|Year : 2017 | Volume
| Issue : 2 | Page : 66-70
The effect of postural stability exercises in benign paroxysmal positional vertigo: Pre–post experimental study
Asmita Damodar Tari, Sanjiv Kumar
Department of Neurophysiotherapy, KLEU Institute of Physiotherapy, Belgaum, Karnataka, India
|Date of Submission||17-Jul-2017|
|Date of Acceptance||07-Nov-2017|
|Date of Web Publication||19-Jan-2018|
Dr. Asmita Damodar Tari
KLEU Institute of Physiotherapy, Belgaum, Karnataka
Source of Support: None, Conflict of Interest: None
BACKGROUND: Among vestibular functions benign paroxysmal positional vertigo (BPPV) is one of the common conditions leading to dizziness, visual vertigo, and postural instability.
PURPOSE: The purpose of this study was to find the effect of postural stability exercises on postural instability in BPPV patients.
DESIGN: This was pre–post experimental study.
SETTING: The study was conducted at a tertiary healthcare center, Belagavi, India.
PATIENTS: A total of 12 patients positive for Dix-Halpike test between the age group of 20 and 60 years of both the genders were included in the study.
INTERVENTION: Postural stability exercises were given for postural instability in BPPV patients. Treatment was administered for 2 weeks.
MEASUREMENTS: Patients were assessed at baseline using libra electronic balance master, dizziness handicap inventory, visual vertigo analog scale, and Berg Balance Scale, and re-assessed after 2 weeks.
RESULTS: Mean, standard deviation, independent t-test, and dependent t-test were used. There was statistically significant change in terms of dizziness, postural stability, visual vertigo, static, and dynamic balance with the value of P < 0.05
CONCLUSION: Improvement in postural stability was seen in the participant receiving postural stability exercises. The exercises were found effective in reducing postural instability among BPPV patient. The study also concluded that BPPV was found common among females and in the age group of 30–40 years.
Keywords: Balance, benign paroxysmal positional vertigo, dizziness, postural stability exercises
|How to cite this article:|
Tari AD, Kumar S. The effect of postural stability exercises in benign paroxysmal positional vertigo: Pre–post experimental study. Physiother - J Indian Assoc Physiother 2017;11:66-70
|How to cite this URL:|
Tari AD, Kumar S. The effect of postural stability exercises in benign paroxysmal positional vertigo: Pre–post experimental study. Physiother - J Indian Assoc Physiother [serial online] 2017 [cited 2019 Dec 11];11:66-70. Available from: http://www.pjiap.org/text.asp?2017/11/2/66/223696
| Introduction|| |
The vestibular system is one of the most important systems in the human body that is important for hearing ability and for maintaining balance. Information about linear and angular acceleration of head is provided by the system and position of the head in relation to the gravitational axis.
Most of these peripheral vestibular lesions undergo spontaneous resolution and have benign etiology.
The benign paroxysmal positional vertigo (BPPV) is a condition, in which the dislodged otoconia from the utricle freely floats into one or more semicircular canals, resulting in brief episodes of vertigo provoked with changes in head position causing postural instability and risk of fall. It is the most common cause for peripheral vestibular vertigo and is the most common vertiginous disorder in the community.
BPPV accounts for at least 20% of diagnoses among vestibular dysfunction. Elderly people are at increased risk and various studies are conducted on them to assess nonbalance related complaints, and it was found that 9% had unrecognized BPPV. Women are more affected than men. The reported recurrence rate of BPPV is 20%–30%.
Most of the patients having BPPV are idiopathic; nearly 50%–70% of all the reported cases are seen affecting the age group of 50–70 years. The second most common cause is head trauma representing 7% to 17%. Of all the cases other causes of secondary BPPV are viral neurolabrynthitis that accounts for 15% of cases, Meniere's disease 5%, migraines 5%, and otologic and nonotologic surgeries 1%.
The vertigo in BPPV is generally intermittent and positioning dependent, which usually resolves within 30 s in posterior canal BPPV, but many patients also complaints of light-headedness, nausea, imbalance, and standing and walking disturbances. Other characteristic of BPPV include rotational vertigo (in 86%), oscilloscope (31%), nausea (33%), vomiting (14%), imbalance (49%), fear of falling (36%), and falls (1%).
