Physical therapy interventions for older people with vertigo, dizziness and balance disorders addressing mobility and participation: a systematic review

Regauer V, Seckler E, Müller M, Bauer P. Physical therapy interventions for older people with vertigo, dizziness and balance disorders addressing mobility and participation: a systematic review. BMC Geriatrics. 2020;20(1). doi:10.1186/s12877-020-01899-9

Link to Original Article: https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-020-01899-9

Key Points

- Vertigo, dizziness, and balance disorders (VDB) are significant contributors to disability in older adults and are associated with immobility and limitations in activities of daily living.

- The study aimed to identify the quality of evidence for physical therapy interventions for older patients with VDB that address mobility and participation.

- The review included 22 studies with a total of 1876 patients. The studies were heterogeneous in terms of interventions and outcome measures.

- Vestibular rehabilitation (VR) was examined in 12 studies, computer-assisted VR in 5 studies, Tai Chi as VR in 3 studies, and other interventions in 2 studies.

- The results showed mixed effects for body structure/function and activities/participation outcomes. VR was found to be superior to usual care in improving balance, mobility, and symptoms.

- The quality of evidence was moderate, and high-quality randomized trials are needed to inform clinical decision making for older patients with VDB.

Background

This study focuses on vertigo, dizziness, and balance disorders (VDB) in older adults and their impact on disability. VDB affects up to 50% of older individuals and is associated with limitations in daily activities and reduced participation. These complaints are risk factors for falls and can lead to activity restriction and disability. The underlying causes of VDB in older individuals are complex due to the interaction of the vestibular, visual, and proprioceptive systems. Degeneration and changes in the vestibular system can contribute to peripheral vestibular disorders such as benign paroxysmal positional vertigo (BPPV). Visual impairment and sensorimotor deficits due to aging and neurodegenerative conditions also contribute to imbalances and decreased postural stability. The paper highlights the challenges in diagnosing and treating VDB, especially in older patients with multifactorial causes. Physical therapy interventions, such as canal repositioning manoeuvres, vestibulo-ocular reflex exercises, balance exercises, and patient education, have been shown to benefit older patients with VDB. The study aims to provide an overview of the effects of physical therapy interventions on mobility and participation in older patients with VDB.

Methods

Identification of studies

The researchers followed the PICOS scheme and the Cochrane Handbook for Systematic Reviews of Interventions 6.0 to develop their search strategy. They included studies that focused on the treatment of vertigo, dizziness, and balance disorders in older adults, considering them as multifactorial conditions. The inclusion criteria consisted of studies that had a population with a mean age of ≥65 years or described a subgroup of individuals with vertigo, dizziness, or balance disorders. Physical therapy interventions and related components were considered as the intervention. All study designs with control groups, including randomized and non-randomized trials, were included. Systematic reviews and meta-analyses were also included for backward citation tracing. Studies conducted between 2007 and 2019 and published in German or English were included. Studies with healthy adults or insufficient age description, as well as surgical or pharmacological interventions, were excluded. The initial search was conducted in November 2017, with an update in July 2019, and additional sources were identified through various means.

Study selection

The researchers used Covidence software to manage records identified from database searching and dedupilication of the database records. All studies were screened by two independent authors.

Data extraction and critical appraisal

In this section, two independent reviewers extracted data from the included studies using a template for intervention description. The methodological quality of 8 studies was assessed in duplicate, while the remaining 13 studies were assessed for feasibility reasons. The risk of bias was assessed using the Cochrane handbook 5.1.0, and graphs were generated using RevMan 5.3 software. Any disagreements between the reviewers were resolved through discussion and consensus, or by consulting a third reviewer if necessary. The authors have made the data extraction sheet available upon request.

Data synthesis

The data synthesis section of the research paper highlights the heterogeneity of the included studies in terms of interventions and outcome measures. Inductive categories were used to group the studies based on interventions, comparisons, and outcomes. A narrative synthesis was conducted, covering various aspects of the World Health Organization's model of the International Classification of Functioning, Disability and Health (ICF), quality of life, and general health. Mean or median differences between groups at the last follow-up were used to define the change direction. Due to insufficient or heterogeneous reported data, a meta-analysis was not possible. Harvest plots were used to summarize and visualize the data, comparing distinct interventions to no/sham intervention or usual care. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) guidelines were used to rate the certainty of findings for each outcome. The effects of interventions on the primary outcome were reported, along with a summary of the direction of effects on secondary outcomes.

