Portuguese Version

Year:  2003  Vol. 69   Ed. 4 - (15º)

Artigo Original

Pages: 535 to 540

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Vestibular rehabilitation in elderly patients with benign paroxysmal positional vertigo

Author(s): Carolina R. Resende1,
Carlos K. Taguchi2,
Juliane G. de Almeida3,
Reginaldo R. Fujita4

Keywords: vestibular rehabilitation, elderly and vertigo

Abstract:
The Benign Paroxysmal Positional Vertigo (BPPV) is a vestibular disorder where the patients complain brief moments of vertigo and/or present postural instability, caused by a brusque change in the cephalic or body movement. Aim: The objective of the present study is certificate the benefit of the vestibular rehabilitation in elderly people with Benign Paroxysmal Positional Vertigo. Study Design: Clinical prospective. Material and Method: Sixteen patients with BPPV were thread with extract of Ginkgo-biloba (40mg of 12/12h) during 30 days. Eight patients (the Experimental Group) were submitted to vestibular rehabilitation and the other called Control Group, didn't perform any kind of exercises. In order to perform the evaluation of the benefit we used the Scale of Activity of Daily Life and Vestibular Disorders by Kohen and Kimball, and used the t-student test to statistical analysis. Conclusion: The vestibular rehabilitation in group showed benefit in the treatment in the Experimental Group; the Scale of Activity of Daily Life and Vestibular Disorders, was an important tool for the qualitative evaluation in our rehabilitation proposal and the vestibular rehabilitation in group showed as an excellent therapeutic strategy.

INTRODUCTION

In the occurrence of a conflict between integration of sensorial information that supports posture control we face dysfunction of body balance that can be translated into dizziness affecting subjects of all age ranges, especially adults and elderly patients. The body balance affection is the second main cause of medical visit1, 2.

Vestibular rehabilitation is a therapeutic resource applied as treatment in patients with body balance disorders and the plan is based on mechanisms related to neuronal plasticity of the central nervous system, promoting visual stabilization during head movements, improving vestibular-visual interaction during head movement, expanding static and dynamic posture stability in conditions that produce conflicting sensorial information and reducing individual sensitivity to head movement 1, 3.

Vestibular compensation can be defined as the mechanism for functional recovery of body balance and consists of a series of events that regularize symmetry of vestibular responses of the brainstem 4.

The patient improvement is achieved thanks to multifactorial neural adaptations, sensorial replacement, functional recovery of vestibular-cochlear and vestibular-spinal reflexes, global conditioning, changes in life style and positive psychological effect with recovery of physical and psychical safety. The success of treatment requires cooperation of the patient and its active participation, leading to more satisfactory results and improvement in quality of life 2, 3, 5.

There are three forms of treatment for labyrinth dysfunctions: drug-related, surgical and vestibular rehabilitation. Other authors add changes in habits and addictions (smoking, alcoholism, feeding behaviors), and when necessary, psychological follow-up. Others emphasize that vestibular rehabilitation is the best therapeutic treatment and can be used with or without medications 1, 2, 4, 6.

Benign paroxysmal positive vertigo (BPPV) is a frequent vestibular disorder in otoneurology and more prevalent in female patients. The patients that suffer from the disease report brief episodes of vertigo and/or mild posture instability caused by a sudden change in head or body movement. Normally, the patients can identify the position that triggers the crisis and try to avoid them consistently, leading to posture disorders that worsen the picture and increase functional inability, generating a vicious cycle that has to be interrupted. Dizziness is not always rotatory and it can sometimes be followed by nausea 7-11.

Vestibular rehabilitation is the therapeutic treatment whose objective is to promote improvement of global balance, quality of life and restoration of spatial orientation as close to physiological levels as possible, by means of exercises that encourage the phenomena of adaptation involving habituation and compensation 12-14.

If patients with BPPV are submitted to supervised vestibular rehabilitation and properly medicated with anti-vertigo drugs as therapeutic supplement, eradication of dizziness can be quick and complete10, 15, 16.

The purpose of the present study was to check the benefit of vestibular rehabilitation conducted in groups of patients aged over 60 years, with BPPV, using the exercise protocol by Cawthorne and Cooksey17,18. To assess the benefits, we applied the Activity of Daily Living and Vestibular Disorders Scale proposed by Cohen and Kimball19.

