www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
REVIEW
ARTICLE
Effectiveness
of
Otolith
Repositioning
Maneuvers
and
Vestibular
Rehabilitation
exercises
in
elderly
people
with
Benign
Paroxysmal
Positional
Vertigo:
a
systematic
review
夽
Karyna
Figueiredo
Ribeiro
a,b,∗,
Bruna
Steffeni
Oliveira
b,
Raysa
V.
Freitas
b,
Lidiane
M.
Ferreira
c,
Nandini
Deshpande
d,
Ricardo
O.
Guerra
a,eaUniversidadeFederaldoRioGrandedoNorte(UFRN),ProgramadePós-Graduac¸ãoemCiênciasdaSaúde,Natal,RN,Brazil bUniversidadeFederaldoRioGrandedoNorte(UFRN),DepartamentodeFisioterapia,Natal,RN,Brazil
cUniversidadeFederaldoRioGrandedoNorte(UFRN),ProgramadePós-Graduac¸ãoemSaúdePública,Natal,RN,Brazil dQueen’sUniversity,FacultyofHealthSciences,SchoolofRehabilitationTherapy,Kingston,Canada
eUniversidadeFederaldoRioGrandedoNorte(UFRN),ProgramadePós-Graduac¸ãoemFisioterapia,Natal,RN,Brazil
Received3February2017;accepted2June2017 Availableonline29June2017
KEYWORDS BenignParoxysmal PositionalVertigo; Elderly; Vertigo; Dizziness; Rehabilitation Abstract
Introduction:BenignParoxysmalPositionalVertigoishighlyprevalentinelderlypeople.This conditionisrelatedtovertigo,hearingloss,tinnitus,poorbalance,gaitdisturbance,andan increaseinriskoffalls,leadingtoposturalchangesandqualityoflifedecreasing.
Objective: ToevaluatetheoutcomesobtainedbyclinicaltrialsontheeffectivenessofOtolith Repositioning Maneuver and Vestibular Rehabilitationexercises in the treatment ofBenign ParoxysmalPositionalVertigoinelderly.
Methods:TheliteratureresearchwasperformedusingPubMed,Scopus,WebofScienceand PEDro databases, andincludedrandomized controlled clinicaltrials inEnglish, Spanish and Portuguese,publishedduringJanuary2000toAugust2016.Themethodologicalqualityofthe studieswasassessedbyPEDroscoreandtheoutcomesanalysiswasdonebycriticalrevisionof content.
Results:Sixstudieswerefullyreviewed.Theaverageageofparticipantsrangedbetween67.2 and 74.5 years.The articles were classified from 2 to7/10 through the PEDro score. The main outcomemeasures analyzed werevertigo,positional nystagmus andposturalbalance.
夽 Pleasecitethisarticleas:RibeiroKF,OliveiraBS,FreitasRV,FerreiraLM,DeshpandeN,GuerraRO.EffectivenessofOtolithRepositioning
ManeuversandVestibularRehabilitationexercisesinelderlypeoplewithBenignParoxysmalPositionalVertigo:asystematicreview.BrazJ Otorhinolaryngol.2018;84:109---18.
∗Correspondingauthor.
E-mail:[email protected](K.F.Ribeiro).
PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial. https://doi.org/10.1016/j.bjorl.2017.06.003
1808-8694/©2017Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
110 RibeiroKFetal.
Additionally,thenumberofmaneuversnecessaryforremissionofthesymptoms,thequalityof life,andthefunctionalitywerealsoassessed.ThemajorityoftheclinicaltrialsusedOtolith RepositioningManeuver(n=5)and3articlesperformedVestibularRehabilitationexercisesin additiontoOtolithRepositioningManeuverorpharmacotherapy.Onestudy showedthatthe additionofmovementrestrictionsaftermaneuverdidnotinfluencetheoutcomes.
Conclusion:TherewasatrendofimprovementinBenignParoxysmalPositionalVertigo sympto-matologyinelderlypatientswho underwentOtolithRepositioningManeuver.Thereissparse evidence from methodologically robust clinical trials that examined the effects ofOtolith RepositioningManeuver andVestibularRehabilitation exercises for treatingBenign Paroxys-malPositionalVertigointheelderly.Randomizedcontrolledclinicaltrialswithcomprehensive assessmentofsymptoms,qualityoflife,functionandlong-termfollowuparewarranted. © 2017 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/). PALAVRAS-CHAVE Vertigemposicional paroxísticabenigna; Idosos; Vertigem; Tontura; Reabilitac¸ão
Eficáciadasmanobrasdereposicionamentodeotólitoseexercíciosdereabilitac¸ão vestibularemidososcomvertigemposicionalparoxísticabenigna:umarevisão sistemática
Resumo
Introduc¸ão:Avertigemposicionalparoxísticabenignaéaltamenteprevalenteemidosos.Esta condic¸ãoestárelacionadaavertigem,perdaauditiva,zumbido,equilíbrioprecário,distúrbios damarchaeaumentodoriscodequedas,levandoamudanc¸asposturaisereduc¸ãodaqualidade devida.
