Effectiveness of Otolith Repositioning Maneuvers and Vestibular Rehabilitation 111

Braz J Otorhinolaryngol. 2018;84(1):109---118

Brazilian Journal of OTORHINOLARYNGOLOGY

www.bjorl.org

REVIEW ARTICLE

Effectiveness of Otolith Repositioning Maneuvers and

Vestibular Rehabilitation exercises in elderly people

with Benign Paroxysmal Positional Vertigo:

ଝ a systematic review

a,b,∗ b b

Karyna Figueiredo Ribeiro , Bruna Steffeni Oliveira , Raysa V. Freitas ,

c d a,e

Lidiane M. Ferreira , Nandini Deshpande , Ricardo O. Guerra

Universidade Federal do Rio Grande do Norte (UFRN), Programa de Pós-Graduac¸ão em Ciências da Saúde, Natal, RN, Brazil

Universidade Federal do Rio Grande do Norte (UFRN), Departamento de Fisioterapia, Natal, RN, Brazil

Universidade Federal do Rio Grande do Norte (UFRN), Programa de Pós-Graduac¸ão em Saúde Pública, Natal, RN, Brazil

Queen’s University, Faculty of Health Sciences, School of Rehabilitation Therapy, Kingston, Canada

Universidade Federal do Rio Grande do Norte (UFRN), Programa de Pós-Graduac¸ão em Fisioterapia, Natal, RN, Brazil

Received 3 February 2017; accepted 2 June 2017

Available online 29 June 2017

KEYWORDS Abstract

Introduction: Benign Paroxysmal Positional Vertigo is highly prevalent in elderly people. This

Benign Paroxysmal

condition is related to vertigo, hearing loss, tinnitus, poor balance, gait disturbance, and an

Positional Vertigo;

Elderly; increase in risk of falls, leading to postural changes and quality of life decreasing.

Vertigo; Objective: To evaluate the outcomes obtained by clinical trials on the effectiveness of Otolith

Dizziness; Repositioning Maneuver and Vestibular Rehabilitation exercises in the treatment of Benign

Rehabilitation Paroxysmal Positional Vertigo in elderly.

Methods: The literature research was performed using PubMed, Scopus, Web of Science and

PEDro databases, and included randomized controlled clinical trials in English, Spanish and

Portuguese, published during January 2000 to August 2016. The methodological quality of the

studies was assessed by PEDro score and the outcomes analysis was done by critical revision of

content.

Results: Six studies were fully reviewed. The average age of participants ranged between 67.2

and 74.5 years. The articles were classiﬁed from 2 to 7/10 through the PEDro score. The

main outcome measures analyzed were vertigo, positional nystagmus and postural balance.

ଝ

Please cite this article as: Ribeiro KF, Oliveira BS, Freitas RV, Ferreira LM, Deshpande N, Guerra RO. Effectiveness of Otolith Repositioning

Maneuvers and Vestibular Rehabilitation exercises in elderly people with Benign Paroxysmal Positional Vertigo: a systematic review. Braz J

Otorhinolaryngol. 2018;84:109---18. ∗

Corresponding author.

E-mail: [email protected] (K.F. Ribeiro).

Peer Review under the responsibility of Associac¸ão Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial.

https://doi.org/10.1016/j.bjorl.2017.06.003

access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

110 Ribeiro KF et al.

Additionally, the number of maneuvers necessary for remission of the symptoms, the quality of

life, and the functionality were also assessed. The majority of the clinical trials used Otolith

Repositioning Maneuver (n = 5) and 3 articles performed Vestibular Rehabilitation exercises in

addition to Otolith Repositioning Maneuver or pharmacotherapy. One study showed that the

addition of movement restrictions after maneuver did not inﬂuence the outcomes.

Conclusion: There was a trend of improvement in Benign Paroxysmal Positional Vertigo sympto-

matology in elderly patients who underwent Otolith Repositioning Maneuver. There is sparse

evidence from methodologically robust clinical trials that examined the effects of Otolith

Repositioning Maneuver and Vestibular Rehabilitation exercises for treating Benign Paroxys-

mal Positional Vertigo in the elderly. Randomized controlled clinical trials with comprehensive

assessment of symptoms, quality of life, function and long-term follow up are warranted.

by Elsevier Editora Ltda. This is an open access article under the CC BY license (http://

creativecommons.org/licenses/by/4.0/).