With depriving visual inputs, patients with BPPV rely heavily on the vestibular system for balance. Lack of accurate vestibular information from one side may cause ineffective sensory organization and abnormal vestibulospinal output and thus result in an increased sway in such condition detected by means of dynamic posturography.
When a patient is visually dependent, a moving visual scene can be misinterpreted as self-motion, and the induced corrective postural adjustments can cause instability. Therefore, dependency on these visual cues should be minimal, and these patients should be trained to walk on different sensory pathways. Postural stability is recovered slowly compared to gaze stability recovery.
Vestibular rehabilitation therapy is an important therapeutic option for a therapist in treating patients with significant postural and balance deficits. The goals of VRT, and especially for postural stability, are to help patients to learn to use stable visual references and surface somatosensory information for their primary postural sensory system, use the remaining vestibular function, identify efficient and effective alternative postural movement strategies, and recover normal postural strategies.
Patient's finds difficulty in performing activities of daily living as postural instability is persistent in BPPV patients due to this visio-proprioceptive conflict. In BPPV, patient's recovery of postural stability is slower thus it is important to improve instability in such patients.
| Methods|| |
The study design was a pre–postexperimental study. The study was conducted on local residents restricted to Belgaum city, province Karnataka, country India. Ethical committee approval was obtained from the Institutional Ethical Review Committee. All patients positive for Dix-Halpike test confirmed by an ENT specialist and based on the clinical features were screened to be included in the study the inclusion criteria were as follows: (1) Age group 20 years to 60 years. (2) Participants willing to participate. (3) Symptomatic male and females and exclusion criteria were as follows: (1) Patients with secondary BPPV. (2) Inner ear disease. (3) Migraine. (4) Cerebrovascular disease. (5) Systemic illness. Before the commencement of the procedure, written informed consent was taken from the patients. The purpose of the study was explained following which demographic data were collected from the patients [Figure 1]. The assessment was performed at the beginning and at the end of the protocol, to find the significant changes. Patient received postural stability exercises and progression in the exercises was made accordingly.
After obtaining informed consent and pretest score on the outcome measure such as Berg balance scale, visual vertigo analog scale, dizziness handicap inventory (DHI), and global balance score on balance master [Figure 2] patients were allocated to postural stability exercises patients were not on any medication so as to avoid any form of bias in the study. The patient had to stand with feet close together as possible. Participants were allowed to take the support of wall for maintaining balance by touching a wall if needed. Followed by turning head right to left for 1 min without stopping and then reducing the support to minimal.
Participants were asked to stand with the feet shoulder width apart with eyes open, looking at the target on the wall. Progression was made narrowing the base of support from feet apart to feet together, to semi-heel, to toe position. The above exercise was performed with arms outstretched then with arms close to the body then arms folded across the chest. Each position is held for 15 s before progression to next exercise, practices for 5 min.
The patient was asked to stand on a cushioned surface progressing it to more difficult tasks involving hard floor, thin carpet, and thin pillow. Backward walking was attempted cautiously [Figure 3]. Walking was made more difficult by asking the patient to count backward while walking. Participants were asked to walk on different surfaces, initially with a narrow base of support; patients were allowed to take the support of the wall if needed, progressing with intermittent touching and then, no support of the wall was permitted.
Participants were then asked to turn around while walking, first making a large circle but gradually making smaller turns. Turning was done in both the direction.
The patient was asked to maintain balance while sitting and bouncing on an exercise ball maintaining visual fixation of a stationary target. At the end, participants were made to walk in external environment where a different type of sensory feedback was provided, and visual dependency of the patient was reduced to minimal.
The total duration of this procedure was for – 20–25 min daily for 2 weeks.
The data of the study were computed and analyzed using Statistical Package for Social Science software version 21 (IBM SPSS statistics). Statistical analysis was performed using independent t-test and dependent t-test.
| Results|| |
In the present study, the pre–post-test results were based on outcome measures, Global score on Libra Balance master, DHI, visual vertigo analog scale, and Berg Balance Scale score.
Probability values <0.05 were considered to be statistically significant. There were 11 female participants and 1 male participant included with the mean age of 31 years and the duration of vertigo 2 years and 8 months [Table 1]. It was seen that female participants were more frequently affected with BPPV. Specific canal involvement was not included that can be considered as one of the limitations of the present study.