MATERIAL AND METHOD

The present study was developed in the city of Sao Paulo, at Hospital Ruben Berta, and we randomly referred 16 female patients aged over sixty years. They were all assessed by an ENT physician and diagnosed as having BPPV based on clinical history, ENT examination and vectoelectronystagmography, with no other associated systemic disease. They were treated with Gingko-biloba extract (40mg BID) for 30 days.

We excluded from the study patients that had:

 Visual disorders;
 Severe auditory disorders;
 Systemic diseases (hypertension, diabetes mellitus, heart diseases);
 Significant neurological affections;
 Musculo-skeletal disorders that prevented them from practicing the exercises;
 Psycho-emotional abnormalities that prevented them from following up the treatment.

Patients were randomly divided into two groups: the control group (CG) comprising 8 patients and the experimental group (EG) including 8 patients as well.

The patients signed the free informed consent term and the initial project was submitted to the Ethics Committee of Hospital Rubem Berta, which approved it in full. Next, we used a history questionnaire and all patients responded the questionnaire of Activities of Daily Living and Vestibular Disorders in the first interview and again on the last day of treatment. The scale was developed by Cohen and Kimball, relating vestibular disorders and daily living activities allowing qualitative analysis of physical, instrumental and walking evolution of patients. The scale, which was translated to Brazilian Portuguese by the authors, presents 28 questions that assess activities such as personal care, house care, social and family contact, work, hobby and leisure (annex 1).

For the exercises, we selected the exercise protocol by Cawthorne and Cooksey. The patients in the experimental group submitted to this protocol were seen in group twice a week for vestibular rehabilitation, completing five weeks of treatment or ten sessions.

Eight patients in the Control group answered the questionnaire at the beginning of the medication treatment, simultaneously with the EG.

To analyze data, we used t-Student test and adopted the significance level of 0.05 or 5% for null hypothesis, marking significant results with an asterisk.

RESULTS

The age range of the patients in the experimental group ranged from 61 to 82 years, mean age of 70.5 years, whereas the age range in the Control group was 60 to 78 years, mean age of 69.3. There were no statistically significant differences.

Table 1 describes the score obtained by the 16 patients (EG and CG) in the questionnaire before treatment. The means found in Table 1 show similar values between the groups, and there was no statistically significant difference P > 0.05 (Graph 1).

Comprising the questionnaire on activities of daily living and vestibular disorders to the step before and after vestibular rehabilitation, we depict in Table 2 the distribution of scores and means. The applied statistical test comparing pre and post-treatment values presented P <0.01 (Graph 2).

The scores and means obtained for the control group on the first and last days are shown in Table 3. As we can see, there were no changes in values of scores and means of the CG between the first and last day (Graph 3).

We observed post-treatment means and scores between EG and CG and found different values in Table 4. The results of the t-Student test showed significant benefit in the experimental group compared to the control group, in which the result was P<0.009 (Graph 4).

Table 1. Distribution of pre-treatment scores for physical, walking and instrumental scales in patients with BPPV that comprised the Experimental Group and the Control Group, including the mean for each scale.



Table 2. Distribution of scores in the physical, walking and instrumental scales pre and post-treatment of vestibular rehabilitation of (8) patients with BPPV that comprised the Experimental group, including the differences in scores and the mean for each scale.

* P < 0.01.


Table 3. Distribution of scores for physical, walking and instrumental scales of eight (8) patients with BPPV that comprised the Control Group, including the differences of scores and means for each scale.



Table 4. Distribution of post-treatment scores for physical, walking and instrumental scales in patients with BPPV that comprised the Experimental Group and the Control Group including means for each scale.




Graph 2. Distribution of mean scores of physical, walking and instrumental scales pre and post-treatment in the Experimental Group.



Graph 3. Distribution of mean scores of physical, walking and instrumental scales pre and post-treatment in the Control Group.



Graph 4. Comparison of post-treatment means of physical, walking and instrumental scales between the Experimental Group and the Control Group.

DISCUSSION

In the present study, we observed that all patients treated were female patients aged over 60 years, which agrees with the studied literature, which reports that BPPV is the most common cause of vertigo in the elderly and it is prevalent in female patients7, 8, 9. It has also provided uniformity in our sample preventing that other factors such as menopause, hormone replacement therapy and use of systemic medications interfered in the results.

