Effects of customized vestibular rehabilitation plus canalith repositioning maneuver on gait and balance in adults with Benign Paroxysmal Positional Vertigo: A Randomized Controlled Trial

Abstract

BACKGROUND:

Adults with unilateral posterior canal benign paroxysmal positional vertigo (BPPV) may continue to present with residual dizziness and balance impairments after the canalith repositioning maneuver (CRM). Customized Vestibular rehabilitation (VR) in addition to the standard CRM may improve postural control in adults with BPPV. However, the effectiveness of this intervention for improving dyanmic gait measures in adults with BPPV is unknown.

OBJECTIVE:

We aimed to determine the effectiveness of customized VR in addition to the standard CRM on dynamic gait measures among adults with unilateral posterior canal BPPV.

METHODS:

In this double blind, randomized controlled trial, 28 adults with BPPV were randomized to either control (n = 14, age: 54.36±8.55) or experimental (n = 14, age: 50.71±9.88) groups. The experimental and control groups received customized VR plus standard CRM for six weeks and standard CRM for two weeks respectively. Dynamic gait measures (duration of a complete gait cycle, stride velocity, turning duration and number of steps while turning) were recorded using a portable mobility sensor (iTUG) at baseline, week 4 and 6. A mixed model ANOVA was used to estimate the main effects of the interventions.

RESULTS:

During walking, a group effect was demonstrated on gait duration, stride velocity, turning duration and number of steps while turning (p < 0.05).

CONCLUSIONS:

Six weeks of customized VR performed in addition to the standard CRM was more effective than the standard CRM alone in improving balance and gait in adults with posterior canal BPPV. (252 words)

Keywords

Keywords:Vestibular rehabilitation canalith repositioning maneuver benign paroxysmal positional vertigo BPPV balance gait mobility

1 Introduction

Benign Paroxysmal Positional Vertigo (BPPV) is the most common peripheral vestibular disorder accounting for one third of the vestibular diagnoses seen in the general population [39]. Lifetime prevalence of BPPV is estimated to be 2.4%in the general population with prevalence of BPPV increasing with advancing age [33]. BPPV commonly occurs between the ages of 50–70 years and it is more frequent in women than men [32]. Adults with BPPV often present with positional vertigo, nystagmus, dizziness, nausea and/or balance impairments [2].

Consequences of BPPV include increased health care costs, interrupted daily activities and lost days of work [16, 39]. In addition, it was found that older persons with BPPV experience greater incidence of falls, depression and impairments that may affect their quality of life. Oghalai et al. also reported that individuals with undiagnosed BPPV self-reported more falls and had reduced activities of daily living scores [31]. It is known that older adults with BPPV are more likely to sustain significant injuries from falls compared to younger individuals [11, 24].

Vestibular rehabilitation (VR) is a form of physical therapy designed to reduce symptoms of dizziness and disequilibrium due to vestibular impairments [14, 35]. The general categories of exercises consist of adaptation, habituation, optokinetic, and substitution exercises [12 , 41]. Vestibular rehabilitation is a program tailored by a physiotherapist to meet the individual’s specific needs. The main aim of VR is to improve postural balance and decrease symptoms of dizziness.

The canalith repositioning maneuver (CRM) is the most recognized method of treating posterior canal BPPV [9]. The CRM involves moving the otoconia from the posterior semicircular canal back into the otolith organ, therefore relieving symptoms of vertigo. Balance impairments have been documented in previous studies with two-thirds (n = 12/19) of patients with BPPV experiencing balance deficits even after a successful CRM [3 , 40].

Combining the CRM and VR reduces vertigo symptoms and improves balance in patients with BPPV [1, 23]. In a recent review of 27 randomized controlled trials regarding VR for unilateral peripheral vestibular disorders, it was found that there were improvements in dizziness, balance, gait, gaze stability and activities of daily living [23, 29]. CRM is optimal treatment for BPPV, while the CRM plus VR was demonstrated to be more effective in improving functional mobility [15]. Others have reported that BPPV in older persons is related to increased reports of falls and reductions in gait speed [26]. Persons with acute peripheral vertigo including BPPV one year following an emergency department visit were at higher risk for upper extremity and trunk injuries [19]. Decrements in balance and gait performance have been reported after an episode of BPPV [19].

Balance control includes stability during quiet stance, postural reactions to external disturbances, anticipatory postural adjustments, postural responses to perturbations and dynamic balance during gait [21, 36]. Evaluation of dynamic balance, namely postural transitions such as turning during gait, have not been examined in adults with BPPV[5 , 7].