Pretest global balance score in BPPV patients were 36.59 ± 14.25 and posttest score was 24.23 ± 12.40 with the probability value of P = 0.0025 [Table 2]. Global balance score gave accurate measures of Postural stability in these patients. DHI score in these subjects preintervention was 39.67 ± 19.48 and posttest score was 17.17 ± 7.93 probability value was noted as P = 0.0002. Dizziness reduced significantly in these patients following postural stability exercises. Pretest visual vertigo analog scale score in these patients was 32.13 ± 12.29 and postintervention was 25.30 ± 10.83. Reduction in visual vertigo leads to reduced postural deviations and thus improved quality of life (QOL) in these patients. Berg balance score pretest was 35.58 ± 7.01 and posttest was 47.50 ± 3.85 where improvement in balance score was noted that reduced the risk of fall in vertigo patients.
|Table 2: Comparison within pre- and posttest outcome measures in group postural stability exercises|
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| Discussion|| |
Participants in the present study were of age group 20–60 years. The mean age in this study was 31 years. The above finding suggestive of BPPV issue is common in the age group between 30 and 40 years. It was found in alignment with another study in which the age group of participants with BPPV was between 35 and 72 years. However, there is evidence suggestive of that BPPV can occur in any age group but is less prevalent in children. It was also noted by different authors that the onset of age was found to be 50 years and BPPV was said to be more prevalent in the age group of 50–70 years. The peak incidence of onset was also found in the 6th decade of life. Our study differed from above-mentioned work as we could note that most of the participants belonged to the age group of 30–40 years. With aging, there is a loss of hair cells and vestibular neurons which causes degenerative changes in only one labyrinth producing sudden severe vertigo and disequilibrium. Degeneration of various neural structures takes place including the central, vestibular, proprioceptive, cerebellar, and visual pathways. BPPV in the middle-aged population can be due to labyrinthitis or ischemia in the distribution of the anterior vestibular artery. It is also seen that BPPV is more prevalent in females than in males.
Most of the participants in this study were female (11) only a few were male (1) were involved in this study. This suggests that BPPV commonly seen among females in the middle age population. Females in the present study complained of more dizziness and inconvenience from prolonged dizziness, but this difference disappeared after treatment.
The posterior semicircular canal is more affected, as dislodged otoconia from the utricle freely floats in one or more semicircular canals mostly in gravity-dependent position resulting in brief episodes of vertigo causing postural instability and risk of falls. The components of balance evaluation systems are based on postural control. Postural equilibrium involves coordination of somatosensory strategies to stabilize the body's center of mass during self-initiated and externally triggered disturbances in postural stability.
In the present study, balance testing on Libra Balance Master showed significant loss of balance in almost all the patients having BPPV. With a moving platform, there was instability and an increased sway in the lateral plane. These patients were more dependent on the proprioceptive system and also had to follow a pathway displayed on the screen of Balance Master which was providing a visual cue for maintaining balance. With postural stability exercises, there was a significant improvement in the balance score on Berg Balance Scale.
Greater sway velocity was noted initially in the acute stage. Patients had difficulty in repeated head movements, standing on one leg and walking on a line as well as on uneven surfaces. Similarly, in one study, non-treated BPPV patients showed impairments in balance and greater sway velocity compared to that of healthy adults. When the visual inputs were deprived, these patients depended on the vestibular system for balance.
Lack of information from one side may have caused ineffective sensory organization and abnormal vestibulospinal output, thus resulting in an increased sway in such conditions. Hence, these patients might find it difficult to maintain an upright posture when both visual and vestibular inputs are altered. In the present study, BPPV patients had normal stability on a stable platform regardless of any alteration of visual inputs like while doing sitting to standing, standing unsupported, with feet closer. Greater sway velocity was noted while performing single leg standing and standing with both feet on a firm or foam surfaces.
Improved postural stability both instance and during ambulation as well as the diminished perception of disequilibrium in patients treated with vestibular rehabilitation was observed during the early stage of recovery in one of the study. Dizziness can cause extreme stress in patients having paroxysmal attacks that can further attribute to depression, anxiety, and somatoform disorders. During the short phases of nystagmus with vertigo, patients experienced dizziness which hindered their activities of daily living and hence, QOL was also affected. Similarly, in the present study dizziness contributed to the loss of balance and participants found difficulty in performing a simple task like looking upward or downward and visual fixation was also one of the major concerns.
Postural stability was greatly impaired among the participants and improved significantly with postural stability exercises.
