Otolaryngology http://oto.sagepub.com/ -- Head and Neck Surgery
The Efficacy of Vestibular Rehabilitation in Patients with Benign Paroxysmal Positional Vertigo: A Rapid Review Ellis S. van der Scheer-Horst, Peter Paul G. van Benthem, Tjasse D. Bruintjes, Roeland B. van Leeuwen and Hester J. van der Zaag-Loonen Otolaryngology -- Head and Neck Surgery 2014 151: 740 originally published online 25 August 2014 DOI: 10.1177/0194599814546479 The online version of this article can be found at: http://oto.sagepub.com/content/151/5/740
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On behalf of:
American Academy of Otolaryngology- Head and Neck Surgery
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Rapid Systematic Review Otolaryngology– Head and Neck Surgery 2014, Vol. 151(5) 740–745 Ó American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599814546479 http://otojournal.org
The Efficacy of Vestibular Rehabilitation in Patients with Benign Paroxysmal Positional Vertigo: A Rapid Review Ellis S. van der Scheer-Horst, MSc1, Peter Paul G. van Benthem, MD, PhD1, Tjasse D. Bruintjes, MD, PhD1, Roeland B. van Leeuwen, MD, PhD1, and Hester J. van der Zaag-Loonen, MD, PhD1
No sponsorships or competing interests have been disclosed for this article.
Received May 13, 2014; revised June 17, 2014; accepted July 17, 2014.
Abstract Objective. To systematically review the evidence on the effectiveness of vestibular rehabilitation in addition to a canalith repositioning maneuver in patients with benign paroxysmal positional vertigo.
Introduction
Data Sources. A literature search was performed in the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, and EMBASE databases. Review Methods. A comprehensive search was performed up to July 2013. Two authors independently scanned the search results to identify randomized controlled trials of vestibular rehabilitation in addition to a canalith repositioning maneuver in patients with benign paroxysmal positional vertigo. We included trials that were available in the English language and did not apply publication year or publication status restrictions. Studies were methodologically assessed using the Cochrane risk of bias tool. Primary outcome was the effect on vertigo attacks and balance. Results. Of 76 identified trials, only 2 trials fulfilled our inclusion criteria and were included in this review, involving 106 patients. One study was methodologically weak, the other strong. The studies differed in type of intervention, type of outcome, and follow-up time. Both studies reported no significant difference in the vertigo intensity between groups. A small effect was found on balance. Conclusion. Two level II studies in benign paroxysmal positional vertigo showed no effect of vestibular rehabilitation in addition to a canalith repositioning maneuver on vertigo intensity and a small, beneficial effect on balance. We therefore conclude that there is no evidence for an effect of vestibular rehabilitation in addition to a canalith repositioning maneuver in patients with benign paroxysmal positional vertigo. Keywords vestibular rehabilitation, physiotherapy, benign paroxysmal positional vertigo, vertigo
Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular disorder characterized by brief episodes of vertigo triggered by changes in head position. The prevalence of BPPV has been reported to range from 10.7 to 64 per 100,000 population, with a lifetime prevalence of 2.4%.1 The age of onset is most commonly between the fifth and seventh decades of life. Elderly people are at increased risk, and they experience a greater incidence of falls, depression, and impairments of their daily activities as a result of the vertigo.2 The cause of BPPV is believed to be canalithiasis, mostly affecting the posterior semicircular canal.3 Canalithiasis is characterized by the presence of free-floating debris in the semicircular canal. Less frequently, BPPV is caused by otoconial debris adhering to the cupula, cupulolithiasis. The diagnostic strategies and treatment options of canalithiasis differ from cupulolithiasis. Approximately 85% to 95% of BPPV cases constitute posterior canal BPPV.4 Therefore, this review focuses on the posterior canal BPPV. The current clinical practice guideline recommends a canalith repositioning maneuver (CRM), for instance the Epley maneuver, as evidence-based treatment.1 Vestibular rehabilitation (VR), a form of physical therapy using head and trunk movements, has been available since 1944.5 Since then, the exercises have taken many forms: Brandt-Daroff exercises, Cawthorne-Cooksey exercises, viewing exercises, or balance exercises. The aim is to improve the visual-vestibular interaction and increase static and dynamic postural stability. The exercises are also 1 Apeldoorn Dizziness Netherlands
Centre,
Gelre
Hospitals,
Apeldoorn,
Corresponding Author: Ellis S. van der Scheer-Horst, Gelre Hospitals Apeldoorn, Albert Schweitzerlaan 31, 7334 DZ, Apeldoorn, The Netherlands. Email: [email protected]
Downloaded from oto.sagepub.com at Northeastern University on November 12, 2014
The
Records after duplicates removed: 60
Eligibility
Records identified through database searching: 76
Records excluded after reading title and abstract: 56 (intervention 36, diagnosis 7, design 12, language 1) Full-text articles assessed for eligibility: 4 Exclusion due to design: 211;13
I ncluded
believed to contribute to an improvement in daily quality of life and a reduction of symptoms of dizziness and anxiety.6 The clinical recovery is thought to rely on the following mechanism: compensation/habituation, which is a central process and refers to the reduction in symptoms produced by specific movements and occurs through repetitive exposure to the movement; adaptation, which is the recovery of the dynamic vestibulo-ocular responses due to the ability of the vestibular system to make long-term changes in the neuronal response to input; and substitution, which is the use of other strategies to replace the lost function.7 With respect to BPPV, VR programs most commonly focus on habituation exercises. The current clinical practice guideline of BPPV reports superior treatment outcomes of CRM compared to VR.8-10 Some however believe that there is a role for VR in addition to the CRM, but there is no pathophysiological background for this, and the evidence for this role is lacking.11 Therefore, the purpose of this review was to systematically search for and appraise the evidence on the effectiveness of VR in addition to the CRM in patients with BPPV.
