Rajiv Gandhi University of Health Sciences, Karnataka,
| |” |
| |Brief resume of the intended work: |
| |Need for the study |
| |The vestibular system, which contributes to balance and sense of spatial orientation, is the sensory system that provides the leading contribution |
|6 |about movement and sense of balance.1 The peripheral vestibular system serves as a primary focus for the origin of patient signs and symptoms2 and |
| |functions include stabilization of visual images on the fovea, maintaining postural stability especially during head movement, and providing |
| |information used for spatial orientation. The three semi circular canals which are arranged perpendicular to one another 3, respond to the direction|
| |of angular head rotations4 due to the movement of endolymphatic fluid present within them.5 |
| |People with dysfunction within the vestibular system frequently report the occurrence of symptoms such as disorientation, lightheadedness, |
| |disequilibrium, and visual blurring is responsible for sensing motion of the head and maintains stability of images on the fovea of the retina and |
| |postural control during that motion.6 Some patients may recover rapidly and spontaneously after the acute lesion will complain of residual vertigo |
| |oscillopsia and disequilibrium.7 These impairments lead to significant restrictions in activity and participation in the affected person.8 |
| |Depending upon the set of symptoms and area affected the vestibular dysfunction is categorized into many subtypes. Vertigo can be caused by both |
| |peripheral and central vestibular deficits. About three-fourths of vestibular disorders are peripheral (inner ear and vestibular nerve). The most |
| |common peripheral vestibular disorder is benign paroxysmal positional vertigo9,10 followed by uncompensated Ménière disease, vestibular neuritis, |
| |labyrinthitis, perilymphatic fistula, and acoustic neuroma. Central vestibular deficits cause about one-fourth of dizziness. The most common central|
| |cause of dizziness and vertigo are cerebrovascular disorders, cerebellar disease, migraine, multiple sclerosis, tumors of the posterior fossa, |
| |neurodegenerative disorders, medications, and psychiatric disorders. |
| |Vestibular Rehabilitation Therapy 11 (VRT) is a form of physical therapy that uses specialized exercises called adaptation exercises and eye head |
| |exercises 12 that result in gaze13 stabilization and gait stabilization. Most exercises involve head movement, and head movements 14 are essential |
| |in stimulating and retraining the vestibular system. Vestibular rehabilitation therapy has been a highly effective modality for most adults and |
| |children with disorders of the vestibular or central balance system. In a number of studies, customized vestibular rehabilitation therapy programs |
| |were significantly more effective than generic exercises in resolving symptoms. |
| |Cawthorne-Cooksey exercises were developed to encourage and hasten restoration of balance that had been upset by a disorder in the inner ear. Any |
| |sudden impairment of the inner ear function, whether due to injury or other causes, is followed by giddiness, which in the first few days may be |
| |very intense. Fortunately this giddiness diminishes as compensation takes place, but usually there remains a residue of dizziness that is |
| |particularly provoked by sudden turning or bending movements of the head. These exercises are designed to bring about a variety of head movements |
| |and encourage the patient to master the disturbing effect of any dizziness as a result of partial or complete loss of function of one labyrinth15. |
| |Canalith repositioning maneuver is a specialized form of VRT often referred to as the Epley maneuver, and involves a series of specifically |
| |patterned head and trunk movements to move tiny displaced otoliths to a place in the inner ear where they can’t cause symptoms16. |
| |The Semont maneuver (liberatory maneuver) involves a procedure whereby the patient is quickly moved from lying on one side to lying on the other and|
| |is 90% effective after 4 treatment sessions. |
| |The Brandt-Daroff exercises are a method of treating BPPV, usually used when the office treatment fails. They succeed in 95% of cases but are more |
| |arduous than the office treatments. |
| |The basis for the success of vestibular rehabilitation therapy is the use of existing neural mechanisms in the human brain for adaptation, |
| |plasticity, and compensation. The extent of vestibular compensation and adaptation is closely related to the direction, duration, frequency, |