Long-term postural abnormalities were studied using static posturography in BPPV patients and in normal individuals in whom BPPV patients showed increased body sway in lateral and anteroposterior planes. Repositioning maneuver decreased the lateral body sway, whereas anteroposterior body sway remained unchanged which proved that long-term postural disturbance associated in BPPV differs from acute disequilibrium. Hence, ideally, a longer period of intervention is needed which contradicts the present study where improvement in postural instability was seen in 2 weeks.
We could note in the present study that the patients with short duration of vertigo issue were having more symptoms of dizziness, whereas the patients with longer duration of BPPV were showing more issues related to postural stability.
Postural stability exercises help the patients to rely on the remaining vestibular function as much as possible and hence that visual and somatosensory function is not needed to substitute for the vestibular loss.
In the acute stage, patients rely more on somatosensory cues from the lower extremities whereas in the chronic stage they depend more on visual cues. In the present study, it was found that these patients relied more on their visual system thus when vision was occluded there was postural instability. It was also seen that these patients were moving in a blocked pattern with difficulty in gaze fixation. Repeated head movements in these patients caused vertigo.
Whereas geriatric population has longer visuomotor processing time which could contribute to delays in postural reactions causing instability which further leads to falls and reduced functional activities.
A long-term follow-up is needed for this study to understand the persistence of effect occurred from this intervention. The compensatory postural strategy is lacunae in the evaluation of the present study. Risk of falls and QOL are the missing outcomes in the present study. Older people were not included which could comprise a major part of the prevalence of BPPV.
| Conclusion|| |
Improvement in postural stability was seen in the participant receiving postural stability exercises. Instability among BPPV patients in the study also concluded that it is common among females and in the age group of 30–40 years.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Chang WC, Hsu LC, Yang YR, Wang RY. Balance ability in patients with benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 2006;135:534-40.
Shepard NT, Telian SA, Smith-Wheelock M. Habituation and balance retraining therapy. A retrospective review. Neurol Clin 1990;8:459-75.
Ramachandran S, Goon M, Singh P. Physical therapy rehabilitation of benign paroxysmal positional vertigo: Evidence based case report. Indian J Otol 2013;19:72. [Full text]
Hornibrook J. Benign paroxysmal positional vertigo (BPPV): History, pathophysiology, office treatment and future directions. Int J Otolaryngol 2011;2011:835671.
Oghalai JS, Manolidis S, Barth JL, Stewart MG, Jenkins HA. Unrecognized benign paroxysmal positional vertigo in elderly patients. Otolaryngol Head Neck Surg 2000;122:630-4.
Sonu P, Sujata S, Jagriti B, Rekha C. Benign paroxysmal positional vertigo: Pathophysiology, causes, canal variants and treatment. Int J 2015;3:54-60.
Vannucchi P, Pecci R. Pathophysiology of lateral semicircular canal paroxysmal positional vertigo. J Vestib Res 2010;20:433-8.
Horak FB, Nashner LM, Diener HC. Postural strategies associated with somatosensory and vestibular loss. Exp Brain Res 1990;82:167-77.
Horak FB. Postural compensation for vestibular loss and implications for rehabilitation. Restor Neurol Neurosci 2010;28:57-68.
Herdman SJ, Clendaniel R. Vestibular Rehabilitation. Atlanta, Georgia: FA Davis; 2014.
Baloh RW, Jacobson K, Honrubia V. Horizontal semicircular canal variant of benign positional vertigo. Neurology 1993;43:2542-9.
Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ 2003;169:681-93.
Han BI, Song HS, Kim JS. Vestibular rehabilitation therapy: Review of indications, mechanisms, and key exercises. J Clin Neurol 2011;7:184-96.
Stambolieva K, Angov G. Postural stability in patients with different durations of benign paroxysmal positional vertigo. Eur Arch Otorhinolaryngol Head Neck 2006;263:118-22.
Yardley L, Masson E, Verschuur C, Haacke N, Luxon L. Symptoms, anxiety and handicap in dizzy patients: Development of the vertigo symptom scale. J Psychosom Res 1992;36:731-41.
Giacomini PG, Alessandrini M, Magrini A. Long-term postural abnormalities in benign paroxysmal positional vertigo. ORL J Otorhinolaryngol Relat Spec 2002;64:237-41.
Smith-Wheelock M, Shepard NT, Telian SA. Physical therapy program for vestibular rehabilitation. Otol Neurotol 1991;12:218-25.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]