Objetivo:Avaliar os desfechos obtidospor ensaios clínicos sobre a eficáciada Manobra de Reposicionamento de Otólitos ede exercícios de Reabilitac¸ão Vestibular notratamento de vertigemposicionalparoxísticabenignaemidosos.
Método: Apesquisadaliteraturafoirealizada usandobancos dedadosdoPubMed,Scopus, WebofScienceePEDroeincluiuensaiosclínicoscontroladosrandomizadoseminglês,espanhol eportuguês,publicados dejaneirode2000aagostode2016.Aqualidademetodológicados estudosfoiavaliadapeloescorePEDroeaanálisedosdesfechosfoirealizadaporrevisãocrítica doconteúdo.
Resultados: Seisestudosforamtotalmenterevisados.Aidademédiadosparticipantesvariou entre67,2-74,5anos.Osartigosforamclassificadosde2a7/10peloescorePEDro.Asprincipais medidasdedesfechoanalisadasforamvertigem,nistagmoposicionaleequilíbriopostural.Além disso,onúmerodemanobrasnecessáriasparaaremissãodossintomas,aqualidadedevida eafuncionalidadetambémforamavaliados.Amaioriadosensaiosclínicos usouManobrade ReposicionamentodeOtólitos(n=5)e3artigosrealizaramexercíciosdeRV,alémdeManobrade ReposicionamentodeOtólitosoufarmacoterapia.Umestudomostrouqueaadic¸ãoderestric¸ões demovimentoapósamanobranãoinfluenciouosresultados.
Conclusão:Houveumatendênciademelhoranasintomatologiadavertigemposicional parox-ística benignaem pacientesidosossubmetidos àManobradeReposicionamentode Otólitos. Existemevidênciasescassasdeensaiosclínicosmetodologicamenterobustosqueexaminaram osefeitos dosexercíciosde Manobrade ReposicionamentodeOtólitose Reabilitac¸ão Vesti-bularparaotratamentodavertigemposicionalparoxísticabenignanosidosos.Ensaiosclínicos controladosrandomizadoscomavaliac¸ãoabrangentedesintomas,qualidadedevida,func¸ãoe acompanhamentodelongoprazosãojustificados.
© 2017 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http:// creativecommons.org/licenses/by/4.0/).
Introduction
Dizzinessis oneof themostcommon symptomsinelderly
peopleand itis considered a geriatric syndrome.1 Among
thecausesofdizziness,BenignParoxysmalPositionalVertigo (BPPV) is the most frequent vestibular disorder, affecting
approximately 20% of patients presenting this symptom.
