Portuguese Version

Year:  2002  Vol. 68   Ed. 4 - (7º)

Artigo Original

Pages: 496 to 499

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Vestibular rehabilitation in children: preliminary study

Author(s): Roseli S. M. Bittar 1,
Maria E. B. Pedalini 2,
Ítalo R. T. Medeiros 3,
Marco A. Bottino1 1,
Ricardo F. Bento 4

Keywords: Vestibular rehabilitation, dizziness, child

Abstract:
The authors analyze prospectively 22 children (mean age 8,6 years) with vestibulopathy treated with Vestibular Rehabilitation in order to verify its results. Twenty two children with peripheral vestibular disorders associated or not to central symptoms were submitted to vestibular stimulation by the method of Cawthorne & Cooksey. The methods used to quantify the vestibular abnormalities were the electronystagmography and rotational chair testing, but a suggestive history of vestibular disorder was accepted even the exams were normal. All the patients improved and our results suggest that VR is a therapeutic alternative for the treatment of vestibular disorders in the children.

INTRODUCTION

By understanding body balance disorders as a limitation of the essential systems for survival helps us grasp the importance of quick and precise approach of the problem. Many patients limited in their performance of basic functions develop inappropriate conditioning, phobias and emotional problems, which are many times difficult to solve1, 2.

Even though vestibulopathies in childhood are not as rare as supposed, diagnosis is hindered by the diversity of symptoms that children manifest, which are very different from those in adults3. In addition to this difficulty, children do not understand that dizziness is an "abnormal symptom" because they are not sure about what they feel and, when really young, they have not mastered language yet4, 5. In order to manifest discomfort, children cry and look for support, try to grab the mother or some nearby object, which are behaviors misinterpreted as manifestations of pain, tantrum or stubbornness crisis3.

In most cases, vestibular problems in children are caused by functional abnormalities resultant from system immaturity, thus tending to be self-limiting3, 6. This is the main reason why some authors believe it is unnecessary to clinically approach the pathology, except for cases of convulsive seizures or secretory otitis7. In our clinical experience, however, we observed that both adults and children suffer repercussions of vestibular disorders in their daily lives, presenting cognitive impairment and social isolation that influence directly and negatively their development3, 6.

Although the use of oral drugs had been the preferred treatment up to some time in the past, its use may be necessary for a prolonged period of time and there may be side effects, such as drowsiness and reduction of attention, which are highly inappropriate in the critical period of intellectual formation of the child6. In any stage of life, etiological treatment is always the best treatment option for dizziness, followed by methods that stimulate central compensation, and drugs are the last resort to be employed to improve the clinical condition of patients8, 9.

Based on the good results with adults10, and knowing that vestibular affections in children are normally functional, we tried to treat children using Vestibular Rehabilitation. These are our preliminary results.

MATERIAL AND METHOD

The sample consisted of a group of 24 children aged from 4 to 15 years (mean age 8.6 years; SD = 3.09 years) who presented peripheral vestibular pathologies, associated or not to central symptoms, seen from 1998 to 2001.

The treatment protocol was previously approved by the Ethics Committee and parents or responsible people were required to authorize the participation of the child in the study. In order to be included in the protocol, the child had to have normal audiometry and otoscopy and complaints of dizziness and/or motion sickness, associated or not to headache. We excluded from the sample children who had degenerative diseases or CNS tumors and those who presented vestibular pathologies of metabolic origin and responded satisfactorily to clinical treatment.

The patients were assessed by the group of otoneurologists from the Department of Otorhinolaryngology, Hospital das Clinicas, Medical School of University of São Paulo, which followed the same criteria for assessment and diagnosis of the cases. We performed careful history, complete neurological and ENT examinations, including electroencephalogram if necessary.

To diagnose the pathology, we conducted audiometric and vestibular tests. Vestibular tests included electronystagmography and decreasing rotational tests, which were performed together or separated, depending on the age and the cooperation of the subject11. We included in the study children who presented labyrinthic predominance and/or directional preponderance in the caloric test or rotational test, or those who had highly suggestive history in the presence of normal vestibular tests.

The method used for the treatment with vestibular rehabilitation was the technique initially described by Cawthorne & Cooksey, modified and adapted to our population12. Guidance and recommended exercises were the same used in the routine treatment of adults10. We conducted 4 sessions of follow-up on days 1, 15, 30 and 60.

During the first assessment, children answered an initial questionnaire in which they quantified the number and duration of dizziness or queasiness episodes. Children and the adults were informed about the origin of symptoms and instructed about exercises that included eye and head movement, eye fixation, gait and ball games. Exercises were expected to be made daily, twice a day, 10 times repetition each, for 60 days.

During the two intermediate follow-up sessions the difficulties they had had during the treatment period were analyzed and new exercises were added or corrected as necessary, customizing the treatment to each child.