There is little information regarding the effectiveness of VR in addition to CRM among adults with first time unilateral posterior canal (UPC) BPPV. Although Angeli et al. 2003, reported that VR for 6 weeks after the CRM demonstrated improvement, the only outcome measurement used was the Dix Hallpike with no balance assessments performed [1]. Kumar et al. (2013) reported that a 3-week training period of VR improved vertigo symptoms and balances recorded via a questionnaire [23]. Therefore, the aim of our study was to evaluate the effectiveness of VR in addition to the CRM in improving balance and gait among adults with first time idiopathic unilateral posterior canal BPPV.

2 Participants and methods

Fig. 1

Flow chart of number of participants in the study.

Participants were recruited from the Otolaryngology Clinic, Serdang Hospital, Malaysia. Participants were between the ages of 30–65 diagnosed with their first episode of idiopathic unilateral posterior canal BPPV (using positive sign on Dix- Hallpike test) within 3 months of initial symptom onset, plus were independent in functional activities. Exclusion criteria were having central nervous system (CNS) involvement, Meniere’s disease, labyrinthitis, vestibular neuritis, any unstable medical condition (e.g. severe hypertension or unstable cardiac diagnosis) and orthopedic or neurologic diagnoses including sensory loss (e.g diabetes) that might affect postural control and have an impact on functional mobility. All participants were given verbal and written information and were required to provide informed written consent. The study was approved by Research and Ethics Committee of Universiti Kebangsaan Malaysia (UKM 1.5.3.5/244/NN-068-2014) and the Ministry of Health (NMRR 14-168-19645 IIR). This trial was registered with the Australia New Zealand Clinical Trials Registry: ACTRN12614000945628.

In this double blind randomized controlled trial, twenty-eight participants were randomized into two groups, using block randomisation with the concealed allocation method. Assessments were conducted at baseline, at week four and week six post intervention by a trained assessor who was blinded to the groups. Demographic and clinical data was obtained as depicted in Table 1.

Table 1

Baseline characteristics of the participants

Variables	Experimental group n = 14	Control group n = 14	p-value baseline
Age (years)/Mean (SD)	50.71±9.88	54.36±8.55	0.30 ⁺
Gender n (%)
Females	9 (64%)	13 (93%)	0.16^#
Males	5 (36%)	1 (7%)
Race n (%)
Malay	9 (64%)	9 (64%)	0.78^#
Chinese	3 (22%)	4 (29%)
Indian	2 (14%)	1 (7%)
BPPV lesion site n (%)
Right	8 (57%)	11 (79%)	0.42^#
Left	6 (43%)	3 (21%)
Duration of onset on	62.14±24.86	35.36±20.10	0.44⁺
BPPV (days)
Mean (SD)
Gait
Gait Duration (seconds)	23.70±3.30	24.40±2.20	0.50⁺
Stride velocity(m/s)	1.15±0.12	1.11±0.10	0.40⁺
Dynamic balance (turning)
Turn Duration (seconds)	2.83±0.49	2.92±0.61	0.65⁺
Turn steps (steps)	5.90±0.91	6.10±1.09	0.58⁺
DHI	53.29±9.84	54.43±12.03	0.39⁺
ABC (%)	58.37±8.02	60.36±5.82	0.25⁺

GLM: General linear measures. ηp² –partial eta- square⁺+p-value for independent samples T-Test. ^#p-value for Chi-Square Test.

The experimental group (n = 14) received the CRM (modified Epley) once a week for 2 weeks plus once a week VR (one hour per session) for six weeks for a total of six visits. The VR exercise program was adapted from Herdman et al. (1998) [14]. The exercise program was administered by a physiotherapist and the exercises were customized and progressed to address balance and mobility problems. The control group (n = 14) received the CRM (modified Epley) once weekly for two consecutive weeks as in the current practice locally. The CRM treatment for both groups was repeated until no positional nystagmus was elicited during the Dix-Hallpike with a maximum of 2 CRM’s performed per session.

A trained physiotherapist with 10 years experienced in the area of vestibular rehabilitation performed the CRM for both groups. Participants were requested to report if there was any discomfort or worsening of their BPPV. Adverse events were recorded and were reported to the participant’s consultant physician. All participants from both groups were instructed not to participate in any other formal or home exercise program.

2.1 Outcome measures

The mobility lab (APDM / Ambulatory Parkinson’s disease monitoring, Portland, USA) was used to record balance and mobility. This APDM device has wireless wearable inertial sensors with a docking station and an access point for wireless data transmission which automatically analyses the data. The APDM is a fast, sensitive, reliable measure of postural sway and functional movement during task performance [27]. The inbuilt software that included the instrumented Time-Up and Go (iTUG) was utilized.