Results

The research team initially identified 2316 records through database searching and an additional 603 papers through manual searching and citation tracing. After deduplication, 3280 titles and abstracts were screened, and the full texts of 428 studies were reviewed. In the end, the final sample for analysis comprised 22 studies with 1876 participants. The majority of the studies (20 out of 22) were randomized controlled trials, while the remaining two were non-randomized controlled trials.

Setting and participant characteristics

The studies for this research were conducted in 14 countries between 2008 and 2018, in various settings including hospitals, primary care practices, outpatient clinics, residential homes, and at home. The age of the participants ranged from 60 to 85.5 years, with some studies specifically focusing on individuals aged 65 and older. The symptoms of vestibular dysfunction varied among the studies, including dizziness, balance disorder, general vestibular dysfunction, and specific pathologies such as Parkinson's disease, benign paroxysmal positional vertigo, stroke, fall-related conditions, visual impairment, and cervicogenic dizziness. The paper also includes a table with additional details on the characteristics of the study participants.

Outcome measures

The outcome measures used in the 22 studies included in this research varied greatly. The majority of the studies (16) focused on assessing static or dynamic balance and postural control. Nine studies examined aspects of mobility, such as walking ability, functional mobility, or activity level. Dizziness symptoms, including frequency, intensity, and impact, were evaluated in eight studies. Falls and the (risk of) falls were assessed in six studies, and quality of life was addressed in five studies. Lower extremity muscle strength was reported in four studies, while proprioception was analyzed in two studies. Some single studies evaluated various self-perceived outcomes. Eleven studies stated primary outcome(s) measures, with four assessing body functions and structures according to the International Classification of Functioning, Disability, and Health (ICF) components, five focusing on activities and participation, and two assessing both components. Additional details on primary and secondary outcome measures can be found in Additional file 4.

Canal repositioning manoeuvres: CRM versus CRM variations

The research paper compared the effectiveness of the Epley manoeuvre (CRM) to CRM variations, such as wearing a neck collar or using a mini-vibrator during the manoeuvre, for treating posterior canal BPPV caused by canalolithiasis. The study found no advantage for these variations in terms of reducing dizziness and improving quality of life, as measured by the Dizziness Handicap Inventory. In another part of the paper, the authors explored vestibular rehabilitation (VR) as a treatment option for BPPV. They found that VR was the most investigated intervention, with 12 studies involving 1,284 participants. Overall, this research suggests that CRM and its variations may not be superior to other interventions, and that VR is a commonly studied approach for managing BPPV.

VR compared to usual care

A comparison of internet-based virtual reality (VR) and usual care for patients with dizziness showed that VR was more effective in reducing dizziness symptoms, as measured by the Vertigo Symptom Scale. Secondary outcomes also favored VR, including improvements in the Dizziness Handicap Inventory score and patient-reported improvement. However, no significant differences were found in anxiety and depression levels. Another study comparing usual care with a multicomponent program for dizziness found no difference in outcomes related to fall risk, anxiety and depressive disorders, quality of life, and fall frequency. A randomized controlled trial comparing the Otago program to usual care for balance disorders showed mixed results, with some improvements in muscle strength and functional tests but no significant differences in primary outcomes. A non-randomized study comparing an exercise program to physical therapy showed benefits in fear of falling and gait, but no differences in balance or likelihood of falls. Finally, a study on patients with Parkinson's disease found mixed results, with VR showing benefits in balance and confidence but no significant differences in other measures. Overall, there is moderate evidence that VR is superior to usual care in improving dizziness symptoms, balance, and mobility, but not in other areas such as postural control, activities of daily living, and quality of life.

VR versus no intervention

The section compares the use of virtual reality (VR) interventions to no intervention in two different studies. The first study included 85 participants with fall-related wrist fractures and found no differences in primary outcomes such as tandem standing and walking. Secondary outcomes, including postural sway and vibration sense, also showed no differences between the two interventions.

The second study consisted of 58 participants with multisensory dizziness and did not have a primary outcome. However, mixed effects were observed, with improvements in standing on one leg with eyes closed and walking heel to toe. No differences were found in other measurements, such as standing on one leg with eyes open or tandem standing, as well as other factors related to dizziness and falls.

Finally, a study with 139 participants experiencing balance impairment without a vestibular disease compared training computer dynamic posturography exercises to no intervention. No differences were found in the various measures evaluated, including SOT, LOS, DHI, TUG, and FES-I.

In conclusion, these studies suggest that VR interventions do not provide significant advantages over no intervention in terms of improving balance and reducing falls in the populations studied.

