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

Effect of Cawthorne and Cooksey exercise on balance control and fall risk among middle-aged population: A single group pre-post experimental study

BACKGROUND

Balance impairment is one of the causes of the risk of falls among all age groups and is a continuing threat to morbidity and mortality across the world. Previous studies stated that the vestibular system is affected in middle-aged population, which leads to imbalance and a high risk of falls. There is a lack of research in this account so this study has been done to find the effect of Cawthorne and Cooksey exercise in vestibular rehabilitation on balance control and the risk of falls among middle-age population.

MATERIALS AND METHODS

According to the criteria of selection 30 subjects were recruited for this study. Baseline demographic measurements were recorded. Timed up and go (TUG) test time, Sway analysis using a force plate, and Morse fall scale measures were used as outcomes. Cawthorne and Cooksey exercise was given for 8 weeks 3 sessions per week. Pre and post-intervention outcome measures with 3-month follow-up were recorded for data analysis.

RESULTS

The mean age of participants was 49.55 ± 5.67 years. The paired sample t-test showed mean values of TUG 1.86 ± 1.03, COPx 1.17 ± 1.50, COPy 1.78 ± 1.78, MFS 8.75 ± 12.23 with P value of 0.00 (P < 0.05) for all measures. The repeated measures ANOVA showed 3-month follow-up results for TUG P ≤ 0.00, COPx P ≤ 0.01, COPy P ≤ 0.00, and MFS P ≤ 0.00.

CONCLUSION

There is a statistically significant effect of Cawthorne and Cooksey exercise on balance control and fall risk among middle-aged population of 40-60 years.

Optokinetic stimulation for the treatment of vestibular and balance disorders: a systematic review with meta-analysis

OBJECTIVES

To analyse the effectiveness of optokinetic stimulation (OKS) for improving symptoms and function in patients with vestibular and balance disorders.

METHODS

PubMed (MEDLINE), SCOPUS, Web of Science (WOS), CINAHL Complete, and PEDro databases were searched to identify randomized controlled trials (RCTs) that included patients with vestibular and balance disorders and compared the effects of OKS versus other interventions or no intervention on subjective or objective functional outcomes. Data were analysed by the standardized mean difference (SMD) and its 95% confidence interval.

RESULTS

A total of 10 studies were selected including 468 patients, 177 of whom received OKS. There were no significant differences in scores on the Dizziness Handicap Inventory (DHI) (SMD = 0.02; 95% CI - 0.18 to 0.23; p = 0.83) or the visual analogue scale (VAS) for vertigo (SMD = 0.16; 95% CI - 1.25 to 1.58; p = 0.82). However, there were statistically significant differences in the timed up and go (TUG) test, with a large effect (SMD = - 1.13; 95% CI -2 to - 0.28; p = 0.009), and in the sensory organization test (SOT), with a medium effect (SMD = - 0.7; 95% CI - 1.21 to - 0.19; p = 0.007). Subgroup analysis showed significant effects of OKS on VAS (p = 0.017), TUG (p = 0.009) and SOT (p = 0.001) only in patients with balance disorders without vestibular disease (p > 0.05).

CONCLUSIONS

OKS may improve dizziness intensity measured with VAS or dynamic balance measured whit TUG and SOT in patients with balance disorders not due to vestibular disease. The quality of the evidence was low or very low due to the small number of included studies.

PROSPERO REGISTRY NUMBER

CRD42023445024.

Limits of Stability during a Therapeutic Exercise Intervention for Instability: Progression, Responders' and Non-Responders' Analysis and Predictors