BPPVis highlyprevalentinelderly,probablyduetosenile
degenerative changes.2,3 Diagnosis of BPPV is confirmed
usingDix-Hallpiketest,anditisclassifiedasobjectivewhen
nystagmusisobservedduringthetest,or subjectivewhen
thereisvertigowithoutnystagmus.4 Femalepatientshave
beenshowntobemostaffectedbyBPPV,whichmaybe
jus-tifiedbythefactthatthehomeostasisoflabyrinthinefluids
maybecompromisedbyfemalehormonesdecreasingfrom
PrevalenceofBPPVisestimatedat25%inelderlypeople over70yearswithcomplaintsaboutdizzinessandthis symp-tompersistsformorethanoneyear.6---8Vertigoisreportedas
themaincomplainofBPPVpatientsandmaybeassociated
tohearingloss,tinnitus,poorbalance,gaitdisturbance,and anincreaseinriskoffalls.9PatientswithBPPVrestricttheir
activities inorder toavoidcrises due vertiginous
sympto-matology, leading to postural changes and quality of life
decreasing.8,10 Such movement restrictions associated to
comorbiditiesandhighprevalenceofBPPVinelderlyusually resultinfunctionallossandinability.11,12
BPPValsoincreasesincidenceoffallsinolder patients,
aswellaschance offracture, headtraumas(concussion),
hospitalizations anddepression.13 Elderly withBPPV show
worsescoresinfunctionaltestsduetocoexistenceof mul-tiplemorbidities,fearoffallingthatcharacterizesgeriatric populationandthesenescenceofvestibularsystemusually foundinthispopulation,whichmayfurtherdamagepostural balance in these individuals.13,14 Furthermore, static and
dynamic posturalcontrol in elderlypatients with vestibu-lopathiesisdamaged,whichmaycontributetoafunctional
limitation and greater low balance confidence regarding
fallsinthispopulation.3,15---18
Vertigo and other associated symptoms are triggered
by the displacement of statocone (otoconia) fragments
fromtheutriclemacula.The statoconefreelyfloatin the
endolymphofoneormoresemicircularcanalswhichbecome
sensitivetochangesinheadposition.19 Forthesereasons,
BPPV is mainly treated by Otolith Repositioning
Maneu-vers(ORM) inordertomovetheotoconiaoutofthecanal
andlead it backtothe vestibule.However,some authors
indicate that ORM is not sufficient to improve or recover
postural stability in elderly people with BPPV.20---22 Other
non-pharmacologicalinterventionforpatientswithbalance disturbancesistheVestibularRehabilitation(VR)exercises, whichincludesvestibularadaptation,habituationand sub-stitutionexercises,andpatienteducation.23---25
Although the use of ORM and VR exercises on
treat-ingBPPVarecommonly proposedin theliterature, itwas
observed that the majority of studies include a hugeage
variation in their experimental designs and intervention
forms.Therefore,thepresentreviewaimedtoevaluatethe
outcomesfromrandomizedcontrolledclinicaltrialsabout
theeffectivenessofORMandVRexercisesinthetreatment ofBPPVinelderlypeople.
Methodology
Forthepresent systematicreview,thescientificquestion:
‘‘What is the effectiveness of ORM and/or VR exercises
in thetreatment of BPPVinelderly people?’’,was
estab-lished usingthePICOstrategy.26 The P-Patientcomponent
of the PICO strategy refers to elderly with BPPV; the
I-Intervention refers to ORM and/or VR exercises; and
the O-Outcomesis related tovertigo, dizziness, and
pos-turalbalance.ThecomponentC-Comparisonwasexcluded
from the study because there is no comparison between
interventions.Bibliographicresearchwasperformedduring
September2016concomitantlyinPubMed,Scopus,Webof
ScienceandPEDrodatabases.ItwaslimitedtoPortuguese,
EnglishandSpanishlanguagepaperswhichwerepublished
from January, 2000 to August, 2016. The strategy used
wasthe combination of the descriptors‘‘benign
paroxys-malpositionalvertigo’’AND‘‘physicaltherapymodalities’’ OR‘‘rehabilitation’’OR‘‘exercisetherapy’’AND‘‘vertigo’’ OR‘‘dizziness’’OR‘‘posturalbalance’’.Afterthisprocess,
only two key-words were combined (‘‘Benign paroxysmal
positional vertigo’’ AND ‘‘therapy’’; ‘‘Benign Paroxysmal
Vertigo’’AND‘‘Exercises’’;‘‘BenignParoxysmal Positional
Vertigo’’ AND ‘‘Treatment’’; ‘‘Benign Paroxysmal
Posi-tionalVertigo’’AND‘‘PhysicalTherapy’’).Duplicatearticles
amongthedatabaseswereexcluded.
The following inclusion criteria were applied: (1)
Par-ticipants with an average age of 65 years and over; (2)
Individuals with BPPV and; (3) Interventions by VR
exer-cisesand/orORM.The studieswereexcludediftheywere
non-randomizedclinicaltrials,qualitativestudies,and stud-ieswithpharmacologicalor surgical interventionswithout associationtoVRexercisesand/orORM.
The construction of this systematic review was guided
bythecriteriaofthePreferredReportingItemsfor
System-aticReviewsandMeta-Analysis(PRISMA statement).27 The
methodologicalqualityofselectedstudieswasassessedby
PEDro score, which is comprised of 11 criteria about the
internalvalidityandinterpretationofclinical trials.28 The
scoreattributes1pointforeachcriterionpresentedbythe study.However,thefirstcriterion(eligibilitycriterion)isnot counted.Therefore,thecloserthescoreisto10obtained bythe study,the better isits methodologicalqualityand datareproducibility.Eacharticle scoreisgivenby trained specialistsanditisavailableinPEDrodatabase.29
The studies selected for a full review were analyzed
by two independent researchers and the disagreements
betweenthemweresolvedinconsensuswithassistanceof
athirdevaluatorwhoanalyzedthedivergentquestions.