PALAVRAS-CHAVE Eﬁcácia das manobras de reposicionamento de otólitos e exercícios de reabilitac¸ão

vestibular em idosos com vertigem posicional paroxística benigna: uma revisão Vertigem posicional sistemática paroxística benigna; Idosos;

Vertigem; Resumo

Tontura; Introduc¸ão: A vertigem posicional paroxística benigna é altamente prevalente em idosos. Esta

Reabilitac¸ão condic¸ão está relacionada a vertigem, perda auditiva, zumbido, equilíbrio precário, distúrbios

da marcha e aumento do risco de quedas, levando a mudanc¸as posturais e reduc¸ão da qualidade

de vida.

Objetivo: Avaliar os desfechos obtidos por ensaios clínicos sobre a eﬁcácia da Manobra de

Reposicionamento de Otólitos e de exercícios de Reabilitac¸ão Vestibular no tratamento de

vertigem posicional paroxística benigna em idosos.

Método: A pesquisa da literatura foi realizada usando bancos de dados do PubMed, Scopus,

Web of Science e PEDro e incluiu ensaios clínicos controlados randomizados em inglês, espanhol

e português, publicados de janeiro de 2000 a agosto de 2016. A qualidade metodológica dos

estudos foi avaliada pelo escore PEDro e a análise dos desfechos foi realizada por revisão crítica

do conteúdo.

Resultados: Seis estudos foram totalmente revisados. A idade média dos participantes variou

entre 67,2-74,5 anos. Os artigos foram classiﬁcados de 2 a 7/10 pelo escore PEDro. As principais

medidas de desfecho analisadas foram vertigem, nistagmo posicional e equilíbrio postural. Além

disso, o número de manobras necessárias para a remissão dos sintomas, a qualidade de vida

e a funcionalidade também foram avaliados. A maioria dos ensaios clínicos usou Manobra de

Reposicionamento de Otólitos (n = 5) e 3 artigos realizaram exercícios de RV, além de Manobra de

Reposicionamento de Otólitos ou farmacoterapia. Um estudo mostrou que a adic¸ão de restric¸ões

de movimento após a manobra não inﬂuenciou os resultados.

Conclusão: Houve uma tendência de melhora na sintomatologia da vertigem posicional parox-

ística benigna em pacientes idosos submetidos à Manobra de Reposicionamento de Otólitos.

Existem evidências escassas de ensaios clínicos metodologicamente robustos que examinaram

os efeitos dos exercícios de Manobra de Reposicionamento de Otólitos e Reabilitac¸ão Vesti-

bular para o tratamento da vertigem posicional paroxística benigna nos idosos. Ensaios clínicos

controlados randomizados com avaliac¸ão abrangente de sintomas, qualidade de vida, func¸ão e

acompanhamento de longo prazo são justiﬁcados.

por Elsevier Editora Ltda. Este e´ um artigo Open Access sob uma licenc¸a CC BY (http:// creativecommons.org/licenses/by/4.0/).

2,3

Introduction degenerative changes. Diagnosis of BPPV is conﬁrmed

using Dix-Hallpike test, and it is classiﬁed as objective when

Dizziness is one of the most common symptoms in elderly nystagmus is observed during the test, or subjective when

1 4

people and it is considered a geriatric syndrome. Among there is vertigo without nystagmus. Female patients have

the causes of dizziness, Benign Paroxysmal Positional Vertigo been shown to be most affected by BPPV, which may be jus-

(BPPV) is the most frequent vestibular disorder, affecting tiﬁed by the fact that the homeostasis of labyrinthine ﬂuids

approximately 20% of patients presenting this symptom. may be compromised by female hormones decreasing from

BPPV is highly prevalent in elderly, probably due to senile climacteric phase.