Background/Objectives: Instability is one of the main symptoms in patients with vestibular and neurological disorders and therapeutic exercise interventions are increasing in popularity as a form of treatment. Additionally, the limits of stability measurement are known to be a good tool for balance evaluation and monitoring of these interventions. The aim of this work is to better understand how a specific protocol provokes changes on this variable and to study the characteristics of those who do and do not respond to it. Methods: A retrospective study was developed with the data of 40 patients treated in the Otorhinolaryngology department in Clínica Universidad de Navarra (Madrid, Spain). They had an initial reduction in limits of stability, completed the proposed protocol with home-based and hospital-based exercises and with frequent limits of stability remeasurement, and were assisted to a follow-up retest after 1-2 months. Results: A progressive improvement in limits of stability measure was developed through the intervention and was partially retained at follow-up visit. Several differences were found between those patients who improved with the treatment (responders) and those who did not improve (non-responders). More specifically an initial measure of the limits of stability was able to differentiate those groups with a cut-off data of 56 cm2. Conclusions: The proposed protocol was able to induce motor learning in patients included in this study with good retention after 1-2 months. Furthermore, there is some variability in how patients respond to the treatment. Age and diagnosis should be considered and an interesting cut-off data for clinal decision making was found.

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.

Use of Physical Therapy and Subsequent Falls Among Patients With Dizziness in the US

Importance

Among adults who present for clinical evaluation of dizziness, there is a critical need to identify interventions, such as physical therapy (PT), to mitigate the risk of falls over time.

Objective

The primary objective was to examine the association between receipt of PT and falls requiring medical care within 12 months of presentation for dizziness. Secondary objectives included identification of factors associated with falls requiring medical care and factors associated with receipt of PT after presentation for dizziness.

Design, Setting, and Participants

This cross-sectional study examined US commercial insurance and Medicare Advantage claims from January 1, 2006, through December 31, 2015. In all, 805 454 patients 18 years or older with a new diagnosis of symptomatic dizziness or vestibular disorders were identified. Data were analyzed from October 1, 2021, to February 1, 2023.

Main Outcomes and Measures

Receipt of PT services and the incidence of falls requiring medical care were measured. The association between receipt of PT and falls that occurred 12 months after presentation for dizziness was estimated after accounting for presentation setting (outpatient clinic or emergency department), Charlson Comorbidity Index (CCI; with higher scores indicating greater morbidity), diagnosis code, and sociodemographic characteristics.

Results

A total of 805 454 patients presented for dizziness from 2006 through 2015 (median [range] age, 52 [18-87] years; 502 055 females [62%]). Of these patients, 45 771 (6%) received PT within 3 months of presentation for dizziness and 60 060 (7%) experienced a fall resulting in a medical encounter within 12 months after presentation for dizziness. In adjusted models, patients least likely to receive PT were female (adjusted odds ratio [AOR], 0.80; 95% CI, 0.78-0.81), those aged 50 to 59 years (AOR, 0.67 [95% CI, 0.65-0.70] compared with patients aged 18-39 years), and those with more comorbidities (AOR, 0.71 [95% CI, 0.70-0.73] for CCI ≥ 2 vs 0). Receipt of PT services within 3 months of presentation for dizziness was associated with a reduced risk of falls over the subsequent 12 months, with the greatest risk reduction found within 3 months after PT (AOR, 0.14 [95% CI, 0.14-0.15] at 3-12 months vs 0.18 [95% CI, 0.18-0.19] at 6-12 months and 0.23 [95% CI, 0.23-0.24] at 9-12 months).

Conclusions and Relevance

Results of this cohort study suggest that receipt of PT after presentation for dizziness was associated with a reduction in fall risk during the subsequent 12 months; thus, timely PT referral for dizziness may be beneficial for these patients. Future research, ideally with a clinical trial design, is needed to explore the independent impact of PT on subsequent falls for adults with dizziness.

Quantitative Assessment of Balance Function Characteristics in Older Patients with Orthostatic Hypotension

BACKGROUND

Orthostatic hypotension (OH) is a common blood pressure abnormality in older adults that makes them prone to balance disorders and falls. The maintenance of balance relies on a complex regulatory system. The use of computerized dynamic posturography (CDP) can provide a quantitative evaluation of balance function. The objective of this study was to utilize CDP to measure balance indicators in older individuals with OH.

METHODS

A total of 303 older adults were divided into an OH group of 91 and a non-OH group of 212. Various factors, including chronic diseases, medication history, laboratory tests, and balance indicators, were compared between the two groups.