Results
Theresearchperformedbythehealthdescriptorsand
key-words resulted in 3337 articles, but 1085 studies were
duplicates.Outofthese,1844studieswereexcludedsince theydidnotmeettheinclusioncriteria.Fourhundredand eightabstractswerescrutinized.Byreadingtheabstracts, itwasfoundthat306werenotrandomizedcontrolled clin-icaltrials,92hadaverageageslowerthan65yearsordid notshowtheaverageageinfulltextand4didnotinclude BPPVasasamplecharacteristic(Fig.1).Thereby,6 random-izedcontrolledclinicaltrialspassedthecriteriarequiredfor thisreviewandwereselectedforcriticalanalysisoftheir content.Thesynopsisofmaindatafromthereviewed arti-clesisdisplayedinTable1.Table2showsthatPEDroscore rangedfrom2to7.
Amongthesixselectedstudies,thesamplenumber
var-ied from 14 to 156 patients, totaling 300 participants.
The average age varied from 67.2 to 74.5 years. One
article30 used Semont Liberatory Maneuver (SLM) as the
intervention,whilefourstudiesusedEpleymaneuver20,31---33
and one study implemented movement restrictions after
the ORM and used a cervical collar and a mini-vibrator
appliedonthe mastoidof the affected side.31 Four
112 RibeiroKFetal.
Records identified in
the databases (n=3337)
Articles excluded since they did not meet
the inclusion criteria
(n=1844)
Records screened
(n=408)
Excluded articles (n= 402):
Average age lower than 65 years or not
provided by the authors (n=92)
Other study types (n=306)
Studies that did not aim to treat BPPV
(n=4)
Studies included in the
qualitative analyses
(n=6) Records after duplicates removed
(n=2252)
Figure1 Fluxogramfortheselectionofarticles.
pharmacotherapy.30,34 Table 1 provides details about the
interventionstrategiesusedineachstudy.
Theanalyzedvariablesintheselectedstudiesincluded:
vertigo,20,30,32,33 positional nystagmus20 and postural
balance,33thenumberofnecessarymaneuversforremission
ofsymptoms31,32andthequalityoflifebyDizzinessHandicap
Inventory(DHI)score,31,33andfunctionalitybytheVestibular
DisordersActivitiesofDailyLivingscale(VDADL).30,34
Discussion
The increment of older population around the world
willrequirespecialattention governmenthealthservices. Comorbiditiesrelatedtotheagingprocessunderlinedbythe deficitinphysiological,cognitiveandsocialfunctions, con-tributetothedevelopmentofdiseasesinmultiplebiological
systems.BPPVisthemostcommoncauseofvestibular
ver-tigo and one of the otoneurological conditions that has
the highest prevalence in the geriatric population,
lead-ing tostrong impact on the health and quality of life of
theseindividuals.35Non-pharmacologicalalternativesforits
treatment,includingtheORM,representanimportant ther-apeuticopportunity asa resultof absenceof sideeffects
riskscommonlyseeninolderpeople.
AmongthestudiesevaluatedbyPEDroscore,thehighest classificationwas7/10.Nevertheless,thetwoarticles evalu-atedwiththisscorehadalowsample(only7ineachgroup).
These findings warrant the need to conduct randomized
controlledandblindedclinicaltrialsinelderlypeoplewith
BPPV, with robust methodology. In the majority of
stud-ies,patientspresentedBPPVofposteriorcanal,20,30,31which
accordingtoliteratureisthemostprevalentdiagnosis.18,22,36
Twostudiesdidnotspecifytheaffectedcanal.33,34
As for the ORM intervention in elderly, most studies
appliedthemodifiedEpleymaneuver.20,31---33 Nostudyused
theclassicEpleymaneuver,butthestudyofAndréetal.31
addedamini-vibratoronthemastoidprocessoftheaffected
side. All the studies that used modified Epley maneuver
described improvements in BPPV symptomatology, mainly
for vertigo,dizzinessandnystagmus.These findingsagree
withcurrent literature, which placesthe Epleymaneuver
firstinthetreatmentofBPPVofposteriorcanal.Fifeetal.37
classified the Epleymaneuver for otolith repositioning as
‘‘RecommendationlevelA.’’Inotherwords,thetherapyis effectiveandsafeandmustbeofferedtopatientswithBPPV ofposteriorcanalofallages.
