Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:
To assess the effectiveness of vestibular rehabilitation in the adult, community dwelling population of people with symptomatic unilateral peripheral vestibular dysfunction.
Background
People with dysfunction within the vestibular system (vestibulopathy) often complain of dizziness, visual or gaze disturbances and balance disorders. Dizziness alone accounts for nearly seven million doctor visits in the US (Gans 2002). These signs and symptoms lead to significant activity and participation restrictions for the person affected (Perez 2001). The cause of the dysfunction can be a disease‐related pathology or trauma and can be sited in the central (brain) or peripheral (inner ear) portions of the vestibular system. More specifically, because the vestibular system is replicated symmetrically in the periphery, many commonly presenting vestibulopathies involve unilateral ‐ one sided ‐ peripheral vestibular dysfunction. Examples of these disorders include benign paroxysmal positional vertigo, vestibular neuritis, Ménière's disease (and endolymphatic hydrops) and perilymphatic fistula. Unilateral peripheral dysfunction can also occur after surgical interventions such as unilateral labyrinthectomy or neurectomy (acoustic or vestibular) (Curthoys 2000; Fetter 2000). This review will only address the management of these unilateral peripheral diagnoses.
There has been increasing interest in the use of vestibular rehabilitation for the treatment or management of vestibular dysfunction (Gans 2002; Telian 1996; Whitney 2000). Vestibular rehabilitation is an exercise‐based group of approaches that began with the aim of maximising central nervous system compensation for vestibular pathology (Denham 1997). The original protocols by Cooksey and Cawthorne used group activities in a hierarchy of difficulty to challenge the central nervous system (Cooksey 1946). More recently, specific components have been further defined in the vestibular rehabilitation armamentarium, each having differing physiological or behavioural rationales as summarised below:
Habituation of pathologic responses (for positional or motion‐provoked symptoms), based on the inherent plasticity of the central nervous system and using motion to habituate or reduce responsiveness to repetitive stimuli and to rebalance tonic activity within the vestibular nuclei (Gans 2002).
Adaptation for visual‐vestibular interaction (gaze stabilisation) and possibly eye/hand coordination, using repetitive and provocative movements of the head and/or eyes to reduce error and restore vestibulo‐ocular reflex gain.
Substitution which promotes the use of individual or combinations of sensory inputs (such as visual or somatosensory) to bias use away from the dysfunctional vestibular input or conversely to strengthen use and drive compensation.
Postural control exercises, falls prevention, (re)conditioning activities and functional/occupational retraining which are based on motor learning principles to change movement behaviour and/or to promote movement fitness.
In addition there are specific repositioning manoeuvres that may be incorporated into the overall vestibular rehabilitation package for particular diagnostic groups of vestibular dysfunction (i.e. benign paroxysmal positional vertigo) (Bronstein 2003; Hilton 2001). These manoeuvres, which are based on a mechanical rationale to shift vestibular debris, will not be considered in this review.
In conclusion, signs and symptoms from vestibular dysfunction of varying aetiologies are frequent and often chronic and disabling. Vestibular rehabilitation is a growing method used to reduce resultant impairments and is believed to be predominantly management‐based. It tends to be delivered, and investigated, as a package and its prescription based on the presence of symptoms rather than a specific diagnosis. No review of the level or quality of evidence of vestibular rehabilitation has been conducted to date with the exception of repositioning manoeuvres for benign paroxysmal positional vertigo.
Objectives
To assess the effectiveness of vestibular rehabilitation in the adult, community dwelling population of people with symptomatic unilateral peripheral vestibular dysfunction.
Methods
Criteria for considering studies for this review
Types of studies
Randomised controlled trials.
Types of participants
Community dwelling adults with vestibular dysfunction of unilateral peripheral origin, experiencing a combination of symptoms/signs that may include one or all of the following: dizziness, vertigo, balance deficits, visual or gaze disturbances.
Participants will have a diagnosis confirming symptomatic unilateral, peripheral vestibular dysfunction which may be named as: peripheral vestibular hypofunction, vestibular neuritis, acoustic neuroma/schwannoma, perilymphatic fistula, Ménière's disease, benign paroxysmal positional vertigo or combination of these terms.