Identification
741
Screening
van der Scheer-Horst et al
Articles included in systematic review: 214;15
Figure 1. Flowchart for selection of studies on the effect of vestibular rehabilitation for patients with benign paroxysmal positional vertigo.
Methods Criteria for Considering Studies We searched for randomized controlled trials (RCTs) of adults who had a clinical diagnosis of BPPV. A positive Dix-Hallpike test should be part of the clinical diagnosis. A CRM should be compared to a CRM in combination with VR. VR could include Brandt-Daroff exercises, habituation exercises, balance exercises, or self-treatment but not medical, electrophysiological, or pharmacological management.
Types of Outcome Measures Our primary outcomes were intensity of vertigo attacks, assessed subjectively; Dix-Hallpike responses and results of posturography (balance); and follow-up.
exercises, intervention frequency, intervention intensity, intervention duration, and outcomes of intervention. We independently assessed the risk of bias for the included articles using the criteria recommended by the Cochrane Collaboration.12 The 5 domains were adequate sequence generation, allocation concealment, blinding of outcome, incomplete outcome data, and free of selective reporting. We gave an overall judgment for each of the domains for each study using 3 levels: low risk of bias, unclear risk of bias, and high risk of bias.
Results
Search Methods for Identification of Studies
Results of the Search
We conducted systematic searches in the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, and EMBASE for RCTs. We only included trials that were available in the English language and did not apply any publication year or publication status restrictions. The date of the last search was July 15, 2013. Potentially relevant studies were identified by the following search strategy: (‘‘Benign paroxysmal positional vertigo’’) AND (‘‘physical therapy modalities’’ OR ‘‘exercise therapy’’ OR ‘‘exercise’’ OR exercises OR ‘‘rehabilitation’’ OR vestibular rehabilitation) AND (randomized controlled trial OR controlled clinical trial).
A total of 76 references were retrieved from the searches (Figure 1). Sixteen of these were removed in first-level screening (ie, removal of duplicates), leaving 60 references for further consideration. We excluded 56 on the basis of the abstract (36 because the intervention did not meet our criteria, 7 because participants were not uniquely BPPV, 12 because they were not a RCT, and 1 because it was not in English). After reading the full article we excluded 2 other studies because they were not an RCT,11,13 leaving 2 studies in our review (Chang et al 2008,14 Tanimoto et al 200115), including 106 patients (26 and 80, respectively)14,15 (Table 1). In the study by Chang et al,14 the mean age of the experimental group was 56.4 6 11.4 with 30% of the patients between 61 and 80 years of age. The mean age of the control group was 53.9 6 10 with only 16% of the patients between 61 and 80 years of age. In Tanimoto et al,15 the age of patients ranged from 24 to 85 years with a median of 64 years (Table 1).
Data Collection and Analysis Two authors (EvdS and HvdZ) independently scanned the search results to identify studies that met the criteria of this review. The same authors extracted data from the included studies using standardized data forms. We extracted the type of
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Table 1. Characteristics of Included Studies on Benign Paroxysmal Positional Vertigo. Participants (male/female, age)
Intervention
Outcomes
Chang et al 200814
26 patients (11 males, 15 females) Mean age (years, SD): Experimental: 56 (11) Control: 54 (10)
Experimental group: modified Epley maneuver (1 or 2 sessions over 2 weeks) with vestibular exercises (3 times a week, 40 minutes for 4 weeks) Control group: modified Epley maneuver (1 or 2 sessions within 2 weeks)
Posturography (static balance) Tandem Walk Test (dynamic balance) DGI Vertigo intensity (VAS)
Tanimoto et al 200515
80 patients (25 males, 55 females) Median of age (years): 64
Control group: Epley procedure (once) Experimental group: Epley procedure (once) plus selftreatment at home (3 times a day until resolution of positional vertigo for 24 hours)
Dix-Hallpike Test Symptoms by questioning
Effects of Intervention Significant differences between groups at 4week assessment: Static balance: Stance on foam surface with eyes closed (experimental group 1.27, SD = 0.39) versus control group (1.94, SD = 0.77) P \.01 Single leg stance with eyes closed (5.59, SD = 4.88) versus 9.43 (SD = 3.49), P \.05 DGI: 23.5 (SD = 0.7) versus 22.4 (SD = 1.40), P \.01 VAS vertigo: 1.1 (SD = 1.2) versus 1.0 (SD = 1.0) Tandem walk: 3.56 (SD = 0.73) versus 3.90 (SD = 1.39) Negative Dix-Hallpike test: Experimental group: 36 patients (90%) control group: 28 patients (72%) (P = .048) Complete resolution vertigo: Experimental group: 35 patients (88%) Control group: 30 patients (77%) (P = .22)
Abbreviations: DGI, Dynamic Gait Index; VAS, visual analogue scale.