The patients in the present study presented poor quality of life before they started treatment, being that many of them depended on someone else to conduct leisure/work activities. This fact was observed in the analysis of pre-treatment instrumental scale score for both groups, which was in accordance with Cohen (1992), which reported that 20% of the elderly studied by him that were confined to the house presented vertigo and 50% of the cases experienced falls related to vestibular disorders, and Silveira, Taguchi and Ganança (2002) which reported high handicap scores for patients with peripheral vestibular pathologies.

We also confirmed that the group that underwent vestibular rehabilitation presented significant life quality improvement compared to the control group, confirming the report by Ganança et al. (1999) and Bittar & Pedalini (1999), who highlighted that vestibular rehabilitation is the best therapeutic treatment for patients affected with vestibular dysfunction and that can be used with or without medication.

In our studied group, we detected significant difference, pointing to the benefit of the proposed exercise. Vestibular rehabilitation was promoted, therefore, as a significant improvement in patients, which has also been shown by Barbosa (1995), Herdman (1997) and Silveira, Taguchi and Ganança (2002).

The group of patients treated with vestibular rehabilitation received supervision and personalized treatment. Herdman (1997) pointed out that this type of treatment promotes recovery of posture stability in patients with BPPV. Asai, Watanabe and Shimizu (1997) stated that with the vestibular rehabilitation, there would be quick and complete recovery, as we could notice in our study, since patients that were submitted to vestibular rehabilitation presented statistically significant improvement compared to patients in the control group.

The concept used in this study, emphasizing group treatment and not individualized one, provides situations in which the patients participate actively of the exercises, improving the social relationship between them and developing social incentives for activities, increasing their self-esteem and making them realize that balance disorders are common in the elderly, and can lead them to complete disability. We observed that fear or physical disability were constant in the study because we detected in the physical scale analysis, which had the highest score for patients in groups CG and EG. As previously reported by Newman and Jacobson (1997), who stated that vertigo is a disabling factor, limiting subjects from performing skills of daily living, and Ganança et al. (1999) reported that vertigo would result from head position change.

We noticed that the therapeutic regimen provided psychological support to patients of EG, since they proved to be willing, active and had improved mood by the end of treatment. Similarly to other chronic diseases, social interaction is extremely important for the patients to have better understanding of their disability. Vestibular rehabilitation in group proved to be a feasible therapeutic alternative, because it presented good results in people with BPPV, improving the social interaction and integration of subjects and reducing professional and venue costs involved in treatment.

CONCLUSION

Based on the present study, we concluded that:

1. Vestibular rehabilitation in group is beneficial to the treatment of elderly patients with BPPV;
2. The qualitative instrumental assessment - activity of Daily Living and Vestibular Disorder scale proved to be an important tool for the qualitative assessment of vestibular rehabilitation;
3. Vestibular rehabilitation in group proved to be an excellent therapeutic strategy because it was well accepted by patients, promoting social and psychological improvement.

Annex 1
Daily Living Activity Scale and Vestibular Disorders

REFERENCES

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1 Master studies in Neuromotor Rehabilitation Sciences under course, UNIBAN. Physical Therapist, specialist in Neurology, UMESP.
2 Ph.D. in Human Communication Disorders, UNIFESP-EPM. Joint Professor, Medical School, Santa Casa de Sao Paulo,
Professor of the Master course in Neuromotor Rehabilitation Sciences, UNIBAN.
3 Master studies in Neuromotor Rehabilitation Sciences under course, UNIBAN. Physical Therapist, specialist in Neurology, UMESP.
4 Ph.D. in Otorhinolaryngology, UNIFESP-EPM. Head of the Clinical Unit of the Discipline of Pediatric Otorhinolaryngology, UNIFESP-EPM
Study conducted at Hospital Rubem Berta, Sao Paulo
Address correspondence to: Carolina Ramos Resende - Rua Afonso Brás, 155 Ap.231 São Paulo SP 04511-000
Fax (55 11)3842-3162 -E-mail: resendecarolina@hotmail.com
Article submitted on February 21, 2003. Article accepted on July 10, 2003.

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