RESULTS

① Participants with OH had more chronic diseases, including coronary heart disease (p = 0.049) and a history of falls (p < 0.001), than those without OH. A history of multiple medications in the OH group was significantly more likely than in the non-OH group (p = 0.006). ② There was a significant reduction in the composite equilibrium score (SOT-COM) (p < 0.001), vision ratio score (VIS) (p < 0.001), vestibular ratio score (VEST) (p < 0.001), and directional control (DCL) (p = 0.028) in the OH group. ③ A logistic regression analysis revealed that SOT-COM was a significant independent factor associated with OH. The area under the curve (AUC) of SOT-COM was 0.833 (95% confidence interval: 0.778-0.887, p < 0.001), with a sensitivity of 0.826 and a specificity of 0.759.

CONCLUSIONS

This study demonstrates that older individuals with OH are more prone to falls, due to decreased sensory integration for balance.

Quantitative analysis of balance function characteristics in older patients with mild to moderate cognitive impairment

BACKGROUND

Cognitive decline in older adults may affect balance function, but the relationship between the two is not fully understood, especially in the early stages of cognitive impairment. Mild to moderate cognitive impairment can be assessed with the Montreal Cognitive Assessment (MOCA).

AIM

This study quantitatively analyzed balance function in older adults with mild to moderate cognitive impairment using computerized dynamic posturography (CDP) testing.

METHODS

248 older patients were divided into a cognitive impaired group (MOCA <26, n = 126) and a normal group (MOCA ≥26, n = 122) based on the Montreal Cognitive Assessment (MOCA) Beijing Version. Patients underwent CDP testing, which included the sensory organization test (SOT) and the limits of stability test (LOS).

RESULTS

The cognitive impaired group had significantly lower SOT composite and visual scores, as well as reaction time (RT), movement velocity (MVL), endpoint excursion (EPE), maximum excursion (MXE), and directional control (DCL) of the LOS test. Binary logistic regression analysis revealed that RT and MXE were independent factors significantly associated with MOCA, even after adjustment for age and sex.

CONCLUSIONS

Older patients with mild to moderate cognitive impairment may have reduced sensory integration and balance stability limits, mainly manifested as prolonged motor reaction time and shortened maximum movement distance.

Effectiveness of the aquatic physical therapy exercises to improve balance, gait, quality of life and reduce fall-related outcomes in healthy community-dwelling older adults: A systematic review and meta-analysis

BACKGROUND

Opting to use aquatic or land-based physical therapy exercises to improve balance, gait, quality of life and reduce fall-related outcomes in community-dwelling older adults (CDOAs) is still a questionable clinical decision for physiotherapists.

OBJECTIVE

Assess the quality of evidence from randomized or quasi-randomized controlled trials that used aquatic physical therapy exercises to improve balance, gait, quality of life and reduce fall-related outcomes in CDOAs.

METHODS

Articles were surveyed in the following databases: MEDLINE/PubMed, EMBASE, SCOPUS, LILACS, Web of Science, CENTRAL (Cochrane Central Register of Controlled Trials), PEDro, CINAHL, SciELO and Google Scholar, published in any language, up to July 31, 2023. Two independent reviewers extracted the data and assessed evidence quality. The risk of bias of the trials was evaluated by the Cochrane tool and evidence quality by GRADE approach. Review Manager software was used to conduct the meta-analyses.

RESULTS

3007 articles were identified in the searches, remaining 33 studies to be read in full, with 11 trials being eligible for this systematic review. The trials included presented low evidence quality for the balance, gait, quality of life and fear of falling. Land-based and aquatic physical therapy exercises improved the outcomes analyzed; however, aquatic physical therapy exercises were more effective in improving balance, gait, quality of life and reducing fear of falling in CDOAs. The meta-analysis showed that engaging in aquatic physical therapy exercises increases the functional reach, through of the anterior displacement of the center of pressure of CDOAs by 6.36cm, compared to land-based physical therapy exercises, assessed by the Functional Reach test: [CI:5.22 to 7.50], (p<0.00001), presenting low quality evidence.

CONCLUSIONS

Aquatic physical therapy exercises are more effective than their land-based counterparts in enhancing balance, gait, quality of life and reducing the fear of falling in CDOAs. However, due to methodological limitations of the trials, this clinical decision remains inconclusive. It is suggested that new trials be conducted with greater methodological rigor, in order to provide high-quality evidence on the use of the aquatic physical therapy exercises to improve the outcomes analyzed in CDOAs.