Intervention 14
Chang et al studied the effect of oculomotor exercises, repeated head movement exercises, balance training exercises, and functional activities as part of VR. The frequency and intensity of the intervention was 3 times a week, during 40 minutes for 4 weeks, respectively. Tanimoto et al15 described the effect of the modified Epley procedure executed as selftreatment at home.16 This intervention was applied 3 times a day until relief of vertigo was achieved for 24 hours.
Outcomes Chang et al14 measured the intensity of vertigo using a 10 cm visual analogue scale (VAS) ranging from no symptoms
(0 cm) to the worst possible symptoms (10 cm). Tanimoto et al15 measured complete resolution of vertigo by questioning the patients. Both studies reported no significant difference in the intensity of vertigo attacks between groups. Chang et al14 reported a mean VAS score of 1.1 (SD = 1.2) for the experimental group at the 4-week assessment and for the control group a score of 1.0 (SD = 1.0). Tanimoto et al15 reported complete resolution of vertigo in 35 patients of the experimental group (88%) and 30 patients of the control group (77%) (P = .22). Tanimoto et al15 also assessed a negative Dix-Hallpike test in combination with complete resolution of vertigo.
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Table 2. Risk of Bias (Benign Paroxysmal Positional Vertigo). Adequate Sequence Generation?
Allocation Concealment?
Blinding of Outcomes?
Incomplete Outcome Data?
Free of Selective Reporting?
1 ?
1 ?
1 ?
1 ?
1 1
Chang et al 200814 Tanimoto et al 200515
Table 3. Risk of Bias Chang et al.14 Bias
Authors’ Judgment
Support for Judgment
Adequate sequence generation? Allocation concealment? Blinding of outcomes?
Low risk Low risk Low risk
Incomplete outcome data? Free of selective reporting?
Low risk Low risk
Randomization was performed by an independent person Allocation was concealed in sealed envelopes The measurements were executed by one evaluator who was blinded to group assignment. No missing outcome All data reported
Table 4. Risk of Bias Tanimoto et al.15 Bias Adequate sequence generation? Allocation concealment? Blinding of outcomes? Incomplete outcome data? Free of selective reporting?
Authors’ Judgment
Support for Judgment
Unclear risk Unclear risk Unclear risk Unclear risk Low risk
Patients were randomly divided Insufficient information about the method of allocation Blinding is not described No reason for missing data reported All data reported
These rates were 88% in the experimental group and 69% in the control group (P = .48). Besides the intensity of vertigo, Chang et al14 also reported on the static and dynamic balance and the Dynamic Gait Index (DGI). Static balance and dynamic balance were measured as sway velocity by the Balance Master System (posturography). The functional gait was measured by the DGI. The DGI scores 8 mobility tasks (gait on a level surface, change in gait speed, gait with horizontal head turns, gait with vertical head turns, pivot turning, stepping over an obstacle, and ascending and descending stairs) to give a total score of 24 points. Chang et al14 reported a significant difference (P \ .05, the actual P value was not given) between groups at the 4week assessment for the DGI: the experimental group scored a mean of 23.5 (SD = 0.7) while the control group had a score of 22.5 (SD = 1.40). Chang et al14 reported significant differences (P \ .05, the actual P value was not given) between groups for sway velocity at the 4-week assessment for stance on foam surface with eyes closed (experimental group 1.27 [SD = 0.39] vs control group 1.94 [SD = 0.77]) and for single leg stance with eyes closed (5.59 [SD = 4.88] and 9.43 [SD = 3.49],
respectively). Single leg stance with eyes closed at 2-week assessment also gave a significant difference between groups (5.45 [SD = 4.47] and 10.42 [SD = 3.09], respectively). Follow-up assessment ranged from 1 week (Tanimoto et al) to 2 and 4 weeks (Chang et al).
Risk of Bias in Included Studies There was a low risk of bias in all domains for Chang et al.14 The study by Tanimoto et al15 suffered from a low risk of bias for selective reporting and an unclear risk of bias in the remaining domains (Tables 2, 3, 4).