Types of interventions
Interventions described as "vestibular rehabilitation", and that are predominantly exercise and movement‐based, excluding specific repositioning manoeuvres:
Vestibular rehabilitation does not include medical, electrophysiological or pharmacological management.
Possible comparison interventions from the literature include:
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Vestibular rehabilitation versus placebo
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Vestibular rehabilitation versus control
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Vestibular rehabilitation versus other treatment (e.g. pharmacological)
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Vestibular rehabilitation versus another form of vestibular rehabilitation
Types of outcome measures
Primary outcome
Measure(s) of change in the specified symptomatology and/or changes in function or quality of life. Symptomatic ratings must be reported and recorded pre and post trial.
Secondary outcome
Measure(s) of physiological status where reproducibility has been confirmed (for example posturography).
Search methods for identification of studies
We will search the Cochrane Ear, Nose and Throat Disorders Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library Issue 3, 2005, MEDLINE (1966 to 2005) and EMBASE (1974 to 2005).
The following databases will also be searched: AHRQ, CINAHL, AARP (ageline), AMED, Current Contents, Health & Society, AusportMed, ATSIhealth, APAIShealth, AMI and NLM Gateway.
CENTRAL will be searched using the terms:
#1 VESTIBULAR DISEASES [rh] explode all trees (MeSH)
#2 VESTIBULAR DISEASES [nu] explode all trees (MeSH)
#3 VERTIGO [rh] single term (MeSH)
#4 VERTIGO [nu] single term (MeSH)
#5 DIZZINESS [rh] single term (MeSH)
#6 DIZZINESS [nu] single term (MeSH)
#7 VESTIBULAR NEAR REHABILITATION OR VESTIBULAR NEAR ADAPTATION OR VESTIBULAR NEAR HABITUATION
#8 #1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7
#9 LABYRINTH‐DISEASES explode all trees (MeSH)
#10 VESTIBULOCOCHLEAR‐NERVE‐DISEASES explode all trees (MeSH)
#11 PERILYMPH single term (MeSH)
#12 FISTULA single term (MeSH)
#13 #11 and #12
#14 VERTIGO OR VESTIBULOPATH* OR DIZZINESS
#15 (VESTIBULAR NEAR DISORDER*) OR (VESTIBULAR NEAR HYPOFUNCTION*) OR (VESTIBULAR NEAR DYSFUNCTION*) OR (VESTIBULAR NEAR IMPAIR*) OR (VESTIBULAR
NEAR DISABILIT*) OR (VESTIBULAR NEAR PATHOLOG*) OR (VESTIBULAR NEAR DISTURBANCE*)
#16 (BALANCE NEAR DISORDER*) OR (BALANCE NEAR HYPOFUNCTION*) OR (BALANCE NEAR DYSFUNCTION*) OR (BALANCE NEAR IMPAIR*) OR (BALANCE NEAR
DISABILIT*) OR (BALANCE NEAR PATHOLOG*) OR (BALANCE NEAR DISTURBANCE*)
#17 NEUROLABYRINTHITIDES OR NEUROLABYRINTHITIS OR VESTIBULAR NEAR NEURITIS OR VESTIBULAR NEAR NEURONITIS OR VESTIBULAR NEAR NEURITIDES