Effectiveness of Vestibular Rehabilitation in Improving Health Status and Balance in Patients with Fibromyalgia Syndrome: A Single-Blind Randomized Controlled Trial

BACKGROUND

Fibromyalgia Syndrome (FMS) is a highly prevalent health problem whose main symptom is widespread pain, although it presents as other manifestations, such as loss of balance, that seem to mainly affect visuo-vestibular information.

OBJECTIVE

to compare the effects of a Vestibular Rehabilitation (VR) program versus those of a Conventional Physical Exercise (CPE) program on the health status of patients with FMS.

METHODS

A single-blind randomized controlled trial was performed. Patients with FMS were randomly assigned to VR or CPE programs. The protocols were performed in 40 min group sessions, twice weekly, for 16 sessions. Perceived health status, static and dynamic balance, verticality perception, confidence in balance, sensitization and kinesiophobia were measured at baseline, post-treatment and at the three-month follow-up and analyzed using an intention-to-treat approach.

RESULTS

Forty-eight subjects were randomly assigned, of whom thirty-five completed the planned VR (n = 19) or CPE (n = 16) program. At the three-month follow-up, there were differences in physical health status measured with the SF-12 (mean = -4.36, SE = 1.88, p = 0.027), balance during walking (mean = 1.90, SE = 0.57, p = 0.002), the perception of verticality in degrees (mean = 3.61, SE = 1.51, p = 0.024) and the anteroposterior position of the center of pressure (mean = -7.88, SE = 2.80, p = 0.009), as well as a decrease in the number of falls (mean = 0.98, SE = 0.44, p = 0.033), favoring the VR group.

CONCLUSIONS

Vestibular Rehabilitation can be as beneficial as conventional exercise in improving the state of health in patients with Fibromyalgia Syndrome, providing additional improvements in physical health status, body balance, the perception of verticality and the number of falls.

Implementation outcomes of a sensory integration therapy program with computerized dynamic posturography in patients with balance and sensory dysfunction

Objective

We describe the first-year implementation experience of an Instrumented Sensory Integration Therapy Program in Audiological & Balance Center patients.

Design

This is a retrospective descriptive study. Participants included Seventy-three adults with diagnoses of acute, episodic, or chronic vestibular syndromes. They were classified into the following two groups: group 1 included 46 individuals treated with ISIT plus VRT, and group 2 included 27 individuals treated only with ISIT.

Results

The Sensory Organization Test (SOT) for both groups showed a statistical significance for all three sensory inputs; visual systems (G1: p = 0.0003; G2: p = 0.0337), vestibular system (G1: p < 0.0001; G2: p = 0.0003), and balance as demonstrated by compound balance score (G1: p < 0.0001; G2: p = 0.0035), and balance percentage deficit (G1: p < 0.0001; G2: p = 0.0078).

Conclusions

The severity and complexity of functional neurological disorders in the context of vestibular syndromes seem to require between 10 and 20 therapy sessions, and combined ISIT plus VRT appears to be more effective than ISIT as a monotherapy.

Patient-Reported Disability After Computerized Posturographic Vestibular Retraining for Stable Unilateral Vestibular Deficit

Importance

Individuals with persistent unilateral vestibular deficits experience loss of quality of life and increased risk of falling, and they have few well-supported options for effective treatment.

Objectives

To evaluate whether vestibular retraining using computerized dynamic posturography is associated with reduced participant-reported disability for patients with an objectively assessed unilateral peripheral vestibular deficit and to assess the feasibility of conducting a randomized clinical trial of vestibular retraining using computerized dynamic posturography.

Design, Setting, and Participants

This single-group cohort study was conducted from April 29 to July 23, 2021, in a tertiary neurotology clinic among 13 individuals with a stable unilateral vestibular deficit present for more than 6 months, confirmed with videonystagmography and vestibular evoked myogenic potential testing. Statistical analysis was performed from July 7, 2021, to January 25, 2022.

Interventions

Twelve twice-weekly sessions of posturography-assisted vestibular retraining with prescribed weight shifting tasks guided by an interactive display.