Discussion In this review we assessed the effectiveness of vestibular rehabilitation in addition to the canalith repositioning maneuver in patients with benign paroxysmal positional vertigo. We found no effect on vertigo intensity and a small effect on balance in only 2 small studies with very brief follow-up. In this review we chose to include only randomized controlled trials because this type of study incorporates the least risk of bias. We found that RCTs evaluating the effects of VR in addition to a CRM in patients with BPPV are scarce in the
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Otolaryngology–Head and Neck Surgery 151(5)
literature, despite the fact that VR is said to have a therapeutic effect in these patients. We could only include 2 RCTs with a total of 106 patients14,15 in this review. Both studies included patients with BPPV involving the posterior semicircular canal. The studies differed in 5 important aspects: type of intervention, type of outcome, follow-up time, methodological quality, and sample size. With respect to the intervention, the VR that Tanimoto et al15 applied consisted of selftreatment Epley procedure at home. The value of this type of uncontrolled VR can be debated. With respect to the outcomes, Chang et al14 measured the intensity of vertigo while Tanimoto et al15 also used the Dix-Hallpike result as an outcome. Chang et al14 on the other hand reported the static and dynamic balance while Tanimoto et al15 did not measure balance. The follow-up period of both studies was quite brief: Chang et al14 had a follow-up period of 4 weeks while Tanimoto et al15 followed patients for only 1 week. And finally, Tanimoto et al’s15 study was of relatively weak quality while the methodological quality of Chang et al14 was strong while being a small study (26 patients). Any systematic review suffers from its own flaws. We chose to include only English papers, which may have led to an underrepresentation of the true number of studies. Furthermore, publication bias could have been present, with smaller studies with a negative result not having been published. We chose to include only RCTs because this type of study incorporates the least risk of bias. The fact that only 2 RCTs were identified means that it is not possible to reach firm conclusions regarding the use of VR in addition to CRM in patients with BPPV.
Conclusion and Recommendations for Further Research Two level II studies assessed the effect of VR in addition to a CRM in BPPV and showed no effect on vertigo intensity and a small beneficial effect on balance. Due to either small sample size (Chang et al14) or substantial risk of bias (Tanimoto et al15), the evidence is very weak. For the time being, the evidence for routine VR in addition to CRM in patients suffering from BPPV is very weak. Author Contributions Ellis S. van der Scheer-Horst, substantial contributions to conception and design, acquisition of data, analysis and interpretation of data; drafting the article; final approval of the version to be published; Peter Paul G. van Benthem, substantial contributions to conception and design, revising the article critically for important intellectual content, and final approval of the version to be published; Tjasse D. Bruintjes, substantial contributions to conception and design, revising the article critically for important intellectual content, and final approval of the version to be published; Roeland B. van Leeuwen, substantial contributions to conception and design, revising the article critically for important intellectual content, and final approval of the version to be published; Hester J. van der Zaag-Loonen, substantial contributions to conception and design,
acquisition of data, analysis and interpretation of data; drafting the article or revising it critically for important intellectual content; and final approval of the version to be published.
Disclosures Competing interests: None. Sponsorships: None. Funding source: None.
Reference List 1. Bhattacharyya N, Baugh RF, Orvidas L, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2008;139:S47-S81. 2. Oghalai JS, Manolidis S, Barth JL, Stewart MG, Jenkins HA. Unrecognized benign paroxysmal positional vertigo in elderly patients. Otolaryngol Head Neck Surg. 2000;122:630-634. 3. Brandt T, Steddin S. Current view of the mechanism of benign paroxysmal positioning vertigo: cupulolithiasis or canalolithiasis? J Vestib Res. 1993;3:373-382. 4. Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ. 2003; 169:681-693. 5. Krebs DE, Gill-Body KM, Parker SW, Ramirez JV, Wernick-Robinson M. Vestibular rehabilitation: useful but not universally so. Otolaryngol Head Neck Surg. 2003;128: 240-250. 6. Ricci NA, Aratani MC, Dona F, Macedo C, Caovilla HH, Gananca FF. A systematic review about the effects of the vestibular rehabilitation in middle-age and older adults. Rev Bras Fisioter. 2010;14:361-371. 7. Herdman SJ. Vestibular Rehabilitation. 3rd ed.Philadelpha: FA Davis; 2007. 8. Amor-Dorado JC, Barreira-Fernandez MP, Aran-Gonzalez I, Casariego-Vales E, Llorca J, Gonzalez-Gay MA. Particle repositioning maneuver versus Brandt-Daroff exercise for treatment of unilateral idiopathic BPPV of the posterior semicircular canal: a randomized prospective clinical trial with short- and long-term outcome. Otol Neurotol. 2012;33:1401-1407. 9. Cohen HS, Kimball KT. Effectiveness of treatments for benign paroxysmal positional vertigo of the posterior canal. Otol Neurotol. 2005;26:1034-1040. 10. Soto VA, Bartual MJ, Santos PS, et al. Benign paroxysmal vertigo: a comparative prospective study of the efficacy of Brandt and Daroff exercises, Semont and Epley maneuver. Rev Laryngol Otol Rhinol (Bord). 2001;122:179-183. 11. Angeli SI, Hawley R, Gomez O. Systematic approach to benign paroxysmal positional vertigo in the elderly. Otolaryngol Head Neck Surg. 2003;128:719-725. 12. Higgins JPT, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. www.cochrane-handbook.org. The Cochrane Collaboration, 2011. 13. Cohen HS, Sangi-Haghpeykar H. Canalith repositioning variations for benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2010;143:405-412.