| |magnitude, and nature of the retraining stimulus. Specifically designed vestibular rehabilitation therapy exercise protocols take advantage of this |
| |plasticity of the brain to increase sensitivity and restore symmetry. This results in an improvement in vestibulo-ocular control 17, an increase in |
| |the gain of the vestibulo-ocular reflex (VOR), better postural strategies, and increased levels of motor control for movement. Other factors that |
| |affect the degree of individual compensation include overall physical status, the functional status of remaining sensory systems, integrity of |
| |central brain mechanisms, age, and higher sensory functions such as memory, motor coordination, and cognitive ability. |
| |Dizziness associated with dysequilibrium has found to be the major set of symptoms in people with unilateral vestibular hypofunction, is found to be|
| |the major unresolved problem in the community. The studies to date have explained about the individual effects of vestibular rehabilitation in |
| |resolving the problem or compared with other types of vestibular rehabilitation like instrumental training which was found to be more expensive not |
| |affordable by all group of population. The previous studies stated are found to be not effective in treating all the set of symptoms of unilateral |
| |vestibular hypofunction. There are no specific exercises to treat single disorder. Based on the recent advances in the vestibular rehabilitation, |
| |among different vestibular techniques like Cawthrone-Cooksey exercises, Semont maneuver, Epley’s maneuver and brandt daroff exercises etc are found |
| |to be more effective in treating the Benign Paraoxysmal Positional Vertigo. Articles according to Brandt T, Daroff RB and Stefano Corna, MD et al. |
| |says that Brandt Daroff and Cawthrone-Cooksey exercises showed productive results in treating Benign Paroxysmal Positional Vertigo. There are |
| |limited studies to manage the symptoms of Unilateral Vestibular Hypofunction where medication doesn’t show any prognosis when disease is at chronic |
| |stage. This is the period where subjects purely relay on vestibular rehabilitation. There are no such comparative studies to see the effect of |
| |individual protocol on Unilateral Vestibular Hypofunction. |
| | |
| |Hypothesis: |
| |There will be no significant difference between brandt daroff’s exercises vs cawthrone-cooksey exercises in subjects with unilateral vestibular |
| |hypofunction. |
| | |
| |6.2Review of Literature: |
| |Review on Vestibular Rehabilitation in Unilateral Vestibular Hypofunction: |
| |Clendaniel, Richard A. PT, PhD (June 2010) done a study to determine the efficacy of both habituation and adaptation exercise interventions in the |
| |treatment of unilateral vestibular hypofunction. The pre- and post measures of Dizziness Handicap Inventory for symptom impact, motion sensitivity|
| |quotient (MSQ) to assess sensitivity to head movements, and the dynamic visual acuity (DVA) test as a measure of GS during head movements were done.|
| |Improvement in the MSQ score for the GS group and the improvement in the DVA measures for the habituation group were unexpected findings. Head |
| |movement, which is required by both exercise interventions, rather than the specific type of exercise may be the critical factor underlying the |
| |observed improvements in motion sensitivity and DVA.18 |
| |Murat Giray, MD et al (August 2009) by randomly assigning, attempt to evaluate the short-term effects of vestibular rehabilitation on symptom, |
| |disability, balance, and postural stability in patients with chronic unilateral vestibular dysfunction. Subjects were assessed before and after the |
| |rehabilitation program with respect to symptoms (visual analog scale [VAS]), disability (Dizziness Handicap Inventory [DHI]), balance (Berg Balance |
| |Scale [BBS]), and postural stability (modified Clinical Test for Sensory Interaction on Balance [mCTSIB]). Significant improvements were seen in |
| |symptom, disability, balance, and postural stability in chronic unilateral vestibular dysfunction after an exercise program. Customized exercise |
| |programs are beneficial in treatment of chronic unilateral vestibular dysfunction.19 |
| |Peterka RJ et al. (2007) by using NSS statistical analysis, stated that postural control of upright stance was investigated in well-compensated, |
| |unilateral vestibular loss (UVL) subjects compared to age-matched control subjects. The goal was to determine how sensory weighting for postural |
