Efficacy and Comparison of Vestibular Rehabilitation Exercises on Quality of Life in Patients with Vestibular Disorders

Abstract

Vertigo is the sensation of spinning or having one’s surroundings spin about them. It represents about 25% of cases of occurrences of dizziness Yardley et al. (Br J Gen Pract 48(429):1131–1135, 1998). About 40% patients have peripheral vestibular dysfunction (Neuhauser in Curr Opin Neurol 20:40–46, 2007). Quality of life (QOL) is significantly impaired by vertigo (Patatas et al. in Braz J Otorhinolaryngol 75:387–394, 2009). To study the effect and compare vestibular exercises on QOL in patients with vestibular disorders. 120 individuals with vestibular disorders like acoustic neuroma, vestibular neuritis, labyrinthitis, Meniere’s disease, vestibulopathy, ISSNHL and ototoxicity were included. Four groups adaptation exercises, habituation exercises, substitution exercises, and combined exercises were formed and 30 individuals were selected in each group randomly. Vestibular activities and participation (VAP) was administered before and after exercises to fulfill the aim. VAP Scale results revealed significant difference between pre and post treatment score in all groups, suggestive of positive effect on QOL in patients with vestibular disorders. Improvements in VAP Score between all groups were compared and significant difference was observed. Combined exercises group found to be best out of 4 exercises group.

Introduction

In situations of sensory information conflict, individual fells unstable or dizzy. Dizziness is an impairment in spatial perception and stability. The term dizziness is imprecise: it can refer to vertigo, presyncope, disequilibrium, or a non-specific feeling such as giddiness or foolishness.

Vertigo is the sensation of spinning or having one’s surroundings spin about them. Many people find vertigo very disturbing and often report associated nausea and vomiting. It represents about 25% of cases of occurrences of dizziness [23]. About 40% patients have peripheral vestibular dysfunction [15, 23].

The Vestibular Rehabilitation protocols are considered effective at reducing dizziness and its consequences. Treatment of vestibular deficits reduces the burden of fall related injuries and improves quality of life. Vestibular exercises improve balance, decrease risk of falling, decrease dizziness, and improve quality of life. Vestibular exercises improve vestibulospinal compensation in patients with acute peripheral vestibular disorders. Vestibular adaptation exercises result in improved postural stability and in a diminished perception of disequilibrium in both the chronic and acute stages. Vestibular adaptation exercises have also been shown to produce a more rapid recovery during the acute stage following unilateral vestibular loss [12]. Vestibular Rehabilitation 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. VR can promote complete healing in 30% of patients and improvement of different degrees in 85% of patients. 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 Norré.

Subjects and Methods

Aim of present research was to study the effect and compare vestibular exercises on quality of life in patients with vestibular disorders. Total 120 individuals were included in this study with patients with vestibular disorders like acoustic neuroma, vestibular neuritis, labyrinthitis, Meniere’s disease, vestibulopathy, ISSNHL and ototoxicity. Present study included the patients who treated medically first by ENT. After completion of medication, VAP was administered and it was found that still they had issues in quality of life hence vestibular rehabilitation exercises were given to them to improve their quality of life.

Patients who refuse to give written consent and patients did not come for follow-up were excluded from study. Patients who had neurological disorder were excluded from study and no medication was prescribed to the patients during this study.

4 groups were made, 1st adaptation exercises, 2nd habituation exercises, 3rd substitution exercises, and 4th combined exercises group to measure the efficacy and compare exercises, each group had 30 patients, selected randomly. A tailor-made exercise program was made individually based on patients need and complaint. Vestibular activities and participation (VAP) Scale based on international classification of functioning (ICF), disability and health were administered pre and post exercises to evaluate efficacy. Results of 4 groups were compared to find which exercises provides better quality of life in patients with vestibular disorders.

VAP includes domains like attention, daily routine, psychological demands, travelling, job, recreation, and socialization. VAP was developed by Alghwiri in 2012 in English [4]. VAP was adopted in Indian context and translated in Hindi with prior permission from author and reverse translation was done as WHO and authors recommendation. Questions were asked by the clinician and the rating was done on each task. Total score was obtained by calculating the average score without considering NA (not applicable) none = 0, mild = 1, moderate = 2, severe = 3, unable to do = 4, maximum score = 4, minimum score = 0 [1].

Vestibular Rehabilitation Exercises are based on strengthening vestibular reflexes. Adaptation exercises are mainly based on vestibulo-ocular reflex, habituation and substitution exercises are mainly based on vestibulo-spinal reflex [16]. These exercises help in improving balance and stability [18]. In present study we also used combination of adaptation, habituation and substitution exercises. Combined exercises were selected based on patient’s requirement and these were tailor made for each patient [4, 6, 10].