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14. Chang WC, Yang YR, Hsu LC, Chern CM, Wang RY. Balance improvement in patients with benign paroxysmal positional vertigo. Clin Rehabil. 2008;22:338-347. 15. Tanimoto H, Doi K, Katata K, Nibu KI. Self-treatment for benign paroxysmal positional vertigo of the posterior semicircular canal. Neurology. 2005;65:1299-1300.
16. Radtke A, Neuhauser H, von BM, Lempert T. A modified Epley’s procedure for self-treatment of benign paroxysmal positional vertigo. Neurology. 1999;53:1358-1360.
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The Efficacy of Vestibular Rehabilitation in Patients with Benign Paroxysmal Positional Vertigo: A Rapid Review Ellis S. van der Scheer-Horst, Peter Paul G. van Benthem, Tjasse D. Bruintjes, Roeland B. van Leeuwen and Hester J. van der Zaag-Loonen Otolaryngology -- Head and Neck Surgery 2014 151: 740 originally published online 25 August 2014 DOI: 10.1177/0194599814546479 The online version of this article can be found at: http://oto.sagepub.com/content/151/5/740
Published by: http://www.sagepublications.com
On behalf of:
American Academy of Otolaryngology- Head and Neck Surgery
Additional services and information for Otolaryngology -- Head and Neck Surgery can be found at: Email Alerts: http://oto.sagepub.com/cgi/alerts Subscriptions: http://oto.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> Version of Record - Oct 24, 2014 OnlineFirst Version of Record - Aug 25, 2014 What is This?
Downloaded from oto.sagepub.com at Northeastern University on November 12, 2014
Rapid Systematic Review Otolaryngology– Head and Neck Surgery 2014, Vol. 151(5) 740–745 Ó American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599814546479 http://otojournal.org
The Efficacy of Vestibular Rehabilitation in Patients with Benign Paroxysmal Positional Vertigo: A Rapid Review Ellis S. van der Scheer-Horst, MSc1, Peter Paul G. van Benthem, MD, PhD1, Tjasse D. Bruintjes, MD, PhD1, Roeland B. van Leeuwen, MD, PhD1, and Hester J. van der Zaag-Loonen, MD, PhD1
No sponsorships or competing interests have been disclosed for this article.
Received May 13, 2014; revised June 17, 2014; accepted July 17, 2014.
Abstract Objective. To systematically review the evidence on the effectiveness of vestibular rehabilitation in addition to a canalith repositioning maneuver in patients with benign paroxysmal positional vertigo.
Introduction
Data Sources. A literature search was performed in the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, and EMBASE databases. Review Methods. A comprehensive search was performed up to July 2013. Two authors independently scanned the search results to identify randomized controlled trials of vestibular rehabilitation in addition to a canalith repositioning maneuver in patients with benign paroxysmal positional vertigo. We included trials that were available in the English language and did not apply publication year or publication status restrictions. Studies were methodologically assessed using the Cochrane risk of bias tool. Primary outcome was the effect on vertigo attacks and balance. Results. Of 76 identified trials, only 2 trials fulfilled our inclusion criteria and were included in this review, involving 106 patients. One study was methodologically weak, the other strong. The studies differed in type of intervention, type of outcome, and follow-up time. Both studies reported no significant difference in the vertigo intensity between groups. A small effect was found on balance. Conclusion. Two level II studies in benign paroxysmal positional vertigo showed no effect of vestibular rehabilitation in addition to a canalith repositioning maneuver on vertigo intensity and a small, beneficial effect on balance. We therefore conclude that there is no evidence for an effect of vestibular rehabilitation in addition to a canalith repositioning maneuver in patients with benign paroxysmal positional vertigo. Keywords vestibular rehabilitation, physiotherapy, benign paroxysmal positional vertigo, vertigo
Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular disorder characterized by brief episodes of vertigo triggered by changes in head position. The prevalence of BPPV has been reported to range from 10.7 to 64 per 100,000 population, with a lifetime prevalence of 2.4%.1 The age of onset is most commonly between the fifth and seventh decades of life. Elderly people are at increased risk, and they experience a greater incidence of falls, depression, and impairments of their daily activities as a result of the vertigo.2 The cause of BPPV is believed to be canalithiasis, mostly affecting the posterior semicircular canal.3 Canalithiasis is characterized by the presence of free-floating debris in the semicircular canal. Less