Effectiveness of conventional versus virtual reality-based vestibular rehabilitation exercises in elderly patients with dizziness: a randomized controlled study with 6-month follow-up

Kanyılmaz, Tuba; Topuz, Oya; Ardıç, Fazıl Necdet; Alkan, Hakan; Öztekin, Saadet Nur Sena; Topuz, Bülent; Ardıç, Füsun

doi:10.1016/j.bjorl.2021.08.010

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Brazilian Journal of Otorhinolaryngology

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Sumário

Original article • Braz. j. otorhinolaryngol. 88 (Suppl 3) • Nov-Dec 2022 • https://doi.org/10.1016/j.bjorl.2021.08.010 copy

Effectiveness of conventional versus virtual reality-based vestibular rehabilitation exercises in elderly patients with dizziness: a randomized controlled study with 6-month follow-up

Authorship SCIMAGO INSTITUTIONS RANKINGS

Highlights

Vestibular rehabilitation supported with virtual reality appears to be effective in elderly patients with dizziness.

Virtual reality-based vestibular rehabilitation is superior to conventional vestibular rehabilitation therapy alone.

The implementation of the virtual reality environment in the vestibular rehabilitation program may be useful.

Abstract

Objectives:

To investigate the effect of vestibular rehabilitation exercises supported with virtual reality containing real-life environments on dizziness, static and dynamic balance, functional mobility, fear of falling, anxiety, and depression in elderly patients with dizziness.

Methods:

In this prospective randomized controlled study, 32-patients aged 65-years and older who applied to the otorhinolaryngology clinic with dizziness complaint randomly assigned to 2 groups. In Group 1 (n = 16), vestibular rehabilitation program, supported with virtual reality, and in Group 2 (n = 16), conventional vestibular rehabilitation program was applied 30-min a day, 5 sessions per week, 15 sessions in total for 3 weeks. Subjects were evaluated with The Vertigo Symptom Scale (VSS), Dizziness Handicap Inventory (DHI), Berg Balance Test (BBT) and Timed Up & Go Test (TUG), Falls Efficacy Scale-International (FES-I), Postural Stability Test (PST), Geriatric Depression Scale (GDS), Hamilton Anxiety Scale (HAS) at baseline, at the end of the treatment and 6-months after the treatment.

Results:

Statistically significant improvements were seen in the DHI emotional subscale and TUG in Group 1 compared to Group 2 at the end of the treatment in elderly with dizziness (p<0.05). Also, there were significant improvements in the VSS, all DHI subgroups, and total scores, BBT, HAS in Group 1 compared to Group 2 at the 6-months after the treatment (p<0.05).

Conclusion:

The application of vestibular rehabilitation in a virtual reality environment can lead to additional improvements especially in dizziness symptoms, disability, balance, and mobility in the elderly with chronic dizziness.

Keywords
Virtual reality; Vestibular rehabilitation; Dizziness; Elderly

Vestibular exercise program

Exercises for eye movements

Smooth- Pursuit Eye Movements: The patient is asked to move their eyes at first slowly and then quickly in horizontal and vertical directions (10-times). In the 1^st week while sitting, in the 2^nd week while standing, and in the 3^rd week while standing on soft ground.

Saccadic eye movements: The patient is asked to focus by moving their eyes 1-time per second to 2-targets 30 cm away from each other (10-times). Motion is applied in horizontal and vertical directions. While sitting on the 1^st week, standing on the 2^nd week, and standing on soft ground for the 3^rd week.

Exercises for gaze stability

Training of Vestibulo-ocular reflex: 1) The patient is asked to move their headfirst in horizontal, then in vertical directions for 1-minute, focusing on a fixed object. While sitting on the 1^st week, standing on the 2^nd week, and standing on soft ground for the 3^rd week. 2) The patient is asked to move their headfirst in horizontal, then in vertical directions for 1-minute, focusing on a moving object. While sitting on the 1^st week, standing on the 2^nd week, and standing on soft ground for the 3rd week.

Training of Cervico-ocular reflex: The patient sitting on a rotating chair is asked to move their torso to the right and left, keeping his head steady by focusing on a fixed object (10-times). It is conducted in the 1^st and 2^nd weeks.

Exercises for postural stability

Standing up: 1) Week: Bend forward and side to side while sitting, pass from sitting position to standing position and back to sitting position (10-times), standing in various positions (feet together, tandem position) (15 s), marching in place (10-times) is requested. 2) Week: Bending their body front and back, and to their sides (10 front and back, 10 to the sides) while standing, standing in various positions (feet together, tandem position) (15 s), marching in place (10-times) is requested. 3) Week: The exercises in the 2^nd week are conducted on soft ground.