The primary outcomes were the instrumented iTUG to assess functional performance (mobility and dynamic balance) during gait. Gait and postural transition parameters were recorded using the iTUG. The parameters included were related to gait (gait duration and stride velocity) and dynamic balance (turn duration and steps). The participant sat on an armless chair and were instructed to stand up, walk 7m, turn, and return to the sitting position. The Malay version of the Activities-Specific Balance Confidence (ABC) and the Dizziness Handicap Inventory (DHI) Scale were used as secondary measurements [18, 34]. Both the ABC and the DHI were forward and backward translated according to the World Health Organizations published criteria (unpublished data). The score for DHI ranges from 0–100 points, where 100 and 0 points indicate high level and no disability and handicap respectively. ABC comprises of 16 items consisting of the confidence to perform daily living activities. Items are rated on a rating scale ranging from 0%(no confidence) to 100%(complete confidence).

2.2 Statistical analyses

Statistical analyses were performed using SPSS version 20.0 (IBM SPSS Statistics version 20). A mixed model (repeated measures) ANOVA was used to estimate the effects of within, between groups and interaction on dynamic postural control at baseline (0 week, before CRM), fourth and sixth weeks. A significance level of p < 0.05 was set. Significant effect for time and also significant group by test interactions were further run by comparing pre-post intervention differences separately for each group between each time level and also between groups at each time level using post-hoc Bonferroni correction pairwise comparisons. Confidence intervals were set at 95%.

3 Results

The experimental and control group were similar in age, clinical characteristics, balance and gait measures.

Table 2 demonstrates the time, group and interaction effects of gait, dynamic balance parameters, DHI and ABC tests from baseline, 4 weeks and 6 weeks. Significant group by time interaction effects were demonstrated for gait duration F(2,52) = 12.11, p < 0.001, stride velocity F(2,52) = 10.82, p < 0.001, turn duration F(2,52) = 10.26, p < 0.001, turn steps F(2,52) = 8.49, p < 0.001 and ABC score F(2,52) = 28.82, p < 0.001 at the 4th week and the 6th week post intervention. Four weeks was chosen for the first assessment as in the study by Chang et al. (2008) [7]. Greater changes in balance and gait were demonstrated in the assessment of persons with BPPV at four compared to two weeks [7]. The primary aim of the study was to determine if gait and balance improved in persons with de novo BPPV. Since it was known that balance improved at four weeks, the authors were hoping to determine if an additional two weeks provided greater benefit.

Table 2
Dynamic balance, gait measurements, DHI and ABC in the groups at baseline, fourth and sixth week of intervention (presented as means±SD)

Parameter Study Group Experimental Control GLM p-value Repeated p-value Measures p-value

Time effect (ηp²) Group effect (ηp²) Interaction effect (ηp²)

Gait duration (seconds)

0 week 23.7±3.3 24.4±2.2 <0.001^ <0.001^ <0.001^

4 week 16.5±3.0 22.1±3.6 (0.75) (0.44) (0.31)

6 week 14.5±1.9 19.9±2.4

Stride velocity (m/s)

0 week 1.15±0.12 1.11±0.10 <0.001^ 0.002^* <0.001^

4 week 1.33±0.12 1.12±0.13 (0.59) (0.32) (0.29)

6 week 1.38±0.09 1.22±0.12

Turn duration (seconds)

0 week 2.83±0.49 2.92±0.61 <0.001^** 0.010^* <0.001^

4 week 2.13±0.26 2.85±0.81 (0.51) (0.25) (0.28)

6 week 1.80±0.25 2.65±0.69

Turn steps (steps)

0 week 5.9±0.91 6.1±1.09 <0.001^ 0.010^* 0.001^*

4 week 4.6±0.63 5.7±1.57 (0.46) (0.22) (0.24)

6 week 4.0±0.26 5.7±1.48

DHI

0 week 53.29±9.84 54.43±12.03 <0.001^ 0.31 0.47

4 week 18.29±17.32 25.14±12.37 (0.87) (0.04) (0.03)

6 week 5.29±8.25 7.86±8.82

ABC (%)

0 week 58.37±8.028 60.36±5.82 <0.001^ 0.002^* <0.001^**

4 week 86.14±10.65 72.14±5.47 (0.91) (0.30) (0.52)

