

Subjects and Methods: 650 patients with chronic dizziness/vertigo subjected to a multimodal vestibular rehabilitation day care program were analyzed. Information concerning age, gender, medical diagnosis, medical consultations, technical diagnostics performed and therapy achieved before attending the clinic were collected. Furthermore, data were gathered using the Vertigo Severity Scale (VSS), Hospital Anxiety and Depression Scale (HADS), Mobility Inventory (MI), as well as the intensity of and the distress due to vertigo/dizziness using visual analog scales. As a follow-up, the VSS, HADS, MI, and the visual analog scales were collected again 6 months after attending the therapy program. Three age groups were compared to each other (<41, 41–65, and >65 years of age).

Results: One-third of the patients were older than 65 years. This group had typical diagnoses with mainly organic deficits. In contrast to the dominance of mainly multifactorial, organic deficits the older patients reported less medical consultations, fewer technical diagnostics and even fewer treatments than the younger patients. The elderly scored significantly lower in total VSS, in VSS-V (vestibular-balance subscale), in VSS-A (autonomic-anxiety subscale) and in HADS-anxiety. Psychological diagnoses were clearly associated to the younger patients. 424 patients (65.2%) completed the follow-up questionnaire 6 months after attending the therapy week. The older patients revealed improvements of VSS-V and the Avoidance Alone scale of MI as well as decreased distress due to vertigo/dizziness.

Conclusion: In the older patients, who took part in our vestibular rehabilitation program, mainly somatic deficits prevail while anxiety plays a minor role compared to young and middle aged patients. Older patients profited from vestibular rehabilitation especially in mobility and vestibular-balance. Therefore, vestibular rehabilitation programs for the elderly with a focus on physio- and occupational therapeutic interventions and less cognitive behavioral therapy may be reasonable.

Pilot cluster randomized controlled trial of a complex intervention to improve management of vertigo in primary care (PRIMA-Vertigo): study protocol

OBJECTIVES

Vertigo and dizziness are highly prevalent symptoms in primary care, frequently misdiagnosed. Based on a thorough need assessment, INDICORE (INform, DIagnose, COmmunicate, REfer), an evidence-based complex intervention has been developed to transfer knowledge of specialized tertiary clinics to primary care providers (PCPs), improve the referral process and, ultimately, improve the functioning and quality of life of patients with vertigo/dizziness. The main objective of the PRIMA-Vertigo pilot study is to examine whether the INDICORE intervention is feasible and sufficiently promising to warrant a larger trial.

METHODS

We plan to perform a single-blind, pragmatic cluster-randomized controlled pilot study with an accompanying process evaluation. PCPs will be the cluster units of randomization. Patients who consult these PCPs because of vertigo/dizziness symptoms will be included consecutively and considered the units of analysis. The intervention will be multi-faceted training on diagnostics targeted at the PCPs, supported by patient education material and a newly developed tool to structure the referral process. To balance the influence of non-specific effects, all clusters will receive generic communication training.

EXPECTED RESULTS

The process evaluation aims to provide results on the acceptability and feasibility of the INDICORE intervention components to PCPs and patients. Additionally, this study will provide a first estimate of the likely effectiveness of the intervention on patients' quality of life, functioning and participation.

CONCLUSIONS

The PRIMA-Vertigo pilot study will allow further tailoring of the INDICORE intervention to stakeholder needs before its effectiveness is evaluated in a large-scale main study.

Enhancing vestibular function in the elderly with imperceptible electrical stimulation

Age-related loss of vestibular function can result in decrements in gaze stabilization and increased fall risk in the elderly. This study was designed to see if low levels of electrical stochastic noise applied transcutaneously to the vestibular system can improve a gaze stabilization reflex in young and elderly subject groups. Ocular counter-rolling (OCR) using a video-based technique was obtained in 16 subjects during low frequency passive roll tilts. Consistent with previous studies, there was a significant reduction in OCR gains in the elderly compared to the young group. Imperceptible stochastic noise significantly increased OCR in the elderly (Mean 23%, CI: 17–35%). Increases in OCR gain were greatest for those with lowest baseline gain and were negligible in those with normal gain. Since stimulation was effective at low levels undetectable to subjects, stochastic noise may provide a new treatment alternative to enhance vestibular function, specifically otolith-ocular reflexes, in the elderly or patient populations with reduced otolith-ocular function.

Short-term effectiveness of vestibular rehabilitation in elderly patients with postural instability: a randomized clinical trial

Balance becomes more precarious with age, and even without pathological disorders, the physiological decline in balance that occurs with age is a factor that also favors falls. So the aim of the present study is to assess the short-term effectiveness of three different methods of vestibular rehabilitation, compared to a control group, in improving balance in elderly patients with postural instability. 139 elderly patients with high risk of falls were included and randomized to one of the following study arms: computer dynamic posturography (CDP) training, optokinetic stimulus, exercises at home, or control group. Patients were assessed with objective and subjective outcome measures. The individuals that trained using CDP improved significantly more than the control group on the average balance score (p < 0.001) and reducing the number of falls in the sensorial organization test (p < 0.001). In addition, the analysis showed a statistically significant effect in the limits of stability only with the CDP training in comparison with the control group (p < 0.001). In our present study, supervised and customized exercises with CDP were more effective than the control group in the posturographic short-term assessment. An increased age did not affect the potential for improvement after training. So we conclude that elderly patients with high risk of falling should begin vestibular rehabilitation as soon as possible in order to avoid the potential harm of falls, mainly injuries and psychological consequences due to fear of falling again.

The Effect of Vestibular Rehabilitation in Patients with Ménière’s Disease: A Systematic Review

Objective

To systematically review the evidence on the effect of vestibular rehabilitation in patients with Ménière’s disease (MD) on balance and dizziness-related quality of life.

Data Sources

A literature search was conducted in the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, Web of Science, and CINAHL databases.

Review Methods

Articles were reviewed by 2 independent authors and data were compiled in tables for analysis regarding balance (ie, posturography) and dizziness-specific quality of life in patients with MD. A comprehensive search was performed up to November 2015. Studies on relevance and methodological quality were assessed by means of the Cochrane risk of bias tool. For outcome on balance and quality of life, we calculated mean differences and their 95% confidence intervals.

Results

A total of 986 unique studies were retrieved. Five studies, including a total of 498 patients, fulfilled the eligibility criteria, including 2 randomized controlled trials and 3 prospective cohort studies. There was no study with a low risk of bias. We found inconsistent evidence for the effect of vestibular rehabilitation on balance and dizziness-related quality of life.

Conclusion

Based on the low quality of the selected studies, it is inconclusive whether there is a positive effect of vestibular rehabilitation in patients with MD on balance and dizziness-related quality of life.