1. Adaptation exercises:

   • Gaze stability
   • Ocular control exercises

     • Eye movements—at first slow, then quickly

       1. Up and down
       2. From side to side
       3. Focusing on finger moving from 3 feet to 1 foot away from face
   • Horizontal and diagonal head movements

     • Head movements at first slow, then quick; later with eyes closed

       1. Bending forwards and backwards
       2. Turning from side to side
2. Habituation exercises:

   • Balance exercises

     • Touching front wall
     • Ankle sways
     • Circle with a ball
     • Ball Diagonals
   • Gait exercises

     • Walking exercise
     • Sit to stand
     • Gait with a Focal Point

       1. Repetitive exposure to the specific movement that provokes dizziness
       2. Exercises to be done when moving about
     • Circle round centre person who will throw a large ball and to whom it will be returned
     • Walk across room with eyes open and then closed
     • Walk up and down slope with eyes and then closed
     • Walk up and down steps with eyes open and then closed
     • Any game involving stooping or stretching and aiming e.g. basket-ball
3. Substitution exercises

   • Sitting

     • Shoulder shrugging and circling
     • Bending forwards and picking up objects from the ground Standing
     • Changing from sitting to standing position with eyes open and shut
     • Throwing a small ball from hand to hand (above eye level)
     • Throwing ball from hand to hand under knee
     • Change from sitting to standing and turning around in between

On completion of pre-treatment evaluation all exercises were administered using standard protocol. VAP scale was administered after 15 days of exercise. Results were tabulated and Statistical analysis was done using appropriate tools.

Results

All patients gave written consent. 24 patients excluded from study as they did not come for follow up. Out of 120 patients 75 (62.5%) were females and 45 (37.5%) were males with mean age of 49.89 years.

VAP Scale Scores Pre and Post Treatment

VAP scores pre and post-treatment were compared using paired t test for adaptation, habituation, substitution, and combined exercises.

VAP mean score pre and post adaptation exercises were 2.89 with SD 0.14 and 1.45 with SD 1.00 respectively. Paired t test shows highly significant difference between VAP scores pre and post adaptation exercises with P value 0.0008 (Table 1).

Table 1.

Mean VAP scores, SD, and P value within 4 groups

Variables	VAP Scale Scores	Mean	SD	P value	Results
Adaptation exercises	Before exercises	2.89	0.14	0.0008	HS
	After exercises	1.45	1.00
Habituation exercises	Before exercises	3.00	0.13	0.0004	HS
	After exercises	1.145	0.88
Substitution exercises	Before exercises	3.02	0.14	0.0009	HS
	After exercises	1.85	1.01
Combined exercises	Before exercises	3.01	0.25	0.0006	HS
	After exercises	1.01	0.66

VAP mean score pre and post habituation exercises were 3.00 with SD 0.13 and 1.14 with SD 0.88 respectively. Paired t test shows highly significant difference between VAP scores pre and post habituation exercises with P value 0.0004 (Table 1).

VAP mean score pre and post substitution exercises were 3.02 with SD 0.14 and 1.85 with SD 1.01 respectively. Paired t test shows highly significant difference between VAP scores pre and post substitution exercises with P value 0.0009 (Table 1).

VAP mean score pre and post combined exercises were 3.01 with SD 0.25 and 1.01 with SD 0.66 respectively. Paired t test shows highly significant difference between VAP scores pre and post combined exercises with P value 0.0006 (Table 1).

To compare the effect of vestibular exercises, VAP scores pre and post-treatment were compared using AONVA. On ANOVA test before vestibular exercises, no significant different was found between all 4 groups. Table 2 shows results of ANOVA.

Table 2.

ANOVA test results indicative of no significant difference before vestibular exercises and significant difference after exercises

Variables	VAP Scale Scores	Mean	SD	P value ANOVA	Result
Adaptation exercises	Before exercises	2.89	0.14	0.873	NS
Habituation exercises	Before exercises	3.00	0.13
Substitution exercises	Before exercises	3.02	0.14
Combined exercises	Before exercises	3.01	0.25
Adaptation exercises	After exercises	1.45	1.00	0.0419	S
Habituation exercises	After exercises	1.145	0.88
Substitution exercises	After exercises	1.85	1.01
Combined exercises	After exercises	1.01	0.66

Comparison of improvement on VAP Results between 4 groups:

Improvement was calculated by subtracting post-treatment VAP score from pre-treatment VAP scores in all 4 groups i.e. adaptation, habituation, substitution, and combined exercises group. Improvement was compared between groups with ANOVA, statistically significant difference was found between 3 groups (Table 3).

Table 3.

Mean improvement of VAP scores and P value between 4 groups

Group	Mean improvement of VAP scores	P value ANOVA
Adaptation exercises	1.44	0.04
Habituation exercises	1.85
Substitution exercises	1.17
Combined exercises	2.00

While seen individual patients in each sub group it was found that combined exercises provide best outcomes in terms of significant improvement on quality of life in patients with vestibular disorder. Explained in Fig. 1.

Fig. 1.

Comparison between exercises

Discussion

Present study observed that mean age of patients with vestibular disorder was 49.89 years which is in correlation with previous studies [2, 15]. In present study gender distribution revealed that females were 62.50% however previous studies showed that female is to male ratio is higher which is 75 to 85% [8, 9].

