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Vestibular rehabilitation for unilateral peripheral vestibular dysfunction

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Abstract

Background

This is an update of a Cochrane Review first published in The Cochrane Library in Issue 4, 2007.

Unilateral peripheral vestibular dysfunction (UPVD) can occur as a result of disease, trauma or postoperatively. The dysfunction is characterised by complaints of dizziness, visual or gaze disturbances and balance impairment. Current management includes medication, physical manoeuvres and exercise regimes, the latter known collectively as vestibular rehabilitation (VR).

Objectives

To assess the effectiveness of vestibular rehabilitation in the adult, community‐dwelling population of people with symptomatic unilateral peripheral vestibular dysfunction.

Search methods

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The most recent search was 1 July 2010, following a previous search in March 2007.

Selection criteria

Randomised trials of adults living in the community, diagnosed with symptomatic unilateral peripheral vestibular dysfunction. We sought comparisons of VR versus control (placebo etc.), other treatment (non‐VR, e.g. pharmacological) or another form of VR. We considered the outcome measures of frequency and severity of dizziness or visual disturbance; changes in balance impairment, function or quality of life; and measure/s of physiological status with known functional correlation.

Data collection and analysis

Both authors independently extracted data and assessed trials for risk of bias.

Main results

We included 27 trials, involving 1668 participants, in the review. Trials addressed the effectiveness of VR against control/sham interventions, medical interventions or other forms of VR. Individual and pooled data showed a statistically significant effect in favour of VR over control or no intervention. The exception to this was when movement‐based VR was compared to physical manoeuvres for benign paroxysmal positional vertigo (BPPV), where the latter was shown to be superior in cure rate in the short term. There were no reported adverse effects.

Authors' conclusions

There is moderate to strong evidence that VR is a safe, effective management for unilateral peripheral vestibular dysfunction, based on a number of high quality randomised controlled trials. There is moderate evidence that VR provides a resolution of symptoms and improvement in functioning in the medium term. However, there is evidence that for the specific diagnostic group of BPPV, physical (repositioning) manoeuvres are more effective in the short term than exercise‐based vestibular rehabilitation; although a combination of the two is effective for longer‐term functional recovery. There is insufficient evidence to discriminate between differing forms of VR.

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Plain language summary

Vestibular rehabilitation for unilateral peripheral vestibular dysfunction to improve dizziness, balance and mobility

People with vestibular problems often experience dizziness and trouble with vision, balance or mobility. The vestibular disorders that are called unilateral and peripheral (UPVD) are those that affect one side of the vestibular system (unilateral) and only the portion of the system that is outside of the brain (peripheral ‐ part of the inner ear). Examples of these disorders include benign paroxysmal positional vertigo (BPPV), vestibular neuritis, labyrinthitis, one‐sided Ménière's disease or vestibular problems following surgical procedures such as labyrinthectomy or removal of an acoustic neuroma. Vestibular rehabilitation for these disorders is becoming increasingly used and involves various movement‐based regimes. Components of vestibular rehabilitation may involve learning to bring on the symptoms to 'desensitise' the vestibular system, learning to co‐ordinate eye and head movements, improving balance and walking skills, learning about the condition and how to cope or become more active.

We found 27 randomised clinical trials that investigated the use of vestibular rehabilitation in this group of disorders. All studies used a form of vestibular rehabilitation and involved adults who lived in the community with symptomatic, confirmed UPVD. The studies were varied in that they compared vestibular rehabilitation with other forms of management (for example medication, usual care or passive manoeuvres), with control or placebo interventions or with other forms of vestibular rehabilitation. Another source of variation between studies was the use of different outcome measures (for example reports of dizziness, improvements in balance, vision or walking, or ability to participate in daily life). Due to the variation between studies, only limited pooling of data was possible. The results of four studies could be combined, which demonstrated that vestibular rehabilitation was more effective than control or sham interventions in improving subjective reports of dizziness, and in improving participation in life roles. Three studies gave a combined result in favour of vestibular rehabilitation for improving walking. Other single studies all found in favour of vestibular rehabilitation for improvements in areas such as balance, vision and activities of daily living. The exception to these findings was for the specific group of people with BPPV, where comparisons of vestibular rehabilitation with specific physical repositioning manoeuvres showed that these were more effective in dizziness symptom reduction, particularly in the short term. However, other studies demonstrated that combining the manoeuvres with vestibular rehabilitation was effective in improving functional recovery in the longer term. There were no reports of adverse effects following any vestibular rehabilitation, and in the studies with a follow‐up assessment (3 to 12 months) positive effects were maintained. There was no evidence that one form of vestibular rehabilitation is superior to another.

There is a growing and consistent body of evidence to support the use of vestibular rehabilitation for people with dizziness and functional loss as a result of UPVD. The studies were generally of moderate to high quality and were varied in their methods.