A systematic review about the effects of the vestibular rehabilitation in middle-age and older adults

Abstracts

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. CONCLUSIONS: The studies included in this review provide evidence for the positive effects of VR in elderly and middle-aged adults with vestibular disturbances.

vestibular diseases; rehabilitation; older adults

OBJETIVO: Sistematizar os resultados de ensaios clínicos sobre reabilitação vestibular (RV) em indivíduos de meia-idade e idosos com distúrbios vestibulares. MÉTODOS: A busca de publicações sobre a RV em indivíduos com distúrbios vestibulares foi realizada nas bases de dados LILACS, EMBASE, MEDLINE, SciELO, Cochrane, ISI Web of Knowledge e bibliotecas virtuais de teses e dissertações. Foram selecionados ensaios clínicos aleatórios e controlados dos últimos 10 anos em língua inglesa, portuguesa e espanhola. A qualidade metodológica dos estudos foi avaliada pela escala PEDro. A análise dos resultados dos estudos foi feita por meio de revisão crítica dos conteúdos. RESULTADOS: Nove estudos foram revisados na íntegra, sendo a faixa etária dos participantes acima de 40 anos (n=4) e composta exclusivamente por idosos (n=5). Os achados de disfunção vestibular foram diversificados, sendo os mais comuns queixa de desequilíbrio corporal ou instabilidade postural (n=3) e queixa de vertigem ou tontura (n=3). A Escala Visual Analógica (EVA) foi o instrumento mais utilizado para avaliar a percepção subjetiva da sintomatologia da disfunção vestibular (n=4). A escala PEDro revelou que quatro dos artigos apresentaram delineamento de boa qualidade para a condução do estudo experimental. A proposta de intervenção mais utilizada foi o protocolo de Cawthorne & Cooksey (n=4). Os estudos que compararam a RV com outro tipo de intervenção não apresentaram, na maioria dos desfechos analisados, diferença entre os grupos após a terapia. CONCLUSÃO: Estudos aleatorizados controlados disponibilizaram evidências de efeitos positivos da RV em idosos e adultos de meia-idade com distúrbios vestibulares.

tontura; doenças vestibulares; reabilitação; idosos

SYSTEMATIC REVIEW

A systematic review about the effects of the vestibular rehabilitation in middle-age and older adults

Natalia A. Ricci^I; Mayra C. Aratani^II; Flávia Doná^III; Camila Macedo^IV; Heloísa H. Caovilla^IV; Fernando F. Ganança^IV

^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

Correspondence to

ABSTRACT

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.

Introduction

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 frequent^1,2 .

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 capacity^2,3.

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 depression^4,5. 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.

Methods

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.

Results

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.

Sample characteristics

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 women^{28,29,31,33-35}. The data on vestibular dysfunction were variable among the studies, with the most common complaints being body imbalance or postural instability^28,32,35, and dizziness or vertigo^31,33,35. The topography of the vestibular dysfunction was rarely reported, with the most common being vestibular hypofunction^27,29. To obtain the topographic diagnosis of the vestibular syndrome, studies employed electronystagmography^29,30,32 and other tests such as tone threshold audiometry^28,32 , rotatory chair test^27,29,33, 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.

Outcomes

Primary outcomes: The subjective perception of vestibular dysfunction symptoms was assessed in the majority of the studies^{27,28,30-33,35}, and the Visual Analogue Scale (VAS)^27,31,32,35 was the instrument most commonly used for this purpose. Other frequently used outcomes included static^28,30-33,35 and dynamic^30,31,33,35 body balance. Functional scales that evaluate the impact of dizziness in activities of daily living and in quality of life were applied in four studies^30,32-34, with the Dizziness Handicap Inventory (DHI) being the most commonly used^30,33.

Secondary outcomes: The laboratory tests used in the studies were computerized posturography^28,32,35 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 groups^{27,28,30,31,33-35}, or between the VR group and the other active treatment group^29,32 . 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).

Intervention protocol

The experimental intervention most commonly used was the VR protocol from Cawthorne & Cooksey^28,32-34. In most studies, participants were instructed to perform home exercises, which were assisted by information leaflets^27-30,33. In three studies^27,28,30, 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 studies^28,29,33, home exercises complemented the therapy performed in the rehabilitation center. In most studies, exercises were performed in groups^29,31,33-35 and were administered weekly^29,33 or twice a week^31,34,35. The total treatment duration varied between the minimum of five³⁴ to the maximum of 20 weeks^28,30.

Most studies compared the VR protocol with a control group formed by participants who did not perform any type of exercise^{28,30,31,33-35}, 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 intervention^29,32 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 exercises^27,30 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 studies^27,31,32,35 that evaluated the symptoms of dizziness through the VAS, two^32,35 found a significant improvement after intervention. Regarding static balance, there was an improvement in two^{31, 35} of the six studies^{28, 30-33,35} that examined this outcome; similarly, only two studies^33,35 showed results favoring the experimental intervention in terms of gait^29-31,33,35.

None of the studies included in this review reported adverse effects related to VR.