TheliteratureindicatesSLMasthetreatmentfor
cupu-lolithiasis ofanteriorandposteriorcanals.29,36 Onearticle
mentioned having performed it. However,this study
per-formedSLMwithoutclarifyingifpatientshadcupulolithiasis or canalithiasis,30 withthe exceptionbeing André etal.31
thatclarifiedtheirsample asBPPVofposteriorcanalwith
ductolithiasis (canalithiasis). In the study conducted by
Salvinelli etal.,30 the group that underwentSLM
demon-strated a significantly superior percentage of symptom
remissioncomparedtotheonethatusedonly
pharmacolog-icalinterventionwithFlunarizine®(10mg/dbeforesleeping
during60days).Furthermore,symptomrecurrenceratewas
alsolowerinthemaneuvergroupafter6months.
TheeffectofmovementrestrictionsafterORMhasbeen
a targetintervention ofone research,whichassessed the
efficacyofthispracticeafterimplementingthemaneuver.31
Andréetal.31 usedaneckbraceinonegroup,inaddition
tomovementrestrictioninstructions.Accordingtothe find-ingsofthisstudy,themovementrestrictionsafterORMdo
notinfluenceoutcomes.Thesedataareinconcordancewith
theinternationalguidelineelaboratedbyFifeetal.,37which
classifiedmovementrestrictionsas‘‘RecommendationU,’’
therefore,therearenotenoughdatatosupportitsusein clinicalpractice.
Only the studies of André et al.31 and Ribeiro et al.33
evaluatedqualityoflife aftermanagementof BPPV. They
concludedthattheEpleymaneuverimprovespatient’sDHI
score, which indicates that this procedure is effective to
decrease theimpactof thevertiginous symptoms.Similar
findingsarefoundafterthetreatmentofpeoplewithVPPB
inotheragegroups.38
Accordingtonumberofmaneuvers,thestudiesthatused
ORMvariedfrom1to3maneuversingeneral.Fourstudies
applied 1---3 maneuvers in the same session.20,32,33 Two
studies performedone maneuverper sessionwitharange
of 1---3 maneuvers(sessions) among groups andconcluded
that the ORM was effective for symptom remission.30,31
Korn et al.39 suggest that consecutive maneuvers in the
same session seem to be more effective than only one
of Otolith R epositioning Maneuvers and V estibular R ehabilitation 113
Table1 Synopsis ofdatafromrandomizedcontrolled clinicaltrialsabouttheeffectiveness ofOtolithRepositioningManeuvers(ORM)andVestibularRehabilitation(VR) exercisesinthetreatmentofBenignParoxysmalPositionalVertigo(BPPV)inelderlypeople.
Author Year Country
Sample Age(mean-median)in years
Outcomemeasures Intervention Results
Angelietal. (2003)
UnitedStates(PEDro:4/10)
EG:28 CG:19 PC-BPPV EG:74.5±4.5 CG:74.2±3.4 (1)Vertigo: -Reportedduring Dix-Hallpiketest (2)Positional nystagmus: - Electronystagmo-graphyduring Dix-Hallpiketest. 1stPhase:
-EG:ORM(Epleymaneuver);CG:no intervention.
Numberofmaneuvers:1---3.
Follow-up:1month.
2ndPhase:
-CG:ParticipantsinCGwhodidnot achievespontaneousremissionof symptomsreceivedORM(after1month). -Theparticipantsfrombothgroupswho didnotgetremissionofsymptoms, underwentasupervisedVRexercises program.
VRfrequency:2or3timesaweek.
Follow-up:4---6weeks.
1stPhase:
-64%ofpatientsfromEGobtainednegative Dix-Hallpiketest(novertigoornystagmus) comparedtoonly5%inCG(p<0.001). Therewasnodifferenceincurerate betweentheCGsubgroupandthe experimentalgroupaftermaneuver performance(p=0.553).
2ndPhase:
-18patientsreceivedpersonalizedVR. Sevenpatientshadtotalremissionof symptomsand/ornystagmus(negative Dix-Hallpike),6continuedtopresenta positivetestand5didnotconcludethe study.
-Attheend,77%ofpatientsobtained successintreatment. Resendeetal. (2003) Brazil(PEDro:4/10) EG:8 CG:8 Didnot specify thecanal EG:70.5(61---82) CG:69.3(60---78) (1)Functionality (VDADL)
EG:CawthorneandCookseyexercises protocolandpharmacotherapy (Gingko-Biloba---40mgde12/12h);
VRfrequency:2sessionsaweek,during 5weeks.