#18 VESTIBULAR NERVE NEAR INFLAMMATION OR VESTIBULAR NERVE NEAR COMPRESSION
#19 ACOUSTIC NEUROMA* OR ACOUSTIC NEURINOMA* OR ACOUSTIC NEURILEMOMA* OR ACOUSTIC NEURILEMMOMA*
#20 VESTIBULAR SCHWANNOMA* OR ACOUSTIC SCHWANNOMA*
#21 MOTION SENSITIVITY OR VESTIBULAR NEAR PERIPHERAL OR PERILYMPHATIC NEAR FISTULA*
#22 MENIERE* OR ENDOLYMPHATIC ADJ HYDROPS
#23 (LABYRINTH* NEAR HYDROPS) OR (LABYRINTH* NEAR SYNDROME)
#24 BPV OR BPPV OR ANTBPPV
#25 #9 OR #10 OR #13 OR #14 OR #15 OR #16 OR #17 OR #18 OR #19 OR #20 OR #21 OR #22 OR #23 OR #24
#26 OCCUPATIONAL THERAPY single term (MeSH)
#27 PHYSICAL THERAPY TECHNIQUES single term (MeSH)
#28 EXERCISE THERAPY explode all trees (MeSH)
#29 EXERCISE single term (MeSH)
#30 HEAD‐MOVEMENTS single term (MeSH)
#31 VESTIBULAR FUNCTION TESTS explode all trees (MeSH)
#32 REHABILITAT* OR PHYSIOTHERAP* OR (PHYSICAL NEAR THERAP*) OR EXERCIS* OR HABITUAT*
#33 EPLEY OR CANALITH OR SEMONT OR MANOEUVRE* OR MANEUVER* OR (RECONDITIONING ADJ ACTIVIT*)
#34 POSTUROGRAPHY OR POSTURAL ADJ CONTROL OR PFPP
#35 (SENSORY NEAR RELEARN*) OR (SENSORY NEAR RETRAIN*) OR (POSTURAL NEAR RELEARN*) OR (POSTURAL NEAR RETRAIN*)
#36 (POSITION* NEAR PROCEDURE*) OR (REPOSITION* NEAR PROCEDURE*) OR (REPOSITION* NEAR PARTICLE*)
#37 (VISUAL NEAR VESTIBULAR) OR (FUNCTIONAL NEAR RETRAIN*) OR (OCCUPATIONAL NEAR RETRAIN*) OR (OCCUPATIONAL ADJ ADAPTATION)
#38 COOKSEY AND CAWTHORNE
#39 #26 OR #27 OR #28 OR #29 OR #30 OR #31 OR #32 OR #33 OR #34 OR #35 OR #36 OR #37 OR #38
#40 #25 AND #39
#41 #8 OR #40
MEDLINE will be searched using the terms:
1. VESTIBULAR‐DISEASES‐RH#.DE. OR VESTIBULAR‐DISEASES‐NU#.DE. OR VERTIGO‐RH.DE. OR VERTIGO‐NU.DE. OR DIZZINESS‐RH.DE. OR DIZZINESS‐NU.DE.
2. (VESTIBULAR NEAR REHABILITATION OR VESTIBULAR NEAR ADAPTATION OR VESTIBULAR NEAR HABITUATION).TI,AB.
3. 1 OR 2
4. LABYRINTH‐DISEASES#.DE.
5. VESTIBULOCOCHLEAR‐NERVE‐DISEASES#.DE.
6. PERILYMPH.DE. AND FISTULA.DE.
7. VERTIGO.TI,AB. OR VESTIBULOPATH$3.TI,AB. OR DIZZINESS.TI,AB.
8. (VESTIBULAR NEAR DISORDER$2 OR VESTIBULAR NEAR HYPOFUNCTION$2 OR VESTIBULAR NEAR DYSFUNCTION$2 OR VESTIBULAR NEAR IMPAIR$4 OR
VESTIBULAR NEAR DISABILIT$3 OR VESTIBULAR NEAR PATHOLOG$3 OR VESTIBULAR NEAR DISTURBANCE$1).TI,AB.
9. (BALANCE NEAR DISORDER$2 OR BALANCE NEAR HYPOFUNCTION$2 OR BALANCE NEAR DYSFUNCTION$2 OR BALANCE NEAR IMPAIR$4 OR BALANCE NEAR
DISABILIT$3 OR BALANCE NEAR PATHOLOG$3 OR BALANCE NEAR DISTURBANCE$1).TI,AB.
10. (NEUROLABYRINTHITIDES OR NEUROLABYRINTHITIS OR VESTIBULAR NEAR NEURITIS OR VESTIBULAR NEAR NEURONITIS OR VESTIBULAR NEAR NEURITIDES).TI,AB.
11. (VESTIBULAR ADJ NERVE NEAR INFLAMMATION OR VESTIBULAR ADJ NERVE NEAR COMPRESSION).TI,AB.
12. (ACOUSTIC ADJ NEUROMA OR ACOUSTIC ADJ NEURINOMA OR ACOUSTIC ADJ NEURILEMOMA OR ACOUSTIC ADJ NEURILEMMOMA).TI,AB.
13. (VESTIBULAR ADJ SCHWANNOMA OR ACOUSTIC ADJ SCHWANNOMA).TI,AB.