Effectiveness of Otolith Repositioning Maneuvers and Vestibular Rehabilitation 111

Prevalence of BPPV is estimated at 25% in elderly people from January, 2000 to August, 2016. The strategy used

over 70 years with complaints about dizziness and this symp- was the combination of the descriptors ‘‘benign paroxys-

6 --- 8

tom persists for more than one year. Vertigo is reported as mal positional vertigo’’ AND ‘‘physical therapy modalities’’

the main complain of BPPV patients and may be associated OR ‘‘rehabilitation’’ OR ‘‘exercise therapy’’ AND ‘‘vertigo’’

to hearing loss, tinnitus, poor balance, gait disturbance, and OR ‘‘dizziness’’ OR ‘‘postural balance’’. After this process,

an increase in risk of falls. Patients with BPPV restrict their only two key-words were combined (‘‘Benign paroxysmal

activities in order to avoid crises due vertiginous sympto- positional vertigo’’ AND ‘‘therapy’’; ‘‘Benign Paroxysmal

matology, leading to postural changes and quality of life Vertigo’’ AND ‘‘Exercises’’; ‘‘Benign Paroxysmal Positional

8,10

decreasing. Such movement restrictions associated to Vertigo’’ AND ‘‘Treatment’’; ‘‘Benign Paroxysmal Posi-

comorbidities and high prevalence of BPPV in elderly usually tional Vertigo’’ AND ‘‘Physical Therapy’’). Duplicate articles

11,12

result in functional loss and inability. among the databases were excluded.

BPPV also increases incidence of falls in older patients, The following inclusion criteria were applied: (1) Par-

as well as chance of fracture, head traumas (concussion), ticipants with an average age of 65 years and over; (2)

hospitalizations and depression. Elderly with BPPV show Individuals with BPPV and; (3) Interventions by VR exer-

worse scores in functional tests due to coexistence of mul- cises and/or ORM. The studies were excluded if they were

tiple morbidities, fear of falling that characterizes geriatric non-randomized clinical trials, qualitative studies, and stud-

population and the senescence of vestibular system usually ies with pharmacological or surgical interventions without

found in this population, which may further damage postural association to VR exercises and/or ORM.

13,14

balance in these individuals. Furthermore, static and The construction of this systematic review was guided

dynamic postural control in elderly patients with vestibu- by the criteria of the Preferred Reporting Items for System-

lopathies is damaged, which may contribute to a functional atic Reviews and Meta-Analysis (PRISMA statement). The

limitation and greater low balance conﬁdence regarding methodological quality of selected studies was assessed by

3,15---18

falls in this population. PEDro score, which is comprised of 11 criteria about the

Vertigo and other associated symptoms are triggered internal validity and interpretation of clinical trials. The

by the displacement of statocone (otoconia) fragments score attributes 1 point for each criterion presented by the

from the utricle macula. The statocone freely ﬂoat in the study. However, the ﬁrst criterion (eligibility criterion) is not

endolymph of one or more semicircular canals which become counted. Therefore, the closer the score is to 10 obtained

sensitive to changes in head position. For these reasons, by the study, the better is its methodological quality and

BPPV is mainly treated by Otolith Repositioning Maneu- data reproducibility. Each article score is given by trained

vers (ORM) in order to move the otoconia out of the canal specialists and it is available in PEDro database.

and lead it back to the vestibule. However, some authors The studies selected for a full review were analyzed

indicate that ORM is not sufﬁcient to improve or recover by two independent researchers and the disagreements

20---22

postural stability in elderly people with BPPV. Other between them were solved in consensus with assistance of

non-pharmacological intervention for patients with balance a third evaluator who analyzed the divergent questions.

disturbances is the Vestibular Rehabilitation (VR) exercises,

which includes vestibular adaptation, habituation and sub-

23---25

stitution exercises, and patient education.

Although the use of ORM and VR exercises on treat- Results

ing BPPV are commonly proposed in the literature, it was

observed that the majority of studies include a huge age The research performed by the health descriptors and key-

variation in their experimental designs and intervention words resulted in 3337 articles, but 1085 studies were

forms. Therefore, the present review aimed to evaluate the duplicates. Out of these, 1844 studies were excluded since

outcomes from randomized controlled clinical trials about they did not meet the inclusion criteria. Four hundred and

the effectiveness of ORM and VR exercises in the treatment eight abstracts were scrutinized. By reading the abstracts,

of BPPV in elderly people. it was found that 306 were not randomized controlled clin-

ical trials, 92 had average ages lower than 65 years or did

not show the average age in full text and 4 did not include

Methodology BPPV as a sample characteristic (Fig. 1). Thereby, 6 random-

ized controlled clinical trials passed the criteria required for

For the present systematic review, the scientiﬁc question: this review and were selected for critical analysis of their