Discussion

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 studies^27,32,33,35 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 dizziness^31,35, oscillopsia²⁷, postural instability³⁵ and/or body imbalance^27,28,32 . 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 DHI^30,33, 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 static^30,31,33,35 and dynamic^30,31 balance, functional scales³⁰, and computerized posturography^28,32-35. 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 studies^28,32,35 using computerized posturography, stood out the limits of stability³² , the latency until the beginning of movement³² , the displacement of the center of pressure^28,35 and the influence of sensory interaction on body balance^28,35. 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 imbalance^27-35. 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 VR^{28,29,31,33-35} and home exercises^27-30,33. 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 & Cooksey^28,32-34, the adaptation exercises of Herdman³⁹ and static and dynamic body balance exercises^27,29-31,35. 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 & Cooksey^{28,32 -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 population^{40, 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.

References

References

• 1. Massion J. Postural control systems in developmental perspective. Neurosci Biobehav Rev. 1998;22(4):465-72.
• 2. Nashner LM, Black FO, Wall C. Adaptation to altered support and visual conditions during stance: patients with vestibular deficits. J Neurosci. 1982;2(5):536-44.
• 3. Gazzola JM, Perracini MR, Ganança MM, Ganança FF. Fatores associados ao equilíbrio funcional em idosos com disfunção vestibular crônica. Rev Bras Otorrinolaringol. 2006;72(3):983-90.
• 4. Gazzola JM, Ganança FF, Perracini MR, Aratani MC, Dorigueto RS, Gomes CMC. O envelhecimento e o sistema vestibular. Fisioter Mov. 2005;18(5):39-48.
• 5. Hansson EE. Vestibular rehabilitation: for whom and how? A systematic review. Adv Physiother. 2007;9:106-16.
• 6. Ganança FF, Ganança CF. Reabilitação vestibular: princípios e técnicas. In: Ganança MM, Caovilla HH, Munhoz MSL, Silva MLG, editores. Estratégias terapêuticas em otoneurologia. São Paulo: Atheneu; 2001. p. 33-54.
• 7. PEDro - physiotherapy evidence database [homepage na Internet]. Sydney: School of Physiotherapy- University of Sydney, Inc.; c2008 [atualizada em 2008; acesso em 16 Out 2008]. Disponível em: http://www.pedro.org.au
• 8. Enticott JC, Vitkovic JJ, Reid B, O'Neill P, Paine M. Vestibular rehabilitation in individuals with inner-ear dysfunction: a pilot study. Audiol Neurootol. 2008;13(1):19-28.
• 9. Tanimoto H, Doi K, Katata K, Nibu K. Self-treatment for benign paroxysmal positional vertigo of the posterior semicircular canal. Neurology. 2005;65(8):1299-300.
• 10. Cohen HS, Kimball KT. Effectiveness of treatments for benign paroxysmal positional vertigo of the posterior canal. Otol Neurotol. 2005;26(5):1034-40.
• 11. Chang WC, Yang YR, Hsu LC, Chern CM, Wang RY. Balance improvement in patients with benign paroxysmal positional vertigo. Clin Rehabil. 2008;22(4):338-47.
• 12. Venosa AR, Bittar RS. Vestibular rehabilitation exercises in acute vertigo. Laryngoscope. 2007;117(8):1482-7.
• 13. Yardley L, Donavan-Hall M, Smith HE, Walsh BM, Mullee M, Bronstein AM. Effectiveness of primary care-based vestibular rehabilitation for chronic dizziness. Ann Intern Med. 2004;141:598-605.
• 14. McGibbon CA, Krebs DE, Wolf SL, Wayne PM, Scarborough DM, Parker SW. Tai Chi and vestibular rehabilitation effects on gaze and whole-body stability. J Vestib Res. 2004;14(6):467-78.
• 15. Kammerlind AS, Ledin TE, Odkvist LM, Skargren EI. Effects of home training and additional physical therapy on recovery after acute unilateral vestibular loss: a randomized study. Clin Rehabil. 2005;19(1):54-62.
• 16. Pavlou M, Lingeswaran A, Davies RA, Gresty MA, Bronstein AM. Simulator based rehabilitation in refractory dizziness. J Neurol. 2004;251(8):983-95.
• 17. Cohen HS, Kimball KT. Decreased ataxia and improved balance after vestibular rehabilitation. Otolaryngol Head Neck Surg. 2004;130(4):418-25.
• 18. Cohen HS, Kimball KT. Changes in a repetitive head movement task after vestibular rehabilitation. Clin Rehabil. 2004;18(2):125-31.
• 19. Cohen HS, Kimball KT. Increased independence and decreased vertigo after vestibular rehabilitation. Otolaryngol Head Neck Surg. 2003;128(1):60-70.