frequently, BPPV is caused by otoconial debris adhering to the cupula, cupulolithiasis. The diagnostic strategies and treatment options of canalithiasis differ from cupulolithiasis. Approximately 85% to 95% of BPPV cases constitute posterior canal BPPV.4 Therefore, this review focuses on the posterior canal BPPV. The current clinical practice guideline recommends a canalith repositioning maneuver (CRM), for instance the Epley maneuver, as evidence-based treatment.1 Vestibular rehabilitation (VR), a form of physical therapy using head and trunk movements, has been available since 1944.5 Since then, the exercises have taken many forms: Brandt-Daroff exercises, Cawthorne-Cooksey exercises, viewing exercises, or balance exercises. The aim is to improve the visual-vestibular interaction and increase static and dynamic postural stability. The exercises are also 1 Apeldoorn Dizziness Netherlands
Centre,
Gelre
Hospitals,
Apeldoorn,
Corresponding Author: Ellis S. van der Scheer-Horst, Gelre Hospitals Apeldoorn, Albert Schweitzerlaan 31, 7334 DZ, Apeldoorn, The Netherlands. Email: [email protected]
Downloaded from oto.sagepub.com at Northeastern University on November 12, 2014
The
Records after duplicates removed: 60
Eligibility
Records identified through database searching: 76
Records excluded after reading title and abstract: 56 (intervention 36, diagnosis 7, design 12, language 1) Full-text articles assessed for eligibility: 4 Exclusion due to design: 211;13
I ncluded
believed to contribute to an improvement in daily quality of life and a reduction of symptoms of dizziness and anxiety.6 The clinical recovery is thought to rely on the following mechanism: compensation/habituation, which is a central process and refers to the reduction in symptoms produced by specific movements and occurs through repetitive exposure to the movement; adaptation, which is the recovery of the dynamic vestibulo-ocular responses due to the ability of the vestibular system to make long-term changes in the neuronal response to input; and substitution, which is the use of other strategies to replace the lost function.7 With respect to BPPV, VR programs most commonly focus on habituation exercises. The current clinical practice guideline of BPPV reports superior treatment outcomes of CRM compared to VR.8-10 Some however believe that there is a role for VR in addition to the CRM, but there is no pathophysiological background for this, and the evidence for this role is lacking.11 Therefore, the purpose of this review was to systematically search for and appraise the evidence on the effectiveness of VR in addition to the CRM in patients with BPPV.
Identification
741
Screening
van der Scheer-Horst et al
Articles included in systematic review: 214;15
Figure 1. Flowchart for selection of studies on the effect of vestibular rehabilitation for patients with benign paroxysmal positional vertigo.
Methods Criteria for Considering Studies We searched for randomized controlled trials (RCTs) of adults who had a clinical diagnosis of BPPV. A positive Dix-Hallpike test should be part of the clinical diagnosis. A CRM should be compared to a CRM in combination with VR. VR could include Brandt-Daroff exercises, habituation exercises, balance exercises, or self-treatment but not medical, electrophysiological, or pharmacological management.
Types of Outcome Measures Our primary outcomes were intensity of vertigo attacks, assessed subjectively; Dix-Hallpike responses and results of posturography (balance); and follow-up.
exercises, intervention frequency, intervention intensity, intervention duration, and outcomes of intervention. We independently assessed the risk of bias for the included articles using the criteria recommended by the Cochrane Collaboration.12 The 5 domains were adequate sequence generation, allocation concealment, blinding of outcome, incomplete outcome data, and free of selective reporting. We gave an overall judgment for each of the domains for each study using 3 levels: low risk of bias, unclear risk of bias, and high risk of bias.
Results
Search Methods for Identification of Studies
Results of the Search
We conducted systematic searches in the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, and EMBASE for RCTs. We only included trials that were available in the English language and did not apply any publication year or publication status restrictions. The date of the last search was July 15, 2013. Potentially relevant studies were identified by the following search strategy: (‘‘Benign paroxysmal positional vertigo’’) AND (‘‘physical therapy modalities’’ OR ‘‘exercise therapy’’ OR ‘‘exercise’’ OR exercises OR ‘‘rehabilitation’’ OR vestibular rehabilitation) AND (randomized controlled trial OR controlled clinical trial).