14. (MOTION ADJ SENSITIVITY OR VESTIBULAR NEAR PERIPHERAL OR PERILYMPHATIC NEAR FISTULA).TI,AB.
15. (MENIERE$2 OR ENDOLYMPHATIC ADJ HYDROPS).TI,AB.
16. (LABYRINTH$3 NEAR HYDROPS OR LABYRINTH$3 NEAR SYNDROME).TI,AB.
17. BPV.TI,AB. OR BPPV.TI,AB. OR ANTBPPV.TI,AB.
18. 4 OR 5 OR 6 OR 7 OR 8 OR 9 OR 10 OR 11 OR 12 OR 13 OR 14 OR 15 OR 16 OR 17
19. OCCUPATIONAL‐THERAPY.DE.
20. PHYSICAL‐THERAPY‐TECHNIQUES.DE.
21. EXERCISE‐THERAPY#.DE. OR EXERCISE.DE.
22. HEAD‐MOVEMENTS.DE.
23. VESTIBULAR‐FUNCTION‐TESTS#.DE.
24. (REHABILITATION OR PHYSIOTHERAP$3 OR PHYSICAL NEAR THERAP$3 OR EXERCIS$3 OR HABITUAT$3).TI,AB.
25. (EPLEY OR CANALITH OR SEMONT OR MANOEUVRE$1 OR MANEUVER$1 OR RECONDITIONING ADJ ACTIVIT$3).TI,AB.
26. (POSTUROGRAPHY OR POSTURAL ADJ CONTROL OR PFPP).TI,AB.
27. (SENSORY NEAR RELEARN$3 OR SENSORY NEAR RETRAIN$3 OR POSTURAL NEAR RELEARN$3 OR POSTURAL NEAR RETRAIN$3).TI,AB.
28. (POSITION$3 NEAR PROCEDURE$1 OR REPOSITION$3 NEAR PROCEDURE$1 OR REPOSITION$3 NEAR PARTICLE$1).TI,AB.
29. (VISUAL NEAR VESTIBULAR OR FUNCTIONAL NEAR RETRAIN$3 OR OCCUPATIONAL NEAR RETRAIN$3 OR OCCUPATIONAL ADJ ADAPTATION).TI,AB.
30. COOKSEY.TI,AB. AND CAWTHORNE.TI,AB.
31. 19 OR 20 OR 21 OR 22 OR 23 OR 24 OR 25 OR 26 OR 27 OR 28 OR 29 OR 30
32. 18 AND 31
33. 3 OR 32
Reference lists of identified journal articles, textbooks and unpublished theses (Dissertation Abstracts International) will be searched. Authors of published trials and other experts in the field will be contacted. There will be no language, publication year or publication status restrictions on searching.
Data collection and analysis
Study selection
The initial search will produce a list of titles of possible studies. These titles will be reviewed by two review authors against the inclusion criteria. Where ambiguity exists the authors will retrieve the abstract to gain further information and if necessary the full report.
All selected studies will be retrieved in full report and undergo the following process by two authors working independently of each other.
Data extraction
A spreadsheet will be formatted to record data extracted from each identified study. Collection columns will include study ID number, author, date, title, diagnostic group, patient demographic, treatment and comparison, measurement, results/outcomes, study design (level), quality score and notes section.
Quality assessment
The strength of the evidence will be evaluated in two ways. Firstly the level will be confirmed as randomised controlled trial (reflecting the degree to which bias has been eliminated by the study design). Secondly the quality of evidence will be evaluated via the Critical Review Form (Law 1998) for quantitative studies (or another tool as recommended by the Cochrane Ear, Nose and Throat Disorders Group). This process evaluates the methodology under set criteria.
Data analysis
If sufficient, appropriate quality randomised controlled trials are identified with equivalent populations, intervention categories and outcome measures, a meta‐analysis will be conducted. This will require data extraction into a table, recording number of participants and total number (for dichotomous data) and number of participants plus mean and standard deviations for each group (for continuous outcome data).
Failing the identification of such comparable studies, a meta‐synthesis of findings will be constructed. All studies meeting the inclusion criteria will be grouped into a similar spreadsheet (a table of included studies) and the rejected studies into a second table (a table of excluded studies).