In this study significant difference was found between pre and post-treatment mean VAP scores between adaptation, habituation, substitution, and combined exercises group. This reveals that all 4 methods had positive effect on quality of life in patients with vestibular disorders [7, 11, 13, 17, 20, 21]. To find which method is better, improvement in VAP scores were compared and significant difference was found among all 4 groups. Maximum improvement mean score was observed in combined exercises group than habituation exercises group, then adaptation exercises group and least improvement mean score was observed in substitution exercises group. This finding was consistent with the study done by others assessing quality of life using other scales [6, 8]. There are no studies in best knowledge of authors done until now using VAP scale.

During the 40 s, physician Cooksey and the physical therapist Cawthorne, proposed the use of exercises with the goal of treating vestibular disorders. The program was based on a series of eye, head and body movements, usually in the positions in which the rotational dizziness was triggered and which should be done according to the patient’s tolerance and his individual needs [24]. Considered as a therapeutic approach, vestibular exercises try to bring about an improvement in global balance, quality of life, restoring special orientation to as close as possible to physiological conditions. This recovery happens by means of vestibular compensation. Besides these mechanisms, there may also be adaptation, habituation and substitution. As far as adaptation is concerned, the vestibular system can learn again to receive and process information, even when distorted or incomplete, adapting itself to the stimuli presented in order to recover from the altered reflex. Habitation tackles the symptoms, being based on the reduction of sensorial responses based on the repetition of sensorial stimuli, made possible by the repetition of movements, causing a reduction in vestibular response and reduction in nystagmus amplitude [19]. For that, it is necessary to integrate all involved sensorial inputs: visual, vestibular and somatosensory. In the vestibular substitution process there is an exchange of information associated with body balance which are absent or conflicting [4, 5].

VR reduces vestibular symptoms through achieving central compensation through the central mechanisms of neuroplasticity [7]. It should be done as early as possible throughout the time window that happens simultaneously with vestibular nuclei plastic reorganizations. In this study, all patients that customized VR programs showed an improvement in VAP as regarded functional, emotional and physical aspects. These findings were in agreement with findings reported by previous studies, which proved that VR can improve vestibular symptoms in patients with vestibular dysfunction. This improvement due to reduce the challenge and improve the skills required for performing all daily activities. In contrast, the study conducted by Zeigelboim et al. in which a sample of 6 patients aged 43–70 years showed no significant improvement of dizziness and tinnitus as regards the functional, emotional, and physical aspects after VR. At the beginning of this study, the greatest impact was noted on the physical aspect followed by an emotional aspect, which matched with the results of Soares et al. that reported marked affection of physical aspect followed by emotional aspect in patients suffering from the vestibular disorder. In the current study, after VR the greatest influence was observed on the physical aspect despite the marked reduction of the values in the emotional followed by functional aspects as well. It was noted that after the improvement in emotional symptoms, individuals were able to continue their routine activities that were previously limited due to fear of dizziness symptoms and this improvement consequently improved functional aspect. Moreover, Guzmán et al. reported the affection of the social life and daily activities by patient’s performance.

Bittar et al. [3] indicated that the time at which VRT is recommended is crucial for success. Unsatisfactory responses may be due to VRT being conducted at the wrong moment, when the patient has not yet reached a favorable clinical state. In agreement with Jung et al. [14], we believe that an appropriate VRT program may help to minimize the effects of age-related deterioration of the vestibular system and its psychological impact. Our results indicated that vestibular rehabilitation is a useful therapeutic approach to promote a more efficient recovery from vestibular disorders. It is a low-cost, short and safe treatment modality which can be widely employed in outpatients without the need of sophisticated gadgets.

Use of the VAP scale in the study sample revealed that vertigo negatively affected the QoL of patients in all dimensions of daily life. VAP includes domains like attention, daily routine, psychological demands, travelling, job, recreation, and socialization. The functional aspects investigate the effect of vertigo on specific eye, head and body movements, focusing in the subject’s ability to carry out professional, household, social and leisure activities, and his or her independence in performing specific tasks such as walking independently and walking across the house in the dark. The emotional scores of the VAP scale investigate the possibility of dizziness having worsened the QoL of patients and giving rise to frustration, fear of leaving the house unaccompanied, fear of staying alone at home, concerns with the self-image, concentration disorders, feelings of incapacity, changes in family and social relationships, and depression. VAP evaluates participation and limitation of individuals with vertigo in daily activities more extensively than the earlier scale since it is based on ICF model [1, 22].

Conclusion

The result of this study proved the importance and the efficacy of VR. It considered a useful therapeutic approach for improvement in the quality of life of individuals with vestibular disorders. It considered a low-cost, short, and safe treatment technique which can be widely used in outpatients without the need for sophisticated tools.

Compliance with Ethical Standards

Conflict of interest

There are no conflicts of interest.