CG:Pharmacotherapy.
Follow-up:5weeks(EG)and30days (CG).
SignificantdecreaseinVDADLscoresinEG (p<0.01).
Therewerenodifferencesinthefinalscore ofVDADLinCGcomparedtopre-treatment phase.
SignificantbenefittoEGcomparedtoCG (p<0.009).
Salvinellietal. (2004)
UnitedKingdom(PEDro: 4/10)
G1:52 G2:52 G3:52 PC-BPPV G1:73(70---78) G2:74.5(71---80) G3:75(72---79) (1)Vertigo: -Reportedduring Dix-Hallpiketest (2)Functionality (VDADL) -G1:ORM(SLM).
Numberofmaneuvers:1---3consecutive maneuversperweekuntilsymptom resolution.
-G2:Calciumantagonists(10mg/dof Flunarizinebeforesleepingfor60days); -G3:notreatment.
Follow-up:6monthsaftertheendof eachtreatment.
-G1:94.2%ofvertigoremissionafter3 maneuversand3.8%ofrecurrencein6 months.
-G2:57.7%ofsymptomsremission;5.8%of recurrencein6months;
-G3:34.6%hadspontaneousremissionof symptoms;21.1%ofrecurrencein6months; -Astatisticallysignificantpost-treatment improvementinactivitiesofdailylivingand inqualityoflifewasnoticed(p<0.001).
114 Ribeiro KF et al. Table1 (Continued) Author Year Country
Sample Age(mean-median)in years
Outcomemeasures Intervention Results
Andréetal. (2010) Brazil(PEDro:2/10) G1:23 G2:15 G3:15 PC-BPPV Ductolithiasis 67.2(60---91) Authorsdidnot providethemedian agebygroup (1)Dix-Hallpiketest; (2)Clinicalaspects andsymptoms: referredbyBrazilian DHIquestionnaire.
-G1:ORM(Epleymaneuver)+neck brace+Posturalrestrictionsfor48hours aftermaneuver;
-G2:ORM(Epleymaneuver); -G3:ORM(Epleymaneuver)+Mini vibrator
Numberofmaneuvers:onepersession untilcompleteremissionofvertigo.
Followup:timebetweenevaluations wasnotinformed.
-Numberofmaneuversrangedfrom1to3 inallgroups.Nodifferencewasfound betweengroups;
-Statisticallysignificantdifferencewas observedinallaspectsevaluatedbyDHI aftertreatmentinallgroups;
-Significantimprovementonphysical aspectsofG1aftertreatmentwhen comparedtoG2(p=0.009);
-Independentoftheprocedureafter maneuvertheORMwaseffectivebasedon DHIscore. Ribeiroetal. (2016) Brazil (PEDro: 7/10) EG:7 CG:7 PC-BPPV EG:69(65---78) CG:73(65---76) (1)Dix-Hallpiketest; (2) Vertigo---evaluated byVAS; (3)Numberof maneuvers.
EG:ORM(Epleymaneuver)+VR CG:ORM(Epleymaneuver)
Numberofmaneuvers:1to3per session.
VRfrequency:2timesaweek.
Follow-up:13weeks
-Themedianforthenumberof
comorbiditiesintheEGwas4(3---6)and4 (2---6)intheCG,whilethemediannumber ofdrugsusedwas3(1---6)intheEGand3 (3---7)intheCG.
-TheDix-Hallpiketestwasnegativeforall seniorsintheEGafter13weeks,whilethe CGshowedtreatmentfailurein28.6% patients.
-Therewassignificantimprovement gradient,withaprogressivedecreaseinthe numberofmaneuversnecessaryforthe treatmentinEG(p<0.001).
-Therecurrenceratewashigher,yetnot statisticallysignificant,intheCGinthe13 weekperiod.
of Otolith R epositioning Maneuvers and V estibular R ehabilitation 115 Table1 (Continued) Author Year Country
Sample Age(mean-median)in years
Outcomemeasures Intervention Results
Ribeiroetal. (2016) Brazil(PEDro:7/10) EG:7 CG:7 Didnot specify thecanal EG:69(65---78) CG:73.5(72---76) (1)Postural balance---evaluated bycomputadorized posturographyand DGI; (2) Vertigo---evaluated byVAS; (3)Qualityof life---evaluatedby DHI.