6 week 94.36±5.86 79.64±9.86

Parameter	Study Group Experimental	Control	GLM p-value	Repeated p-value	Measures p-value
Gait duration (seconds)
0 week	23.7±3.3	24.4±2.2	<0.001^**	<0.001^**	<0.001^**
4 week	16.5±3.0	22.1±3.6	(0.75)	(0.44)	(0.31)
6 week	14.5±1.9	19.9±2.4
Stride velocity (m/s)
0 week	1.15±0.12	1.11±0.10	<0.001^**	0.002^***	<0.001^**
4 week	1.33±0.12	1.12±0.13	(0.59)	(0.32)	(0.29)
6 week	1.38±0.09	1.22±0.12
Turn duration (seconds)
0 week	2.83±0.49	2.92±0.61	<0.001^**	0.010^*	<0.001^**
4 week	2.13±0.26	2.85±0.81	(0.51)	(0.25)	(0.28)
6 week	1.80±0.25	2.65±0.69
Turn steps (steps)
0 week	5.9±0.91	6.1±1.09	<0.001^**	0.010^*	0.001^***
4 week	4.6±0.63	5.7±1.57	(0.46)	(0.22)	(0.24)
6 week	4.0±0.26	5.7±1.48
DHI
0 week	53.29±9.84	54.43±12.03	<0.001^**	0.31	0.47
4 week	18.29±17.32	25.14±12.37	(0.87)	(0.04)	(0.03)
6 week	5.29±8.25	7.86±8.82
ABC (%)
0 week	58.37±8.028	60.36±5.82	<0.001^**	0.002^***	<0.001^**
4 week	86.14±10.65	72.14±5.47	(0.91)	(0.30)	(0.52)
6 week	94.36±5.86	79.64±9.86

^*p < 0.05, ^**p < 0.001, ^***p < 0.005 GLM: General linear measures. ηp² –partial eta- square⁺.

While Table 3 depicts the Post-hoc Bonferroni pairwise comparison of gait, dynamic balance parameters, and ABC tests between groups at each time levels. Pairwise comparison using the Bonferroni analysis for gait, dynamic balance measurements the ABC score between groups at each time categories showed a significant (p < 0.05) difference between the groups at the 4th and 6th week. The experimental group demonstrated better performance compared to control group.

Table 3

Post-hoc Bonferroni pairwise comparison of dynamic balance and gait measurements between groups at each time level

Level	Level	Mean difference	95%CI	p-value
Gait duration
Baseline	4-week	4.746	(3.367; 6.126)	<0.001 ^**
Baseline	6-week	0.811	(5.194; 8.427)	<0.001 ^**
Stride velocity
Baseline	4-week	0.092	(0.048; 0.135)	<0.001 ^**
Baseline	6-week	0.170	(0.127; 0.212)	<0.001 ^**
Turn duration
Baseline	4-week	0.699	(0.305; 1.092)	0.002 ^***
Baseline	6-week	1.029	(0.592; 1.467)	<0.001 ^**
Turn Steps
Baseline	4-week	0.092	(0.048; 0.135)	0.001 ^***
Baseline	6-week	0.170	(0.127; 0.212)	<0.001 ^**
ABC
Baseline	4-week	19.781	(16.650; 22.913)	<0.001 ^**
Baseline	6-week	27.639	(24.548; 30.729)	<0.001 ^**

^*p < 0.05, ^**p < 0.001, ^***p < 0.005.

These results suggest that customized VR in addition to the standard CRM induced more and quicker improvements in gait, dynamic balance and balance confidence in adults with UPC BPPV after intervention.

4 Discussion

In this study, we examined the effects of an exercise program plus the CRM on dynamic balance control in adults with PC BPPV. The customized VR plus the CRM was more effective in improving dynamic balance control in adults with PC BPPV patients than only the CRM. To our knowledge this is the first study to examine the effects of customized VR in addition to the CRM on gait parameters and postural transition such as turning among adults with unilateral PC BPPV. Also, although the CRM dramatically improves vertigo, some participants may still experience residual dizziness after the CRM. Evidence has shown that two-thirds of adults with BPPV demonstrate residual dizziness after successful CRM [28].

The experimental group showed enhanced improvements in all dynamic balance variables (gait and turning) compared to the CRM group at four and six weeks. There is limited information regarding gait among adults with BPPV. Although not statistically significant, it was reported that combined CRM and non-customized vestibular rehabilitation brought higher levels of improvement in walking speed in a tandem walk test with eyes open using posturography [7].