Main Outcomes and Measures

Change in scores on the Dizziness Handicap Inventory (DHI), the Activities-Specific Balance Confidence (ABC) Scale, and the Falls Efficacy Scale-International (FES-I), which participants completed before and after retraining to measure their perception of their disability. They also completed posturography measurements. Secondary outcomes included tolerability of the intervention and rate of completion of the full protocol.

Results

A total of 13 participants (8 men [62%]; median age, 51 years [range, 18-67 years]) were enrolled. All 13 participants completed the intervention and all follow-up. After treatment, the median changes in scores were -16 points (95% CI, -20 to 2) for the DHI, -9 (95% CI, -14 to 1) for the FES-I, and 11.9 (95% CI, 0-17.3) for the ABC Scale. Eight participants (62%) improved by greater than the minimum clinically important difference (MCID) for the DHI, whereas 4 (31%) exceeded the MCID for the ABC Scale, and 3 (23%) exceeded the MCID for the FES-I. Participants with moderate to severe disability at baseline (n = 7) had a larger magnitude of improvement in DHI scores than those with mild disability (n = 6) (-18 [95% CI, -78 to 2] vs -1 [95% CI, -8 to 16]). Six of the 7 patients (86%) with moderate to severe disability improved by greater than the MCID for DHI, wherease 4 of 7 patients (57%) improved by greater than the MCID for the ABC Scale, and 3 of 7 patients (43%) improved by greater than the MCID for the FES-I.

Conclusions and Relevance

This cohort study suggests that computerized, dynamic posturography-assisted retraining was associated with clinically meaningful improvements in participant-reported disability among those with stable unilateral vestibular deficit and moderate to severe disability. Further studies should compare posturography-assisted vestibular retraining with conventional physical therapy rehabilitation techniques.

Trial Registration

ClinicalTrials.gov Identifier: NCT04875013.

Vestibular rehabilitation with mobile posturography as a "low-cost" alternative to vestibular rehabilitation with computerized dynamic posturography, in old people with imbalance: a randomized clinical trial

BACKGROUND

Vestibular rehabilitation (VR), specifically, VR with dynamic computerized posturography (CDP) has proven to be useful to improve balance and reduce the risk of falling in old patients. Its major handicap is probably its cost, which has hindered its generalisation. One solution to reduce this cost is performing VR with mobile posturography systems, which allow assessment of stability at the center of body mass in daily-life conditions. Also, rehabilitation with vibrotactile neurofeedback training could be used in dynamic tasks.

OBJECTIVE

To assess whether two different protocols of vestibular rehabilitation (using CDP and the Vertiguard system) show significant differences in the improvement of balance among older persons with imbalance METHODS: A clinical trial comparing VR with CDP exercises and VR with mobile posturography (Vertiguard) exercises, was designed. The participants were people over 65 years, with imbalance. The composite (average balance) in the sensory organization test (SOT) of the CDP was the main outcome measure; it was compared before and 3 weeks after VR, and between both intervention groups.

RESULTS

40 patients were included in the study (19 in the CDP-VR group and 21 in the Vertiguard-VR group). Average balance was significantly improved in both intervention groups (51% pre-VR vs 60% post-VR, p = 0.002, CDP-VR group; 49% pre-VR vs 57% post-VR, p = 0.008, Vertiguard-VR group); no significant differences in this improvement were found comparing both groups (p = 0.580).

DISCUSSION AND CONCLUSIONS

VR using mobile posturography is useful to improve stability in old people with instability, showing similar improvement rates to those of VR using CDP.

UNIQUE IDENTIFIER

NCT03034655 www.clinicaltrials.gov Registered on 25 January 2017.