• 20. Teggi R, Caldirola D, Fabiano B, Recanati P, Bussi M. Rehabilitation after acute vestibular disorders. J Laryngol Otol. 2009;123(4):397-402.
• 21. Barozzi S, Berardino F, Arisi E, Cesarini A. A comparison between oculomotor rehabilitation and vestibular electrical stimulation in unilateral peripheral vestibular deficit. Int Tinnitus J. 2006;12(1):45-9.
• 22. Topuz O, Topuz B, Ardiç FN, Sarhus M, Ogmen G, Ardiç F. Efficacy of vestibular rehabilitation on chronic unilateral vestibular dysfunction. Clin Rehabil. 2004;18(1):76-83.
• 23. Angeli SI, Hawley R, Gomez O. Systematic approach to benign paroxysmal positional vertigo in the elderly. Otolaryngol Head Neck Surg. 2003;128(5):719-25.
• 24. Hånsson EE, Månsson NO, Ringsberg KA, Håkansson A. Falls among dizzy patients in primary healthcare: an intervention study with control group. Int J Rehabil Res. 2008;31(1):51-7.
• 25. Silveira SR, Taguchi CK, Ganança FF. Análise comparativa de duas linhas de pesquisa de tratamento para pacientes portadores de disfunção vestibular periférica com idade superior a sessenta anos. Acta ORL (online). 2003;21(1):2-10.
• 26. Santos AC, Ferreira CP, Silva KC, Lima VVAF. Exercícios de Cawthorne e Cooksey em idosas: melhora do equilíbrio. Fisioter Mov. 2008;21(4):129-36.
• 27. Herdman SJ, Hall CD, Schubert MC, Das VE, Tusa RJ. Recovery of dynamic visual acuity in bilateral vestibular hypofunction. Arch Otolaryngol Head Neck Surg. 2007;133(4):383-9.
• 28. Prasansuk S, Siriyananda C, Nakorn AN, Atipas S, Chongvisal S. Balance disorders in the elderly and the benefit of balance exercise. J Med Assoc Thai. 2004;87(10):1225-33.
• 29. McGibbon CA, Krebs DE, Parker SW, Scarborough DM, Wayne PM, Wolf SL. Tai Chi and vestibular rehabilitation improve vestibulopathic gait via different neuromuscular mechanisms: preliminary report. BMC Neurology. 2005;5(3):1-12.
• 30. Vereeck L, Wuyts FL, Truijen S, De Valck C, Van de Heyning PH. The effect of early customized vestibular rehabilitation on balance after acoustic neuroma resection. Clin Rehabil. 2008;22(8):698-713.
• 31. Hånsson EE, Mansson NO, Håkansson A. Effects of specific rehabilitation for dizziness among patients in primary health care. A randomized controlled trial. Clin Rehabil. 2004;18(5):558-65.
• 32. Simoceli L, Bittar RSM, Sznifer J. Eficácia dos exercícios de adaptação do reflexo vestíbulo-ocular na estabilidade postural do idoso. Arq Int Otorrinolaringol. 2008;12(2):183-8.
• 33. Johansson M, Åkerlund D, Larsen HC, Andersson G. Randomized controlled trial of vestibular rehabilitation combined with cognitive-behavioral therapy for dizziness in older people. Otolaryngol Head Neck Surg. 2001;125(3):151-6.
• 34. Resende CR, Taguchi CK, Almeida JG, Fujita RR. Reabilitação vestibular em pacientes idosos portadores de vertigem posicional paroxística benigna. Rev Bras Otorrinolaringol. 2003;69(4):34-8.
• 35. Kammerlind AS, Håkansson JK, Skogsberg M. Effects of balance training in elderly people with nonperipheral vertigo and unsteadiness. Clin Rehabil. 2001;15(5):463-70.
• 36. Ganança MM, Caovilla HH, Munhoz MSL, Silva MLG. Introdução: as vestibulopatias periféricas, centrais e mistas. In: Silva MLG, Munhoz MSL, Ganança MM, Caovilla HH, editores. Quadros clínicos otoneurológicos mais comuns. São Paulo: Atheneu; 2000. p. 1-8.
• 37. Whitney SL, Wrisley DM, Marchetti GF, Furman JM. The effect of age on vestibular rehabilitation outcomes. Laryngoscope. 2002;112(10):1785-90.
• 38. Hillier SL, Holohan V. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database Syst Rev. 2007;17(4):CD005397.
• 39. Herdman SJ. Reabilitação vestibular. São Paulo: Manole; 2002.
• 40. Pereira MM, Oliveira RJ, Silva MAF, Souza LHR, Vianna LG. Efeitos do Tai Chi Chuan na força dos músculos extensores dos joelhos e no equilíbrio em idosas. Rev Bras Fisioter. 2008;12(2):121-6.
• 41. Li F, Harmer P, Fisher KJ, McAuley E. Tai Chi: improving functional balance and predicting subsequent falls in older persons. Med Sci Sports Exerc. 2004;36(12):2046-52.
• 42. Enloe LJ, Shields RK. Evaluation of health-related quality of life in individuals with vestibular disease using disease-specific and general outcome measures. Phys Ther. 1997;77(9):890-903.

Publication Dates

• Publication in this collection
  10 Dec 2010
• Date of issue
  Oct 2010

History

• Reviewed
  13 Oct 2009
• Received
  19 May 2009
• Accepted
  12 Dec 2009