Walking: Patients conduct their exercises while walking at a pace of 1.6 km/h on the treadmill. 1)Week: They are asked to walk forward on the treadmill (1-min). 2) Week: They are asked to walk on the treadmill while moving their head left-right, front-back (1-min). 3) Week: They are asked to walk on the treadmill while focusing on a fixed object and moving their heads first horizontally and then vertically (1-min)

	Group 1 (n = 13)	Group 2 (n = 13)	p
Age (years) median (IQR)	70.00 (6.00)	70.00 (5.00)	0.500
Gender, n (%)
Female	7 (53.8)	9(69.2)	0.420
Male	6 (46.2)	4 (30.8)
BMI (kg/m ² ) median (IQR)	28.40 (5.20)	29.40 (5.70)	0.663
Chronic disease, n (%)
None	6 (46.2)	2 (15.4)	0.211
One	3 (23.1)	6 (46.2)
More than one	4 (30.8)	5 (38.5)
Smoker, n (%)
Current smoker		1 (7.7)	0.308
Never	13 (100)	12 (92.3)
Alcohol, n (%)	–
User	1 (7.7)	–	0.308
Not user	12 (92.3)	13 (100)
Medication, n (%)
None	5 (38.5)	2 (15.4)	0.412
Less than three	6 (6.2)	8 (61.5)
More than three	2 (15.4)	3 (23.1)
Mini-Mental State Test, Median (IQR)	28.00 (1.5)	27.00 (2.00)	0.179
Lower extremity muscle strength, Median (IQR)	14.00 (3.00)	12.00 (4.00)	0.778
Lower extremity sensory examination, n (%)
Normal	12 (92.3)	10 (76.9)	0.277
Abnormal	1 (7.7)	3(23.1)
Eye movements, n (%)
Normal	13 (100)	13 (100)	1.00
Abnormal	–	–
Orthostatic hypotension, n (%)
Present	3 (23.1)	4 (30.8)	0.658
Absent	10 (76.9)	9 (69.2)
Cerebellar test, n (%)
Normal	13 (100)	13 (100)
Abnormal	–	–	1.00
Fall history, n (%)
None	10 (76.9)	8 (61.5)	0.543
One,	1 (7.7)	3 (23.1)
More than one	2 (15.4)	2 (15.4)
Fracture history n (%)
Present	–	1 (7.7)	0.308
Absent	13 (100)	12 (92.3)

	Group 1 Median (IQR)	Group 2 Median (IQR)	p
VSS
PreT	9.00 (11.00)	15.00 (18.00)	0.258
PostT	4.00 (6.50)	11.00 (18.00)	0.257
PostT6M	4.00 (10.00)	10.00 (11.50)	0.025
DHI Functional
PreT	16.00 (12.00)	24.00 (16.00)	0.236
PostT	8.00 (14.00)	20.00 (18.00)	0.188
PostT6M	2.00 (12.50)	22.00 (14.50)	0.032
DHI Emotional
PreT	14.00 (12.00)	8.00 (19.00)	0.918
PostT	4.00 (6.00)	10.00 (15.00)	0.046
PostT6M	0.00 (7.00)	8.00 (18.00)	0.049
PreT	14.00 (12.00)	8.00 (19.00)	0.918
DHI Physical
PreT	18.00 (17.00)	12.00 (12.00)	0.661
PostT	6.00 (11.00)	12.00 (15.00)	0.353
PostT6M	4.00 (12.00)	14.00 (11.00)	0.047
DHI Total
PreT	50.00 (37.00)	48.00 (43.00)	0.625
PostT	18.00 (28.00)	42.00 (38.00)	0.117
PostT6M	8.00 (25.00)	44.00 (35.00)	0.015

	Group 1 Median (IQR)	Group 2 Median (IQR)	p
BBT
PreT	50.00 (6.00)	51.00 (6.00)	0.737
PostT	54.00 (3.00)	52.00 (5.00)	0.108
PostT6M	54.00 (4.00)	51.00 (5.00)	0.042
PST-GSI
PreT	1.20 (0.55)	1.30 (0.85)	0.604
PostT	1.00 (0.75)	0.80 (0.50)	0.777
PostT6M	1.00 (0.45)	1.00 (0.40)	0.979
PST-APSI
PreT	0.90 (0.55)	0.80 (0.45)	0.661
PostT	0.50 (0.55)	0.60 (0.50)	0.470
PostT6M	0.70 (0.35)	0.70 (0.40)	0.757
PST-MLSI
PreT	0.70 (0.40)	0.80 (0.50)	0.502
PostT	0.50 (0.50)	0.50 (0.30)	0.816
PostT6M	0.50 (0.35)	0.40 (0.40)	0.897
FRI
PreT	1.10 (0.50)	1.20 (0.45)	0.439
PostT	0.80 (0.80)	0.70 (0.40)	0.643
PostT6M	0.80 (0.55)	1.00 (0.35)	0.222
TUG
PreT	14.00 (2.50)	15.00 (5.00)	0.286
PostT	11.00 (1.50)	13.00 (4.50)	0.004
PostT6M	13.00 (4.50)	14.00 (6.00)	0.368

	Group 1 Median (IQR)	Group 2 Median (IQR)	p
IFES
PreT	25.00 (18.00)	25.00 (19.00)	0.778
PostT	19.00 (7.00)	26.00 (11.00)	0.123
PostT6M	21.00 (10.50)	26.00 (17.00)	0.205
GDS
PreT	7.00 (11.50)	8.00 (8.00)	0.328
PostT	6.00 (6.50)	9.00 (8.00)	0.246
PostT6M	7.00 (9.00)	12.00 (11.00)	0.302
HAS
PreT	3.00 (6.00)	6.00 (4.00)	0.551
PostT	1.00 (3.50)	2.00 (8.50)	0.176
PostT6M	1.00 (2.00)	5.00 (6.50)	0.008

Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Sede da Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico Facial, Av. Indianópolia, 1287, 04063-002 São Paulo/SP Brasil, Tel.: (0xx11) 5053-7500, Fax: (0xx11) 5053-7512 - São Paulo - SP - Brazil
E-mail: revista@aborlccf.org.br

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[1] * Corresponding author. E-mail: alkangsc@yahoo.com (H. Alkan).