Case Report: Acute Onset Fear of Falling and Treatment With "Cognitive Physical Therapy"

Fear of falling (FoF) is prevalent in older adults, especially those with previous falls, and typically starts insidiously. We present a 78-year-old woman with an abrupt onset FoF and no history of falls, balance problems, vertigo, oscillopsia, psychiatric or psychological issues to account for this. These cognitive changes led to a behavioural alteration of her gait that became slow and wide-based, with her gaze fixed on the floor. She began a tailored program of "Cognitive Physical Therapy (CPT)" combining cognitive behavioural therapy (CBT) and physical rehabilitation. 1 month later her 6 m walk time and steps were reduced by a 25 and 35%, respectively, and the stride length increased by 34%, with further improvement 2 months later. We postulate that the abrupt onset of symptoms triggered a central shift toward postural hypervigilance and anxiety, suppression of anticipatory (feed forward) postural adjustments (APA) leading to FoF. CPT improved objective gait parameters related to FoF and reduced postural anxiety suggesting that early diagnosis and prompt treatment may avoid chronic symptoms and social isolation.

eHealth for Addressing Balance Disorders in the Elderly: Systematic Review

Background

The population is aging on a global scale, triggering vulnerability for chronic multimorbidity, balance disorders, and falls. Falls with injuries are the main cause of accidental death in the elderly population, representing a relevant public health problem. Balance disorder is a major risk factor for falling and represents one of the most frequent reasons for health care demand. The use of information and communication technologies to support distance healthcare (eHealth) represents an opportunity to improve the access and quality of health care services for the elderly. In recent years, several studies have addressed the potential of eHealth devices to assess the balance and risk of falling of elderly people. Remote rehabilitation has also been explored. However, the clinical applicability of these digital solutions for elderly people with balance disorders remains to be studied.

Objective

The aim of this review was to guide the clinical applicability of eHealth devices in providing the screening, assessment, and treatment of elderly people with balance disorders, but without neurological disease.

Methods

A systematic review was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) statement. Data were obtained through searching the PubMed, Google Scholar, Embase, and SciELO databases. Only randomized controlled trials (RCTs) or quasiexperimental studies (QESs) published between January 2015 and December 2019 were included. The quality of the evidence to respond to the research question was assessed using Joanna Briggs Institute (JBI) Critical Appraisal for RCTs and the JBI Critical Appraisal Checklist for QESs. RCTs were assessed using the Cochrane risk of bias tool. We provide a narrative synthesis of the main outcomes from the included studies.

Results

Among 1030 unduplicated articles retrieved, 21 articles were included in this review. Twelve studies explored different technology devices to obtain data about balance and risk of falling. Nine studies focused on different types of balance exercise training. A wide range of clinical tests, functional scales, classifications of faller participants, sensor-based tasks, intervention protocols, and follow-up times were used. Only one study described the clinical conditions of the participants. Instrumental tests of the inner ear were neither used as the gold-standard test nor performed in pre and postrehabilitation assessments.

Conclusions

eHealth has potential for providing additional health care to elderly people with balance disorder and risk of falling. In the included literature, the heterogeneity of populations under study, methodologies, eHealth devices, and time of follow-up did not allow for clear comparison to guide proper clinical applicability. This suggests that more rigorous studies are needed.

Physical therapy interventions for older people with vertigo, dizziness and balance disorders addressing mobility and participation: a systematic review

BACKGROUND

Vertigo, dizziness and balance disorders (VDB) are among the most relevant contributors to the burden of disability among older adults living in the community and associated with immobility, limitations of activities of daily living and decreased participation. The aim of this study was to identify the quality of evidence of physical therapy interventions that address mobility and participation in older patients with VDB and to characterize the used primary and secondary outcomes.

METHODS

A systematic search via MEDLINE (PubMed), Cochrane Library, CINAHL, PEDro, forward citation tracing and hand search was conducted initially in 11/2017 and updated in 7/2019. We included individual and cluster-randomized controlled trials and trials with quasi-experimental design, published between 2007 and 2017/2019 and including individuals ≥65 years with VDB. Physical therapy and related interventions were reviewed with no restrictions to outcome measurement. Screening of titles, abstracts and full texts, data extraction and critical appraisal was conducted by two independent researchers. The included studies were heterogeneous in terms of interventions and outcome measures. Therefore, a narrative synthesis was conducted.