| |control in UVL subjects differed from control subjects, and how sensory weighting related to UVL subjects' functional compensation, as assessed by |
| |standardized balance and dizziness questionnaires. Results |
| |showed that UVL subjects made significantly greater use of proprioceptive, and therefore less use of vestibular, orientation information on all |
| |tests. There was relatively little overlap in the distributions of sensory weights measured in UVL and control subjects, although UVL subjects |
| |varied widely in the amount they could use their remaining vestibular function.20 |
| |Kathleen M Gill-Body et al (August 2000) proposed a study (1) to describe balance impairments, functional performance, and disability in subjects |
| |with unilateral peripheral vestibular hypofunction(UVH) and bilateral peripheral vestibular hypofunction(BVH), (2) to examine the relationship |
| |among these factors, and (3) to determine whether the disability can be explained by commonly used tests of balance and functional performance |
| |using Dizziness Handicap Inventory (DHI) and modified Time Up & Go Test respectively. Balance impairments were measured with computerized |
| |posturography and balance tests. Balance impairments and functional performance appear to be more closely related to disability in individuals |
| |with BVH as compared with those with UVH. Clinical tests of balance impairments and functional performance appear to be useful in explaining |
| |disability.21 |
| |Review recent advances in Vestibular Rehabilitation: |
| |Winkler et al. (September 2011) by randomly assigning, evaluated the effects of an incrementally increasing surface tilt perturbation intervention|
| |for individuals with chronic vestibular pathology on gait, activities of daily living, and dizziness which appears to be more effective for |
| |improving abilities at the activities and participation levels than vestibular exercises alone. In addition, tilt perturbation training reduced |
| |fall risk as measured by the DGI.22 |
| |Pavlou, Marousa PhD, BA, MCSP ( June 2010) stated that the use of exercise in the form of appropriate movements and sensory exposure (i.e. |
| |vestibular rehabilitation) is currently considered the standard of care for individuals with peripheral vestibular disorders regardless of age and|
| |symptom duration. Customized vestibular rehabilitation provides greater benefit compared with a generic exercise program (e.g. Cawthorne-Cooksey |
| |exercise) with significant improvements in subjective symptoms, dynamic visual acuity, gait, and postural stability. Approximately 50% to 80% of |
| |individuals show improvements in symptoms and postural stability. However, complete recovery is less common and occurs in approximately-of all |
| |cases. The reasons why some individuals with peripheral vestibular disorders do not fully recover are not entirely clear. The purpose of this |
| |focused review is to provide an overview of recent work addressing (a) the use of high-tech versus low-tech optokinetic stimulation and the role |
| |of supervision and (b) the mechanism of recovery.23 |
| |Review on Brandt Daroff Exercises: |
| |Susan J Herdman(June 1997) discussed the pathophysiology, evidence of treatment |
| |efficacy, and factors that contribute to improved treatment outcome in vestibular disorders. The Brandt-Daroff exercises were developed based on |
| |the theory that the signs and symptoms of BPPV are due to cupulolithiasis and that the posterior canal is affected. These exercises originally |
| |were believed to produce habituation of the vertigo. Brandt and Daroff noted that the response to treatment occurred immediately in some |
| |patients, and they suggested that the debris was physically dislodged from the cupula. Given the limitations of the Brandt-Daroff exercises, it is|
| |surprising that this treatment was shown to be effective for 95% of patients with BPPV within 2 weeks.24 |
| |Review on Cawthrone-Cooksey Exercises: |
| |Stefano Corna MD et al. (2003) made a study to compare the effectiveness of vestibular rehabilitation by using Cawthorne-Cooksey exercises with |
| |that of instrumental rehabilitation. Interventions made improved patients’ balance.25 |
| |Review on Outcome Measures: |
| |Gary P. Jacobson, PhD; Craig W. Newman, PhD(April 1990) developed 25-item Dizziness Handicap Inventory (DHI) to evaluate the self perceived |
| |handicapping effects imposed by vestibular system disease. Cronbach's α coefficient was employed to measure reliability based on consistency of |
| |the preliminary version. The final version of the DHI was administered to 106 consecutive patients and demonstrated good internal consistency |