A total of 76 references were retrieved from the searches (Figure 1). Sixteen of these were removed in first-level screening (ie, removal of duplicates), leaving 60 references for further consideration. We excluded 56 on the basis of the abstract (36 because the intervention did not meet our criteria, 7 because participants were not uniquely BPPV, 12 because they were not a RCT, and 1 because it was not in English). After reading the full article we excluded 2 other studies because they were not an RCT,11,13 leaving 2 studies in our review (Chang et al 2008,14 Tanimoto et al 200115), including 106 patients (26 and 80, respectively)14,15 (Table 1). In the study by Chang et al,14 the mean age of the experimental group was 56.4 6 11.4 with 30% of the patients between 61 and 80 years of age. The mean age of the control group was 53.9 6 10 with only 16% of the patients between 61 and 80 years of age. In Tanimoto et al,15 the age of patients ranged from 24 to 85 years with a median of 64 years (Table 1).
Data Collection and Analysis Two authors (EvdS and HvdZ) independently scanned the search results to identify studies that met the criteria of this review. The same authors extracted data from the included studies using standardized data forms. We extracted the type of
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Table 1. Characteristics of Included Studies on Benign Paroxysmal Positional Vertigo. Participants (male/female, age)
Intervention
Outcomes
Chang et al 200814
26 patients (11 males, 15 females) Mean age (years, SD): Experimental: 56 (11) Control: 54 (10)
Experimental group: modified Epley maneuver (1 or 2 sessions over 2 weeks) with vestibular exercises (3 times a week, 40 minutes for 4 weeks) Control group: modified Epley maneuver (1 or 2 sessions within 2 weeks)
Posturography (static balance) Tandem Walk Test (dynamic balance) DGI Vertigo intensity (VAS)
Tanimoto et al 200515
80 patients (25 males, 55 females) Median of age (years): 64
Control group: Epley procedure (once) Experimental group: Epley procedure (once) plus selftreatment at home (3 times a day until resolution of positional vertigo for 24 hours)
Dix-Hallpike Test Symptoms by questioning
Effects of Intervention Significant differences between groups at 4week assessment: Static balance: Stance on foam surface with eyes closed (experimental group 1.27, SD = 0.39) versus control group (1.94, SD = 0.77) P \.01 Single leg stance with eyes closed (5.59, SD = 4.88) versus 9.43 (SD = 3.49), P \.05 DGI: 23.5 (SD = 0.7) versus 22.4 (SD = 1.40), P \.01 VAS vertigo: 1.1 (SD = 1.2) versus 1.0 (SD = 1.0) Tandem walk: 3.56 (SD = 0.73) versus 3.90 (SD = 1.39) Negative Dix-Hallpike test: Experimental group: 36 patients (90%) control group: 28 patients (72%) (P = .048) Complete resolution vertigo: Experimental group: 35 patients (88%) Control group: 30 patients (77%) (P = .22)
Abbreviations: DGI, Dynamic Gait Index; VAS, visual analogue scale.
Intervention 14
Chang et al studied the effect of oculomotor exercises, repeated head movement exercises, balance training exercises, and functional activities as part of VR. The frequency and intensity of the intervention was 3 times a week, during 40 minutes for 4 weeks, respectively. Tanimoto et al15 described the effect of the modified Epley procedure executed as selftreatment at home.16 This intervention was applied 3 times a day until relief of vertigo was achieved for 24 hours.
Outcomes Chang et al14 measured the intensity of vertigo using a 10 cm visual analogue scale (VAS) ranging from no symptoms
(0 cm) to the worst possible symptoms (10 cm). Tanimoto et al15 measured complete resolution of vertigo by questioning the patients. Both studies reported no significant difference in the intensity of vertigo attacks between groups. Chang et al14 reported a mean VAS score of 1.1 (SD = 1.2) for the experimental group at the 4-week assessment and for the control group a score of 1.0 (SD = 1.0). Tanimoto et al15 reported complete resolution of vertigo in 35 patients of the experimental group (88%) and 30 patients of the control group (77%) (P = .22). Tanimoto et al15 also assessed a negative Dix-Hallpike test in combination with complete resolution of vertigo.
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Table 2. Risk of Bias (Benign Paroxysmal Positional Vertigo). Adequate Sequence Generation?
Allocation Concealment?
Blinding of Outcomes?
Incomplete Outcome Data?
Free of Selective Reporting?
1 ?
1 ?
1 ?
1 ?
1 1
Chang et al 200814 Tanimoto et al 200515
Table 3. Risk of Bias Chang et al.14 Bias
Authors’ Judgment
Support for Judgment
Adequate sequence generation? Allocation concealment? Blinding of outcomes?
Low risk Low risk Low risk
Incomplete outcome data? Free of selective reporting?
Low risk Low risk
Randomization was performed by an independent person Allocation was concealed in sealed envelopes The measurements were executed by one evaluator who was blinded to group assignment. No missing outcome All data reported
Table 4. Risk of Bias Tanimoto et al.15 Bias Adequate sequence generation? Allocation concealment? Blinding of outcomes? Incomplete outcome data? Free of selective reporting?