By the end of the second month, children answered the same initial questionnaire and the results were classified as:

Total Improvement: Absence of symptoms after treatment;

No Improvement: No modifications in the initial clinical picture described by the mother;

Partial Improvement: Reduction of intensity and/or frequency of initial complaints, but not as good as complete remission of symptoms.

Children who still had symptoms were instructed to keep on with the exercises for another month, maintaining the same exercise plan and adding some, if necessary.

Children were then classified according to the improvement rate after treatment and compared to the total group of patients submitted to vestibular rehabilitation (VR) in the outpatient unit of HCFMUSP during the same period. The statistical analysis included descriptive methods and to study distribution of frequencies, we employed chi-square test with significance level of 5%.

RESULTS

Twenty-four children started treatment and two dropped out during the study. One child who had presented total improvement experienced a recurrence 6 months after the end of treatment. Those who finished treatment are listed in Table 1.

Results obtained in the group of children and the total group of patients submitted to VR in the outpatient unit of HCFMUSP during the same period of observation can be visualized in Table 2.

Distribution of the 22 children submitted to VR was significantly different from the total population (p < 0.02). Children presented better response to the program when compared to the total group of patients submitted to VR, which included adult patients.

Table 1. Distribution of children according to sex, age, complaint, duration and results of treatment.


Table 2. Distribution of the population submitted to RV, according to improvement rate at the end of the program.

DISCUSSION

As pointed out previously, balance dysfunctions in children are normally dependent on functional processes and, according to our cases, 9% of the children do not present abnormal vestibular test results3, reason why suggestive clinical history was considered a criterion for inclusion in our study, even in the presence of normal tests.

When we started working with children, we expected them to resist some exercises normally performed by adults, because they were repetitive and thus, tiring. This idea did not turn out to be true and children responded very well to the classical method, correctly making all exercises. Only one child demonstrated lack of interest in the repetition of movements and she was given new tasks in the form of children's games, such as jumping, playing hop-scotch, or walking barefoot on a floor mat.

We noticed that the recovery of children was more effective than in adults, demonstrating the efficacy of neuronal plasticity during childhood11, 13. They responded significantly better to exercises and it stroke us as if improvement was also quicker, detected after one month of treatment, whereas improvement was noticed in adults within two months of treatment, on average.

The observation of recurrence in a child that had presented total recovery after the program is a fact that remains unexplained. We know that in order to maintain the results obtained with VR it is necessary for the patient to be active, practice sports and games that stimulate the afferent and efferent routes responsible for body balance14. Any physical activity is beneficial to the child but in our opinion, judo and ballet dancing are highly indicated activities because they directly work on body balance, developing posture and coordination.

One of the most frequent complaints in children with vestibulopathies is motion sickness and the limitation they experience when participating in games that involve movement, especially rotation, a basic element in most amusement park attractions. In addition, the movement of public transportation and car rides in long and winding roads is another factor that triggers queasiness and vomiting. This fact is frequently reported by the mother, who becomes concerned about the paleness the child has and its apathy, imaging that the child is about to faint. Children, conversely, feel embarrassed for having vomited near strangers who observe them. For this reason, this symptom was very well investigated in our children and served as a parameter to assess efficacy of treatment. In order to conclude if the therapy was really effective, we sometimes ask mothers to take their children to the amusement park, especially if there were complaints concerning rotation attractions. Most of the times, the children can play normally, without vomit, queasiness or dizziness. Our results confirmed previous findings of significant improvement of motion sickness with VR 15. All children who presented this symptom as the only complaint reported total improvement.

In our group of children, we assessed VR isolated, but the children could also be administered medication simultaneously. We have observed a good response in children to the use of four drugs that are the preferred ones for the treatment of pediatric patients: Ginkgo Biloba, cinarizine, dimenidrate and clonazepam. Among the drugs, however, Ginkgo Biloba seems to be the best option during VR, because the other drugs can have sedating CNS effects, which are not desirable effects during a program of neuronal plasticity activation.

CONCLUSIONS

We believe that VR is a highly recommendable method to treat children with vestibular affections, provided that they are correctly investigated and diagnosed. In cases of pure motion sickness, VR is undoubtedly the first choice treatment.

REFERENCES

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[1] Ph.D., Division of Otoneurology.
[2] Audiologist responsible for the Outpatient Unit of Vestibular Rehabilitation, master studies under course, Graduation in Experimental Pathophysiology, FMUSP.
[3] Doctorate studies in Otorhinolaryngology under course, FMUSP.
[4] Associate Professor, FMUSP.

Discipline of Clinical Otorhinolaryngology, Hcfmusp.

Address correspondence to: Dra Roseli Saraiva Moreira Bittar

Av. Dr. Enéas de Carvalho Aguiar nº 255, 6o andar, ICHC; SP - SP - 05403-000

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