RESULTS

A total of 20 randomized and 2 non-randomized controlled trials with 1876 patients met the inclusion criteria. The included studies were heterogeneous in terms of complexity of interventions, outcome measures and methodological quality. Vestibular rehabilitation (VR) was examined in twelve studies, computer-assisted VR (CAVR) in five, Tai Chi as VR (TCVR) in three, canal repositioning manoeuvres (CRM) in one and manual therapy (MT) in one study. Mixed effects were found regarding body structure/function and activities/participation. Quality of life and/or falls were assessed, with no differences between groups. VR is with moderate quality of evidence superior to usual care to improve balance, mobility and symptoms.

CONCLUSION

To treat older individuals with VDB, VR in any variation and in addition to CRMs seems to be effective. High-quality randomized trials need to be conducted to inform clinical decision making.

TRIAL REGISTRATION

PROSPERO 2017 CRD42017080291 .

Modified Timed Up and Go Test for Tendency to Fall and Balance Assessment in Elderly Patients With Gait Instability

Objective: To compare the results from the modified Timed Up and Go Test (TUG) with posturographic variables, the subjective perception of disability due to gait instability, and the number of falls in a sample of the elderly population with imbalance, to confirm that the TUG Test is a useful clinical instrument to assess the tendency to fall in individuals of this age group.

Materials and Methods: Cross-sectional study conducted in a tertiary university hospital, in 174 people aged 65 years or older with gait instability. Modified TUG Test was performed; time, step count and the need for support during the test were the analyzed variables. They were compared with the number of falls, Computerized Dynamic Posturography scores, and questionnaires scores (Dizziness Handicap Inventory and a shortened version of the Falls Efficacy Scale-International).

Results: The average time to complete the TUG Test was 21.24 ± 8.18 s, and the average step count was 27.36 ± 7.93. One hundred two patients (58.6%) required no support to complete the test, whereas the other 72 (41.4%) used supports. The time taken to complete the Test was significantly related with having or not having fallen in the previous year, with the scores of the questionnaires, and with various parameters of dynamic posturography. A higher percentage of patients who took more than 15 s had fallen in the previous year than those who took up to 15 s to complete the test [P = 0.012; OR = 2.378; 95% CI (1.183, 4.780)]. No significant correlation was found between the step count and the number of falls in the previous year, with falling during the test or not, or with being a single or a frequent faller. No relation was found between the need for supports and the number of falls, with having or not having fallen in the previous year, or with being a single or frequent faller.

Conclusion: The modified TUG Test is in relation with the presence or absence of falls. Time is the essential parameter for analyzing the risk of falling and the 15-s threshold is a good value to differentiate elderly patients at high risk of falling.

Unique Identifier: NCT03034655, www.clinicaltrials.gov.

Vestibular Rehabilitation Using Posturographic System in Elderly Patients with Postural Instability: Can the Number of Sessions Be Reduced?

Purpose

Vestibular rehabilitation (VR) using posturography systems has proved useful in improving balance among elderly patients with postural instability. However, its high cost hinders its use. The objective of this study is to assess whether two different protocols of VR with posturography, one of them longer (ten sessions) and the other shorter (five sessions), show significant differences in the improvement of balance among old patients with instability.

Patients and Methods

This is a prospective, experimental, single-center (Department of Otorhinolaryngology of a tertiary referral hospital), randomized (into balanced patient blocks) study with two parallel arms, in 40 people over 65 years of age, with instability and at a high risk of falling. The percentage of the average balance (composite) in the sensory organization test (SOT) of the CDP (main outcome measure), other CDP scores, time and steps in the "timed up and go" test, scores of Dizziness Handicap Inventory (DHI), short Falls Efficacy Scale - International (short FES-I), and Vertiguard were compared before and 3 weeks after VR between both intervention groups.

Results

The two treatment groups (20 patients per group) were comparable in age, sex, and pre-VR balance evaluation. In both groups, we observed a significant improvement in global balance (composite) after VR (49±11.34 vs 57±13.48, p=0.007, in the group undergoing 10 sessions; 51±12.55 vs 60±12.99, p=0.002, 5 sessions). In both groups, we also observed improvements in other posturographic parameters (in the SOT and limits of stability) but not in the timed up and go scores or in the questionnaires. Comparison of the improvement level achieved in both groups revealed no significant differences between them.