New variations versus established forms of VR

This section of the research paper discusses various studies comparing new variations of virtual reality (VR) interventions to established forms of intervention in different populations. One study compared VR with cognitive rehabilitation therapy (CRM) to CRM alone in individuals with benign paroxysmal positional vertigo (BPPV) and found mixed results for primary and secondary outcomes. Another study compared group-based Otago exercise program to home-based Otago exercise program in older adults referred to a Falls Outpatient Clinic and found no difference in the primary outcome but mixed effects for secondary outcomes. A third study compared a multimodal version of the Cawthorne-Cooksey program to the conventional version in individuals with dizziness resulting from a vestibular disorder and found no difference in primary or secondary outcomes. Lastly, a trial compared VR exercises using computer dynamic posturography to optokinetic stimuli exposure and home exercises in patients with balance impairment and no vestibular disease but did not report specific outcomes. Overall, the evidence suggests that VR combined with CRM may be superior to CRM alone in improving balance, and group-based Otago exercise programs may improve lower extremity strength and mobility more than home-based programs, albeit with very low-quality evidence.

CAVR versus usual care

The paper does not provide any information about the comparison between WiiFit training and traditional exercises for participants with idiopathic Parkinson's Disease. However, it does describe a comparison between virtual reality-based Wii Fit training and treadmill training to fall-prevention education with no structured program. The study included 20 participants with chronic stroke-related complaints and investigated additional balance training using the Wii Fit program in comparison to conventional physical therapy. No primary outcome was stated. The results showed no difference in balance, body symmetry, Berg Balance Scale (BBS), Timed Up and Go (TUG) test, and 7-level functional independence measure (FIM) between the two groups.

CAVR versus other interventions

In this section of the research paper, several interventions were compared to Computer-Assisted Virtual Rehabilitation (CAVR). In a three-arm randomized controlled trial (RCT), virtual reality-based Wii Fit training with subsequent treadmill training was compared to fall-prevention education with no structured program for Parkinson's Disease patients. The results showed mixed findings, but the virtual reality-based intervention showed advantages in various gait parameters, including velocity, stride length, and muscle strength. Another study compared home exercises supported by the Mitii computer program to a printed home program for people with vestibular dysfunction, and found no differences in primary and secondary outcomes. A third study compared in-home virtual reality balance training to in-clinic sensory integration balance training for Parkinson's Disease patients, and found no significant differences in outcomes. Overall, the evidence suggests that virtual reality-based Wii Fit training with subsequent treadmill training can be more effective than fall-prevention education in improving gait parameters, lower extremity strength, balance, and postural control. Additionally, three studies used Virtual Reality Tai Chi and involved a total of 216 participants.

Tai chi VR (TCVR) versus no/sham intervention

In a randomized controlled trial (RCT) comparing Tai chi virtual reality (TCVR) to no intervention, researchers found significant differences in postural control and mobility. The study included 40 participants who experienced dizziness within the past year. In terms of postural control, TCVR showed improvements in forward sway (+61 cm), backward sway (+1.37 cm), and maximal sway area (+28.57 cm^2) of the limits of stability test. Additionally, TCVR led to a decrease in the time taken for the 8-ft up-and-go test (-0.23 s). However, no differences were found in the right and leftward sway of limits of stability. In another RCT comparing TCVR to a sham intervention using music percussion, mixed effects were observed. TCVR showed improvement in the absolute angle error of passive knee joint repositioning (-30.1%), visual ratio (+59.7%), and vestibular ratio (+50.3%) in the sensory organization test. No differences were found in strength or somatosensory ratio. The overall quality of evidence was determined to be low and very low for postural control and mobility improvements, respectively.

TCVR versus other interventions

A randomized controlled trial (RCT) with 136 participants who had a history of stroke examined the effects of Tailor-made Cognitive Rehabilitation (TCVR) compared to breathing and stretching exercises. The study found mixed effects on the primary outcomes of LOS (limits of stability) and SOT (sensory organization test). There was a significant difference in reaction time on the non-affected side and end-point excursion on both the affected and non-affected sides. Additionally, there was a difference in LOS for backwards and forwards movement. However, there were no differences in equilibrium score, sensory ratios of SOT, and reaction time on other sides, as well as the secondary outcome of Timed Up and Go (TUG). The evidence for the superiority of TCVR over breathing and stretching exercises is of very low quality.