| |reliability. With the exception of the physical subscale, the mean values for DHI scale scores increased significantly with increases in the |
| |frequency of dizziness episodes. Test-retest reliability was high.26 |
| | |
| |La Porta F et al.(July 2012) within the context of Rasch analysis, assessed (1) the internal validity and reliability of the Berg Balance Scale |
| |(BBS) in a sample of rehabilitation patients with varied balance abilities; and (2) the comparability of the BBS measures across different |
| |neurologic diseases. This study supports the internal validity and reliability of the BBS-12 as a measurement tool independent of the etiology of |
| |the neurologic disease causing the balance impairment. In view of some sample-related issues and that not all possible etiologies encountered in |
| |the neuro-rehabilitation settings were tested, a larger multicenter study is warranted to confirm these findings.27 |
| | |
| | |
| | |
| |6.3 Objectives of the study: |
| |1. To evaluate the effect of brandt daroff’s exercises vs cawthrone-cooksey execises in subjects with Unilateral vestibular hypofunction. |
| | |
| |Materials and Methods: |
| |7.1 Source of Data |
| |ESI Hospital, Rajajinagar, Bangalore. |
| |Padmashree clinic Nagarbhavi, Bangalore. |
| |Govt. General Hospital, Kurnool district, Andhra Pradesh. |
| | |
| |7.2 Method of collection of data: |
| |Population: People with unilateral vestibular hypofunction. |
| |Sample design: Convenience sampling |
| |Sample size: 30 |
| |Study design: Experimental Study |
| |Duration of the study: 6 months |
| |Inclusion criteria: |
| |Subjects with chronic unilateral vestibular hypofunction as diagnosed by the ENT surgeon. |
| |Subjects 31 to 49 years |
| |Both genders |
| |Exclusion criteria: |
| |Subjects who have undergone any vestibular surgery |
| |Migraine |
| |Tumors |
|7 |Subjects with age related dizziness and vertigo |
| |Auto immune Inner Ear Disease |
| |Non-cooperative patients |
| |Benign Paroxysmal Positional Vertigo subjects |
| |Subjects with other neurological related balance problems |
| |Materials used: |
| |Couch |
| |Chalk for markings on the floor |
| |Floor with even surface |
| |Floor with uneven surface |
| |Ball |
| |Methodology |
| |Ethical clearance will be taken from the concerned hospitals and institutions for the aged. Informed and written consent from each concerned |
| |patient will be taken which will state that the individual has agreed to participate in the study and that the data collected will be analyzed |
| |using evaluation tools. Individual with age of 31 to 49 will be chosen from the hospital and institution. Rotation tests will be performed and |
| |subjects were chosen based on that as diagnosed by the physician. All the subjects will attend a testing session of 10 minutes duration where roll|
| |test is done by the therapist including a familiarization session of 20 minutes. First patient will be explained the overall test procedure, |
| |followed by a practice session of the recommended treatment protocol with standardized set of instructions. The Brandt-Daroff Exercises should be |
| |performed for three weeks, two times per day. Where one session is given under the supervision of the therapist in the clinic and second session |
| |will be done under the supervision of the caretaker at home. Each patient is given a handout of both the exercises and asked to follow the |
| |instructions given in the handout. Whereas Cawthorne-Cooksey exercises are given for 10 minutes each two times per day for three weeks. |
| |Outcome measures: |
| |Dizziness handicap Inventory |
| |Berg Balance Scale |
| | |
| |Statistical Analysis: |
| |Data analysis will be performed by SPSS (version 17) for windows |
| |Mean standard deviation will be used to measure vertigo and balance |
| |Wilcoxon test is used for pre and post test between the two groups |
| |Mann Whitney U test is used to compare level of post test between the two groups |
| | |
| |7.3 Does the study require any investigation or interventions to be conducted on patients or other humans or animals? If so please describe |
| |briefly. |
| |Yes, the study will be carried out on human subjects of both the gender with the age group of 31-49 years having the symptoms of unilateral |
| |vestibular hypofunction to compare the effectiveness of Brandt Daroff exercises versus Cawthrone-Cooksey exercises. |
| | |
| |7.4 Has the ethical clearance been obtained from your institution in case of 7.3 |
| |Yes, ethical clearance has been obtained from the institution. |