In our study, improvements in gait duration were noted at the fourth and sixth weeks of evaluation in the experimental group. Our results were similar to a few previous studies [7 , 38]. However, these studies did not involve patients with BPPV. Tee et al. (2010), reported that dynamic balance measured using the TUG showed improvements in patients with vestibular dysfunction after the VR [38]. The authors of this study used the TUG, which records time to complete the TUG. In our study, we used the iTUG, which can provide several parameters of gait. Another difference is the participants’ diagnoses. Tee et al. (2010), included people with vestibular dysfunction, and our study consisted of only adults with PC BPPV [38]. Others have reported changes in tandem walking but no changes in gait speed between a CRM group and combined VR + CRM group. Chang et al. (2008) and Krebs et al. (2003) also reported improvements in gait speed with a 10-meter walk test after 6 weeks of VR, however the participants included people with unilateral and bilateral vestibular dysfunction and our study only included people with unilateral BPPV [7, 22].

Participants in the experimental group had a 20%increase in stride velocity, compared to the control group participants, who only had a 10%improvement at six-weeks. To the best of our knowledge, there are no reports of turning deficits in adults with BPPV. In numerous studies among older adults and adults with neurological impairments such as PD and stroke, abnormalities in turning have been highlighted [4 , 20]. Turning involves a complex set of movements and requires postural stability. Stack and Ashburn (2008) suggested that people with balance impairments take longer to turn plus take more steps while turning [37]. Improvements in the duration of the turn and number of steps to turn were seen in the experimental group. Changes in duration of turning have also been reported after intervention in persons with PD [20, 42]. People with untreated PD were slower during a 180-degree turn during gait [42].

The number of steps in a turn in our study differentially improved (a 25%difference in improvement was found between groups at six-weeks). The improvements in the experimental group could be due to the specificity of training using customized VR. There are no similar previous studies for comparison.

All participants with BPPV improved in their total ABC scores at the fourth- and sixth-week post intervention. The association between the ABC and objective measures of balance is not strong as balance confidence may be a different construct compared to objective measures of postural control [13, 25]. The changes in the ABC as a result of intervention are large compared to the study by Meretta et al. (2006) [30]. They reported changes in a mixed group of persons with vestibular disorders of 11 points over the course of rehabilitation. Our participants had a mean change of 36 in the experimental group and 19 in the control group on the ABC between baseline and 6 weeks. Both are sizable changes but the change in the experimental group was 3 times greater than changes noted in the study by Meretta et al. (2006) [30].

The DHI changes were also large, with changes of 48 in the experimental group and 46 points in the control group. The mean change in DHI score in the study by Meretta et al. (2006) was 11 [30]. Although there were large changes in both the DHI and ABC, the changes in the ABC score may reflect the customized care that the experimental group received by enhancing their perception of their balance differentially between the two groups.

5 Limitations and future directions

One of our study limitations is that we assessed participants turning only to the preferred direction in the iTUG test. However, it is unknown if there would have been a difference when turning to the affected or unaffected side in relation to their BPPV. Also, the study results are confined to adults with unilateral idiopathic BPPV and may not be applicable to other types of BPPV. The (n) was too small to determine the effect of age on balance status in persons with unilateral PC BPPV. Our participants were all 65 years of age or younger. Age should be investigated as exercise might have an even more powerful effect on persons over 65 years of age. Lastly, the additional 4 weeks of rehabilitation provided to the experimental group on its own would have led to better results. However, it should be noted that it was an addition of Customised VR to CRM which was not the usual current practice.

Future studies may include a turning assessment to both sides among adults with BPPV. The effects of customized VR in addition to CRM could also be examined among adults with other types of BPPV.

6 Conclusion

Six weeks of customized VR performed in addition to the CRM is more effective than CRM alone for improving dynamic balance in persons with BPPV. Post CRM, there were improvements in gait velocity and postural transitions during turning with increased speed during the turn in the experimental group at the 4th week and 6th week post CRM. The control group has smaller positive changes in gait velocity and postural transitions at 6 weeks but no improvements were noted at 4 weeks.

The results of this study help to justify the use of customized VR in addition to the CRM in the rehabilitation of adults with BPPV. In addition, an evaluation of dynamic balance may be beneficial in detecting early signs of mobility impairments in adults with BPPV. This will assist in early intervention to prevent disability and further negative consequences of BPPV.

Footnotes

Acknowledgments

The authors would like to thank all participants in this study. We would also like to acknowledge the Ministry of Health, Malaysia for the support.

Authors’ contributions

All authors participated in the conception and design of the trial as well as helped draft and revise the manuscript. All authors read and approved the final manuscript.

Conflict of interest

The authors report no conflict of interest related to the work.

Sources of funding

No funding was received for this study.

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