Conclusion

The protocols of vestibular rehabilitation by posturography of 5 sessions in elderly patients with postural instability are as effective as those of 10 sessions for improving balance among elderly patients with postural instability.

Trial Registration

ClinicalTrials.gov identifier: NCT03034655. Registered on 25 January 2017.

Does patient environment have any influence on balance?

BACKGROUND

Although patient environment is a factor to consider when planning a vestibular rehabilitation program, there are no studies correlating this factor to outcomes of balance assessment.

AIM

To evaluate whether there are differences in objective evaluation of balance in elderly patients at risk of falls according to the environment in which they live (urban or rural) and their lifestyle (considering cardiovascular risk factors).

METHODS

Cross-sectional study of a sample of 139 elderly patients with high risk of falls assessed with objective outcome measures: Computer Dynamic Posturography (CDP), and the modified Timed Up-and-Go (TUG) test; and subjective outcome measures: Dizziness Handicap Inventory (DHI) and short Falls Efficacy Scale-International (short FES-I). Rural or urban environment was defined according to administrative and legal criteria.

RESULTS

Elderly patients at risk of fall living in rural environment show better composite results in SOT with better scores in Condition 6 and fewer falls during the CDP. They also require fewer steps to perform the TUG test.

DISCUSSION

The present study provides evidence that patient environment has an influence in balance.

CONCLUSION

Patient environment should be considered when analyze tests evaluating static and dynamic balance.

Prognostic factors that modify outcomes of vestibular rehabilitation in elderly patients with falls

BACKGROUND

Our previous study has shown that vestibular rehabilitation (VR) is an effective technique to reduce falls in elderly patients. It would be interesting to establish patients' clinical characteristics in which vestibular rehabilitation is expected to be more effective.

AIMS

Evaluate factors that could modify rehabilitation outcomes in elderly patients with previous falls.

METHODS

Fifty-seven patients randomized to one of the intervention group (computerized dynamic posturography-CDP-training, optokinetic stimulus or exercise at home) and with previous falls were analyzed. Patients were assessed with objective outcome measures (sensorial organization test and limits of stability-LOS-of CDP, modified timed up and go test-TUG-and number of falls) and with subjective outcome measures (dizziness handicap inventory and Short falls efficacy scale-international-Short FES-I) during a 12-month follow-up period.

RESULTS

In the logistic regression model, a worse score in the maximum excursion (MXM), and a shorter time in the TUG significantly associated with a reduction > 50% of falls. Also, association with a higher score in the Short FES-I was close to a statistical significance. There was no statistical significance association with other covariables.

DISCUSSION

In patients with reduced limits of stability, VR seems to be more effective and they should be encouraged to perform it. But on the other hand, patients with longer time in the TUG show worse outcomes and may benefit more with gait training.

CONCLUSIONS

VR in elderly people with previous falls is effective regardless of their age and gender.

Frequency analyses of posturography using logarithmic translation

Background: Power-spectral analysis of the centre of pressure (CoP) frequencies of posturography provides exponentially approximated distributions, whereas logarithmic translation enables linear approximation.Objectives: Frequency analyses were adopted for posturography of healthy subjects and patients with spinocerebellar degeneration (SCD) using logarithmic translation to determine its clinical usefulness for managing the elderly and patients with disequilibrium.Material and methods: We included 172 healthy subjects and 47 SCD patients. Posturography was performed with the eyes fixated and closed, with and without foam rubber. The power-spectral data of the CoP were obtained with the maximum entropy method. Power-spectral data were logarithmically translated for quantitative evaluation.Results: For teenagers, high-frequency fluctuations were dominant and attributable to proprioceptive compensation due to immature postural control. In elderly populations, the increased frequency in the lateral direction was characterised by three peaks indicating postural disturbances attributed to three sensory inputs. The disappearance of one peak in the anteroposterior fluctuation indicates a decrease in vestibular contribution. The foam rubber and the closed-eye condition enhanced fluctuations in two peaks. There were differences in power-spectral distributions of two peaks between the healthy subjects and SCD patients.Conclusions: Logarithmic power-spectral data distribution could provide an age- and disease-specific novel and visually-comprehensible parameter.