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Vestibular rehabilitation (VR) is effective in reducing dizziness and vertigo and associated falls and improving quality of life in people with disorders involving balance mechanisms.

Good balance is essential for daily life, from getting out of bed to crossing the road. A healthy balance system uses information from the brain, inner ears, eyes, and joints, and enables people to see clearly when moving their head.
Balance disorders and dizziness are a growing public health concern across all age groups. Prevalence increases with age and these disorders are some of the most common complaints reported to GPs by older patients.1 Untreated, they result in worsening unsteadiness, loss of confidence and anxiety, difficulty with concentration and memory, inactivity, loss of independence, an increased risk of falls and costly falls-related injuries.1,2

What causes dizziness?

The most common form of dizziness and balance disorder is BPPV (Benign Paroxysmal Positional Vertigo), a disorder of the inner ear resulting in episodes of intense dizziness on certain head movements.

Other causes include side effects from medication or alcohol, brain disorders such as stroke, concussion or cerebellar degeneration, cardiac problems and anxiety.

What is vestibular rehabilitation?

VR is an exercise-based program to encourage the central nervous system to compensate for problems in the inner ear. Following thorough examination, physiotherapists develop personalized exercise-based management plans including home exercise programs.

VR is a successful treatment for people with common balance and dizziness disorders.

A management plan may include:

  • Eye and head movement exercises
  • Exercises to improve standing balance and walking
  • Specific techniques to reposition fragments in the inner ear which cause dizziness in BPPV
  • Education and advice on activities of daily living to improve confidence and function
  • Advice on falls reduction/prevention

Significant improvement is achieved in:

  • 80% of patients with unilateral vestibular loss (e.g. labyrinthitis, acoustic neuroma surgery)4
  • 80% of patients with BPPV after one treatment session5
  • Patients with a central cause (e.g. stroke) may show some improvement
  • Use of VR in concussion,6 migraine,7 and nonspecific balance loss of the elderly may be helpful

Size of the problem

  • 35% of adults over 40 in the USA have balance dysfunction, which increases to 85% for adults over 807
  • 18% of children in the USA have ‘moderate’, ‘big’ or ‘very big’ problems with dizziness or balance; only 62% received treatment
  • 20% with vestibular vertigo avoid leaving the house and 41% require sick leave9
  • Dizziness/balance problems are strongly associated with falling and being injured in a fall10 
  • 80% of older adults who fall have vestibular impairment11  
  • Over 50% of adults over 65 admitted to hospital after a fall were found to have BPPV12

Cost of ill health

  • Falls were the leading cause of injury in 2010 in Canada. About 63% of seniors and one-half of adolescents were injured in falls, as were 35% of working-age adults13
  • Falls cost Canada over $6 billion in 201014 
  • Fall-related injuries cost Alberta over $160,000,000 in 201115
  • A multi-country review found that over a three-month period, 70% of the working population with vertigo reduced their workload and 63% lost as many as 14 working days16  
  • Vertigo can lead to long-term work absence and disability pension17

Physiotherapists are ideally placed to provide early screening and intervention to minimize the impact on daily life of balance and dizziness disorders.

Physiotherapists who practice vestibular rehabilitation provide personalized programs which are clinically effective reducing distressing symptoms and improving quality of life.18

References

  1. Iwasaki S and Yamasoba T, Dizziness and Imbalance in the Elderly: Age-related Decline in the Vestibular System, Aging and Disease vol 6, Number 1, February 2015. doi 10.114336/AD 2014.0128
  2. Harun A et al Understanding the Experience of Age-related Vestibular Loss in Older Individuals: a Qualitative Study, Patient 2016 August: 9(4):303-309  doi 10.1007/s40271 – 015 -0156 – 6
  3. Bhattacharyya N, Baugh RF, Orvidas L, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2008 Nov;139(5 Suppl4): S47--81. http://oto.sagepub.com/content/139/5_suppl/S47.full.pdf
  4. Hillier Susan L, McDonne llM. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database of Systematic Reviews. 2011(2):Art. No.: CD005397. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005397.pub3/abstract005397.pub3/abstract
  5. Hilton MP, Pinder DK The Epley ( canalith repositioning) manoeuvre for benign paroxysmal positional vertigo, Cochrane Database of Systematic Reviews 2014, Issue 12. Art. No.: CD001362. doi 10.1002/14651858.CD003162.pub3
  6. Alsalaheen BA, Mucha A, Morris LO, et al. Vestibular rehabilitation for dizziness and balance disorders after concussion. Journal of Neurologic PhysicalTherapy : JNPT. 2010 Jun;34(2):87¬-93.
  7. Agrawal Y et al, Vestibular Dysfunction: prevalence impact and need for targeted treatment J Vestib Res 2013; (23) 3: 113-117.  doi 10.3233/VES-130498
  8. Li CM, Hoffman HJ et al Epidemiology of Dizziness and Balance Problems in Children in the United States: a Population-based Study J Pediatri 2016; 171: 240-7 DOI:10.1016/j.jpeds.2015.12.002
  9. von Brevern M, Radtke A, Lezius F, et al. Epidemiology of benign paroxysmal positional vertigo: a population based study. Journal of Neurology, Neurosurgery, and Psychiatry. 2007 Jul;78(7):710¬-5. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2117684/pdf/710.pdf
  10. Lin HW; Bhattacharyya N,  Impact of dizziness and obesity on the prevalence of falls and fall-related injuries, Laryngoscope 2014 Dec;124(12):2797-801. doi: 10.1002/lary.24806. Epub 2014 Jul 1.
  11. Liston MB et al, Peripheral vestibular dysfunction is prevalent in older adults experiencing multiple non-syncopal falls versus age matched non-fallers: a pilot study. Age and Aging 2014;43:38-43  doi 10.1093/ageing/aft 129
  12. Abbott J A et al Assessment for benign paroxysmal positional vertigo in medical patients admitted with falls in a district general hospital Clin Med (Lond)..2016 Aug;16(4):335-8. doi: 10.7861/clinmedicine.16-4-335.
  13. Billette JM and Janz T Injuries in Canada: Insights from the Canadian Community Health Survey, Statistics Canada Catalogue no. 82-624-X, http://www.statcan.gc.ca/pub/82-624-x/2011001/article/11506-eng.htm
  14. Public Health Agency of Canada, Seniors Falls in Canada: Second Report 2014, http://www.phac-aspc.gc.ca/seniors-aines/publications/public/injury-blessure/seniors_falls-chutes_aines/index-eng.php
  15. Finding Balance, Seniors’ Falls Injuries in Alberta 2011, seniors falls data.pdf.
  16. Benecke H et al, The Burden and Impact of Vertigo: Findings from the REVERT Patient Registry, Front Neurol 2013 Oct 2;4:136. doi:10.3389/fneur.2013.00136. eCollection 2013.
  17. Skoien A, Wilhemsen K, Gjesdal S. Occupational disability caused by dizziness and vertigo: a register-based prospective study. Br J Gen Pract (2008) 58:619–23. Doi 10.3399/ bjgp08X330744
  18. Whitney SL et al, Recent Evidence About the Effectiveness of Vestibular Rehabilitation, Curr Treat Options Neurol (2016) 18:13 doi 10 1007/s 11940-016-395-4

Acknowledgement

Adapted and used with permission of the Chartered Society of Physiotherapy.