Similarly, another RCT with 86 participants with cervicogenic dizziness compared the effects of Manual therapy using Sustained Natural Apophyseal Glides (SNAGs) to a sham intervention. SNAGs were found to have a significant effect on the primary outcome of dizziness intensity as measured by the Visual Analogue Scale (VAS), but mixed effects were observed in the secondary outcomes. Maitland mobilizations, on the other hand, did not show a significant effect on the primary outcome. However, there were mixed effects in the secondary outcomes. The evidence suggests that SNAGs are superior to a sham intervention but equal to Maitland mobilizations in improving dizziness intensity. Maitland mobilizations are potentially superior to both SNAGs and the sham intervention in improving the impact of Vestibular-related Dizziness (VDB) on activities of daily living (ADL).

Discussions

Main findings

This research paper examined the evidence on physical therapy treatment options for older people with vestibular dysfunction and identified several key findings. The quality of evidence in the studies was variable, and outcome measures differed across studies. Virtual reality (VR), VR in addition to cognitive rehabilitation therapy (CRM), and manual therapy (MT) were found to have beneficial effects, although the quality of evidence was generally low. There is a lack of high-quality evidence for the use of CRMs in older adults, particularly for the treatment of benign paroxysmal positional vertigo (BPPV). VR training in addition to CRM showed moderate-quality evidence for improving balance in older adults. Exercise therapy, such as the Otago exercise program, was found to be effective for improving balance, mobility, quality of life, and falls in older adults. Tai Chi was not effective for improving postural control in older individuals with vestibular dysfunction, but it showed potential for fall prevention in older adults living in the community. Manual therapy was not found to be effective in the target population, and caution should be exercised due to the increased risk of injuries in elderly individuals. Further research is needed to investigate the synergistic effects of MT combined with other interventions.

Limitations

The limitations of this study were primarily due to the various interventions, outcomes, and study populations examined, which made comparison of the findings challenging. Many of the studies on physical therapy for VDB lacked control groups and were conducted on younger populations, particularly in regards to CRMs. The methodological quality of the included studies was also lacking, with insufficient reporting on randomization, allocation concealment, and blinding of participants and personnel. Additionally, there were often imbalances in the number of withdrawals between groups. The review was limited by the restriction of publication years and language, potentially excluding relevant articles. Only a few studies clearly stated a primary outcome, while others reported multiple primary outcomes. The review used a narrative synthesis, leading to a lower ranking of imprecision in the GRADE approach. Despite these limitations, the review provided valuable knowledge for clinical decision making and underwent rigorous quality assessment.

Conclusions

Based on the available evidence, vestibular rehabilitation appears to be effective in treating vestibular dysfunction in older adults. Virtual reality combined with cognitive training also showed similar effectiveness. However, Tai Chi and manual therapy did not provide any additional benefits compared to usual care in this population. It is worth noting that the overall quality of evidence is low, particularly in terms of bias. Many studies focus on surrogate markers rather than patient-relevant outcomes related to mobility and participation. Additionally, there is a lack of transparent reporting of physical therapy interventions as complex interventions. This makes it challenging to implement the findings into daily care. To better inform clinical decision-making for older patients with vestibular dysfunction, high-quality randomized trials should be conducted in the future. This vulnerable population requires more research attention.

Opportunities for Future Research

1. Conduct high-quality randomized controlled trials to further investigate the effectiveness of vestibular rehabilitation (VR) interventions in older adults with vertigo, dizziness, and balance disorders. Specifically, focus on comparing different variations of VR (such as computer-assisted VR and Tai Chi as VR) to determine which interventions yield the best outcomes.

2. Explore the long-term effects of VR interventions, including their impact on quality of life, falls, and fear of falling in older patients with vertigo, dizziness, and balance disorders.

3. Investigate the effectiveness of physical therapy interventions, such as VR and manual therapy, in older adults with specific underlying pathologies that contribute to vertigo, dizziness, and balance disorders (such as Parkinson's disease).

4. Examine the feasibility and effectiveness of using technology-based interventions, such as virtual reality, to enhance physical therapy treatments for older individuals with vertigo, dizziness, and balance disorders.

5. Examine the role of exercise therapy, including individualized or specialized exercise programs, in the treatment of vertigo, dizziness, and balance disorders in older adults. Compare the effectiveness of different exercise programs (such as the Otago program and other balance exercises) to determine the most beneficial strategies.

6. Conduct research on the optimal delivery methods and settings for physical therapy interventions for older adults with vertigo, dizziness, and balance disorders. Compare the outcomes of home-based interventions versus clinic-based interventions to determine the most effective approach for this population.