EG:ORM(Epleymaneuver)+balanceVR CG:ORM(Epleymaneuver)
Numberofmaneuvers:1---3persession.
VRfrequency:2timesaweek.
Follow-up:13weeks
-Nodifferencesbetweengroupswere foundregardingallstandingbalance aspects.However,therewasawithingroup improvementinstandingbalanceinall testsinexperimentalgroup.
-Concerningdynamicbalance,therewere significantdifferencesbetweengroupsin themajorityofthetests.Inwithingroup comparisons,theexperimentalgroup’sall dynamicbalanceparameterssignificantly improved.Conversely,nosignificant differenceswerefoundregardingdynamic balanceinthecontrolgroup.
-Therewerenosignificantdifferencesin dizzinesssymptomsandqualityoflife betweengroups.However,bothgroups showedintragroupsignificantimprovement forbothoutcomemeasures.
EG,experimentalgroup;CG,controlgroup;G1,Group01;G2,Group02;G3,Group03;DHI,DizzinessHandicapInventory;DGI,DynamicGaitIndex;VAS,VisualAnalogScale;VDADL, VestibularDisordersActivitiesofDailyLivingscale;PC-BPPV,BenignParoxysmalPositionalVertigooftheposteriorcanal;VR,VestibularRehabilitation;SLM,SemontLiberatoryManeuver.
116 RibeiroKFetal.
Table2 MethodologicalanalysisbyPEDroscoreofclinicaltrialsabouttheeffectivenessofOtolithRepositioningManeuvers (ORM)andVestibularRehabilitation(VR)exercisesinthetreatementofBenignParoxysmalPositionalVertigo(BPPV)inelderly people. Angelietal. 2003 Resende etal.2003 Salvinelli etal.2004 Andréetal. 2010 Ribeiro etal.2016 Ribeiro etal.2016 1.Eligibilitycriteriawere
specified
Yes Yes Yes Yes Yes Yes
2.Subjectswererandomly allocatedtogroups
Yes Yes No Yes Yes Yes
3.Allocationwasconcealed No No No No Yes Yes
4.Thegroupsweresimilarat baselineregardingthemost importantprognosticindicators
Yes Yes No No Yes Yes
5.Therewasblindingofall subjects
No No No No No No
6.Therewasblindingofall therapistswhoadministeredthe therapy
No No No No No No
7.Therewasblindingofall assessorswhomeasuredatleast onekeyoutcome
No No No No Yes Yes
8.Measuresofatleastonekey outcomewereobtainedfrom morethan85%ofthesubjects initiallyallocatedtogroups
Yes No Yes No Yes Yes
9.Allsubjectsforwhomoutcome measureswereavailable receivedthetreatmentor controlconditionasallocated or,wherethiswasnotthecase, dataforatleastonekey outcomewasanalyzedby ‘‘intentiontotreat’’
No No No No No No
10.Theresultsofbetween-group statisticalcomparisonsare reportedforatleastonekey outcome
Yes Yes Yes Yes Yes Yes
11.Thestudyprovidesbothpoint measuresandmeasuresof variabilityforatleastonekey outcome
No Yes Yes No Yes Yes
Score 4/10 4/10 3/10 2/10 7/10 7/10
conductedaquasi-experimental studyin33olderpatients withBPPVandperformed theORM only oncepersession, then repeated weekly until symptoms and nystagmus disappeared (remission), and also concluded that ORM waseffective. Therefore,despite ORM being an effective interventionforBPPVin elderlyregardlessoftheprotocol performed by the studies, it is not possible to propose a standard number of maneuvers, or if they should be performedinthesamesessionorindifferentones.
Only one study that did not use ORM as therapeutic proposal was found,34 but its main intervention was VR
exercises for an elderly sample. They applied Cawthorne
and Cooksey exercise protocols associated to
Gingko-Biloba in experimental group and only drug intervention
in the control group. The authors obtained significant
improvementreferringtofunctionalitybyperforming ther-apeuticexercises;however,therearenotreportsdenoting
improvements in BPPV symptoms and signs (vertigo and
nystagmus).Angelietal.20alsousedVRexercisesinelderly
peoplewithBPPVandrandomlyassignedthepatientsinto2 groupsinthefirstpartofthestudy:ORMandnotreatment.