Authors’ Judgment
Support for Judgment
Unclear risk Unclear risk Unclear risk Unclear risk Low risk
Patients were randomly divided Insufficient information about the method of allocation Blinding is not described No reason for missing data reported All data reported
These rates were 88% in the experimental group and 69% in the control group (P = .48). Besides the intensity of vertigo, Chang et al14 also reported on the static and dynamic balance and the Dynamic Gait Index (DGI). Static balance and dynamic balance were measured as sway velocity by the Balance Master System (posturography). The functional gait was measured by the DGI. The DGI scores 8 mobility tasks (gait on a level surface, change in gait speed, gait with horizontal head turns, gait with vertical head turns, pivot turning, stepping over an obstacle, and ascending and descending stairs) to give a total score of 24 points. Chang et al14 reported a significant difference (P \ .05, the actual P value was not given) between groups at the 4week assessment for the DGI: the experimental group scored a mean of 23.5 (SD = 0.7) while the control group had a score of 22.5 (SD = 1.40). Chang et al14 reported significant differences (P \ .05, the actual P value was not given) between groups for sway velocity at the 4-week assessment for stance on foam surface with eyes closed (experimental group 1.27 [SD = 0.39] vs control group 1.94 [SD = 0.77]) and for single leg stance with eyes closed (5.59 [SD = 4.88] and 9.43 [SD = 3.49],
respectively). Single leg stance with eyes closed at 2-week assessment also gave a significant difference between groups (5.45 [SD = 4.47] and 10.42 [SD = 3.09], respectively). Follow-up assessment ranged from 1 week (Tanimoto et al) to 2 and 4 weeks (Chang et al).
Risk of Bias in Included Studies There was a low risk of bias in all domains for Chang et al.14 The study by Tanimoto et al15 suffered from a low risk of bias for selective reporting and an unclear risk of bias in the remaining domains (Tables 2, 3, 4).
Discussion In this review we assessed the effectiveness of vestibular rehabilitation in addition to the canalith repositioning maneuver in patients with benign paroxysmal positional vertigo. We found no effect on vertigo intensity and a small effect on balance in only 2 small studies with very brief follow-up. In this review we chose to include only randomized controlled trials because this type of study incorporates the least risk of bias. We found that RCTs evaluating the effects of VR in addition to a CRM in patients with BPPV are scarce in the
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literature, despite the fact that VR is said to have a therapeutic effect in these patients. We could only include 2 RCTs with a total of 106 patients14,15 in this review. Both studies included patients with BPPV involving the posterior semicircular canal. The studies differed in 5 important aspects: type of intervention, type of outcome, follow-up time, methodological quality, and sample size. With respect to the intervention, the VR that Tanimoto et al15 applied consisted of selftreatment Epley procedure at home. The value of this type of uncontrolled VR can be debated. With respect to the outcomes, Chang et al14 measured the intensity of vertigo while Tanimoto et al15 also used the Dix-Hallpike result as an outcome. Chang et al14 on the other hand reported the static and dynamic balance while Tanimoto et al15 did not measure balance. The follow-up period of both studies was quite brief: Chang et al14 had a follow-up period of 4 weeks while Tanimoto et al15 followed patients for only 1 week. And finally, Tanimoto et al’s15 study was of relatively weak quality while the methodological quality of Chang et al14 was strong while being a small study (26 patients). Any systematic review suffers from its own flaws. We chose to include only English papers, which may have led to an underrepresentation of the true number of studies. Furthermore, publication bias could have been present, with smaller studies with a negative result not having been published. We chose to include only RCTs because this type of study incorporates the least risk of bias. The fact that only 2 RCTs were identified means that it is not possible to reach firm conclusions regarding the use of VR in addition to CRM in patients with BPPV.
Conclusion and Recommendations for Further Research Two level II studies assessed the effect of VR in addition to a CRM in BPPV and showed no effect on vertigo intensity and a small beneficial effect on balance. Due to either small sample size (Chang et al14) or substantial risk of bias (Tanimoto et al15), the evidence is very weak. For the time being, the evidence for routine VR in addition to CRM in patients suffering from BPPV is very weak. Author Contributions Ellis S. van der Scheer-Horst, substantial contributions to conception and design, acquisition of data, analysis and interpretation of data; drafting the article; final approval of the version to be published; Peter Paul G. van Benthem, substantial contributions to conception and design, revising the article critically for important intellectual content, and final approval of the version to be published; Tjasse D. Bruintjes, substantial contributions to conception and design, revising the article critically for important intellectual content, and final approval of the version to be published; Roeland B. van Leeuwen, substantial contributions to conception and design, revising the article critically for important intellectual content, and final approval of the version to be published; Hester J. van der Zaag-Loonen, substantial contributions to conception and design,
acquisition of data, analysis and interpretation of data; drafting the article or revising it critically for important intellectual content; and final approval of the version to be published.
Disclosures Competing interests: None. Sponsorships: None. Funding source: None.
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