| |List of References: |
| |Sue Hickey (President). Vestibular Disorders association. Portland,OR: 2012; available from |
| | |
| |Susan B O’ Sullivan, Thomas J Schimtz. Physical Rehabilitation.5th edition. India: Jaypee brothers Medical publishers (P) Ltd; 2007. |
| |Della santina, cc et al. Orientation of human vestibular labyrinth semicircular canals. In proceedings of the 2004 Midwinter Meeting of the |
| |Association for research in Otolaryngology, Dayton Beach FL(Feb 22-26, 2004)Association for research in Otolaryngology, Mt. Royal, NJ, 2004. |
| |Phillip D. Cremer,G. Michael Halmagyi, Swee T. Aw,I an S. Curthoys, Leigh A. McGarvie, Michael J. Todd, Ross A. Black, and Imelda P. Hannigan. |
| |Semicircular canal plane head impulses detectabsent function of individual semicircular canals.1998; 121: 699–716. |
| |Susan B O’ Sullivan, Thomas J Schimtz. Physical Rehabilitation.5th edition. India: Jaypee brothers Medical publishers (P) Ltd; 2007. |
| |Michael C Schubert and Lloyd B Minor. Vestibulo-ocular Physiology Underlying Vestibular Hypofunction. PHYS THER. 2004; 84:373-385. |
| |LH Tee, NW Chee. Vestibular rehabilitation therapy for the dizzy patient. Ann Acad Med Singapore 2005; 34: 289-94. |
| |Sue Hickey (President). Vestibular Disorders association. Portland,OR: 2012; available from |
| | |
| |Sue Hickey (President). Vestibular Disorders association. Portland,OR: 2012; available from |
| | |
| |Sue Hickey (President). Vestibular Disorders association. Portland,OR: 2012; available from |
| |. |
| |Susan B O’ Sullivan, Thomas J Schimtz. Physical Rehabilitation.5th edition. India: Jaypee brothers Medical publishers (P) Ltd; 2007. |
| |Susan J. Herdman, Michael C. Shubert, Vallabah E. Das, Ronald J Tusa. Recovery of Dynamic Visual Activity in Unilateral Vestibular Hypofunction. |
| |Arch Otolaryngol Head Neck Surg.2003; 129: 819-824. |
| |Brandt .T and daroff. RB. Physical therapy for BPPV. Arch otolaryngol .1980; 106:484. |
| |Brandt .T and daroff. RB. Physical therapy for BPPV. Arch otolaryngol. 1980; 106:484. |
| |Cawthorne T. The physiological basis for head exercises. J Chart Soc Physiother. 1944; 30:106–107. |
| |Canalith-repositioning-procedure-for-vertigo. 2010; april 29. Available from |
| |Baloh RW, Honrubia V. Clinical neurolophysiology of the vestibular system. FA DAVIS, Philadelphia, 1990. |
| |Clendaniel RA. The effects of habituation and gaze stability exercises in the treatment of unilateral vestibular hypofunction: a preliminary |
| |results.J Neurol Phys Ther. 2010 June; 34(2):111-6. |
| |Giray M, Kirazli Y, Karapolat H, Celebisoy N, Bilgen C, Kirazli T. Short-term effects of vestibular rehabilitation in patients with chronic |
| |unilateral vestibular dysfunction: a randomized controlled study. Arch Phys Med Rehabil. 2009 Aug;90(8):1325-31 |
| |Peterka RJ, Statler KD, Wrisley DM, Horak FB. Postural compensation for unilateral vestibular loss.Department of Biomedical Engineering, Oregon |
| |Health & Science University Portland, OR, USA. |
|8 |Gill-Body, Kathleen M MS, PT, NCS. Comparison of Different Exercise Programs in the Rehabilitation of Patients with Chronic Peripheral Vestibular |
| |Disfunction. Journal of Neurologic Physical Therapy. 1996 ;Volume 20(3): pp64-65. |
| |Winkler et.al. Platform Tilt Perturbation as an Intervention for People with Chronic Vestibular Dysfunction. Journal of Neurologic Physical |
| |Therapy, 2011, september ;Volume 35(3) :p 105–115 |
| |Pavlou, Marousa PhD, BA, MCSP. The Use of Optokinetic Stimulation in Vestibular Rehabilitation. Journal of Neurologic Physical Therapy. 2010, |
| |June; Volume 34 (2): pp 105-110 |
| |Susan J Herdman. Advances in the Treatment of Vestibular Disorders. PHYS THER. 1997; 77:602-618 |
| |Stefano Corna, MD, Antonio Nardone, MD, PhD, Alessandro Prestinari.MD, Margherita Grasso. ET, Marco Schieppati, MD. Comparison of |
| |Cawthorne-Cooksey exercises and sinusoidal support surface translations to improve balance in patients with unilateral vestibular deficit. |
| |Archives of Physical Medicine and Rehabilitation. 2003, August; Volume 84(8) : pp 1173-1184. |
| |Gary P. Jacobson, PhD; Craig W. Newman, PhD .The Development of the Dizziness Handicap Inventory .Arch Otolaryngol Head Neck Surg, |
| |1990;116(4):424-427. |
| |La Porta F, Caselli S, Susassi S, Cavallini P, Tennant A, Franceschini M. Is the Berg Balance Scale an internally valid and reliable measure of |
| |balance across different etiologies in neurorehabilitation? A revisited Rasch analysis study. Arch Phys Med Rehabil. 2012 July; 93(7):1209-16. |
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