After one month, those patients who did not respond to
treatmentwereenrolledinthesecondpartofthestudyand
were treated with an individualized combination of ORM
andVR,andthen reevaluated3monthslater.The authors
concludedthatthemaneuversaremoreeffectivecompared
tonotreatment,andVRexercisescanbeaddedtoORMto
improveresultsinthetreatmentofBPPVinelderlypeople. Furthermore,Angelietal.20observedaconsiderablerate
andtheysuggestthatVRexercisescandecreaserecurrence rateofBPPV.Theystatedthatthisprotectoreffectcanbe
moreevident inelderlypeople.20 The studyconductedby
Ribeiro et al.32 also aimed to verify the recurrence rate
betweenthegroupthatperformedonlyORMandthegroup
thatperformedVRassociatedtoORM,buttherewasnot
sta-tistically significant differencebetween thegroups. Some
studieshaveshownthatVRexercisesinyoungerandolder
patientswithBPPVaremoreeffectivealonewhencompared
tonotreatmentorplacebotreatment.40,41Silvaetal.24
ana-lyzed two international guidelines37,42 and considered VR
exercisesaspossiblyeffective,becomingasecondaryoption inthetreatmentofBPPV.
The majority of selected articles provide short-term
results ranging from4 weeksto13 weekspost-follow up.
OnlythestudyofSalvinellietal.30presentedalongerfollow
upofsixmonthsandtheyobservedahigherrateof
symp-tomrecurrence(21.1%)innonetreatmentgroupcompared
totheORMgroup(3.8%).43Gananc¸aetal.18reevaluatedan
elderlysampleintheirquasiexperimentalstudyafterone
yearofsuccessfulORMandobservedBPPVrecurrencerate
of21.5%.AccordingtoBrandtetal.44andSimhadrietal.,45
therecurrencerateintreatedcasesvariesbetween10%and 80%.ThisvariabilityfoundinliteratureinrelationtoBPPV
recurrenceratemayoccurduetomethodologydifferences
amongstudies.Gananc¸aetal.18believethatthelongerthe
follow upis,the highertheproportionof recurrencerate
of BPPVcases is. Although results of BPPV treatment are
encouraging,therecurrenceofdizziness,particularlyinthe elderly,isveryhighandnewstudieswithlongtermfollow upwouldbenecessaryforthesepatients.6---8
Although postural balance is often impaired in the
elderly,especiallyin thosewithvestibulardisorders,7,18 it
wasobservedthatonlyoneofthestudiesevaluatedstanding and/ordynamicposturalbalanceinthispopulation.Ribeiro etal.33showedtheeffectsoftheVRintheposturalbalance
inelderlypeoplewithBPPV. Theexercisesincluded oculo-motorexercises(VOR×1),habituationexercises(repeated
head and trunk movements), standing and dynamic
bal-ancetraining,alongwithlower-limbmusclesstrengthening. Foreachexerciseprescription,auniversalsetof10
modi-fiersand progressionpatternswere followed tomake the
exercises morechallenging.46 It wasfound thatthe group
which performed the VR improved the dynamic balance
whencompared tothecontrolgroup that performedonly
theORM. Nonetheless,quasi-experimental studies
demon-strate the efficacy of ORM in improving balance in the
elderlypopulation.12,21,47Gananc¸aetal.18performedastudy
onelderlypeople andconcludedthat thenumber offalls
decreasedinconsequenceofvertigoandnystagmus
remis-sion after a maneuver.The review’slimitations include a
highstandarddeviationinaverageage,whichmeansthere
were alsoyounger persons in some studies. Furthermore,
posturalbalanceandfunctionalitywerebarelyevaluatedin thestudiesdespiteoftheclinicalimportanceintheelderly population,mainlyinthosewhosufferfromdizziness.
AllthestudiesthatusedORMinelderlypeoplewithBPPV
showeda trend ofimprovement in their symptomatology,
mainlyfor vertigo,dizzinessandnystagmus. Regardlessof
theproceduresperformedbythestudies,therewasahuge
range in the number of maneuvers to obtain a negative
Dix-Hallpiketest,thusitisnotpossibletoproposeanORM
standardprotocol.Thereisalackofrobustmethodological
studies that used VR in this population, thus it is not
possibleto concludethat this interventionis effective. It
seemsthat the movement restrictions after maneuver do
notinfluenceresults.Overall,thereissparseevidencefrom methodologicallyrobustclinical trialsthathave examined theeffectsofORMandVRexercisesfortreatingBPPVinthe
elderly population. Randomized controlled clinical trials
with comprehensive assessment of symptoms, quality of
life,functionandlong-termfollowuparewarranted.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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