‘‘What is the effectiveness of ORM and/or VR exercises content. The synopsis of main data from the reviewed arti-

in the treatment of BPPV in elderly people?’’, was estab- cles is displayed in Table 1. Table 2 shows that PEDro score

lished using the PICO strategy. The P-Patient component ranged from 2 to 7.

of the PICO strategy refers to elderly with BPPV; the Among the six selected studies, the sample number var-

I-Intervention refers to ORM and/or VR exercises; and ied from 14 to 156 patients, totaling 300 participants.

the O-Outcomes is related to vertigo, dizziness, and pos- The average age varied from 67.2 to 74.5 years. One

tural balance. The component C-Comparison was excluded article used Semont Liberatory Maneuver (SLM) as the

20,31---33

from the study because there is no comparison between intervention, while four studies used Epley maneuver

interventions. Bibliographic research was performed during and one study implemented movement restrictions after

September 2016 concomitantly in PubMed, Scopus, Web of the ORM and used a cervical collar and a mini-vibrator

Science and PEDro databases. It was limited to Portuguese, applied on the mastoid of the affected side. Four stud-

20,32---34

English and Spanish language papers which were published ies applied VR exercises and two articles applied

112 Ribeiro KF et al.

R ecords identified in Among the studies evaluated by PEDro score, the highest

the databases (n=3337) classiﬁcation was 7/10. Nevertheless, the two articles evalu-

ated with this score had a low sample (only 7 in each group).

These ﬁndings warrant the need to conduct randomized

controlled and blinded clinical trials in elderly people with

Records after

BPPV, with robust methodology. In the majority of stud-

duplicates removed 20,30,31

(n=2252) ies, patients presented BPPV of posterior canal, which

18,22,36

according to literature is the most prevalent diagnosis.

33,34

Tw o studies did not specify the affected canal.

As for the ORM intervention in elderly, most studies

20,31---33

Articles excluded since they did not meet applied the modiﬁed Epley maneuver. No study used

the inclus ion criteria 31

the classic Epley maneuver, but the study of André et al.

(n=1844 )

added a mini-vibrator on the mastoid process of the affected

side. All the studies that used modiﬁed Epley maneuver

described improvements in BPPV symptomatology, mainly

Records screened for vertigo, dizziness and nystagmus. These ﬁndings agree

(n=408)

with current literature, which places the Epley maneuver

ﬁrst in the treatment of BPPV of posterior canal. Fife et al.

classiﬁed the Epley maneuver for otolith repositioning as

Excluded articles (n= 402): ‘‘Recommendation level A.’’ In other words, the therapy is

effective and safe and must be offered to patients with BPPV

Average age lower than 65 years or not

of posterior canal of all ages.

provided by the authors (n=92)

The literature indicates SLM as the treatment for cupu-

29,36

lolithiasis of anterior and posterior canals. One article

Other study types (n=306)

mentioned having performed it. However, this study per-

S tudies that did not aim to treat BPPV formed SLM without clarifying if patients had cupulolithiasis

30 31

(n=4) or canalithiasis, with the exception being André et al.

that clariﬁed their sample as BPPV of posterior canal with

ductolithiasis (canalithiasis). In the study conducted by

Salvinelli et al., the group that underwent SLM demon-

strated a signiﬁcantly superior percentage of symptom

Studies included in the remission compared to the one that used only pharmacolog-

quali tative analyses ®

ical intervention with Flunarizine (10 mg/d before sleeping

(n=6)

during 60 days). Furthermore, symptom recurrence rate was

also lower in the maneuver group after 6 months.

Figure 1 Fluxogram for the selection of articles.

The effect of movement restrictions after ORM has been

a target intervention of one research, which assessed the

30,34 efﬁcacy of this practice after implementing the maneuver.

pharmacotherapy. Table 1 provides details about the 31

André et al. used a neck brace in one group, in addition

intervention strategies used in each study.

to movement restriction instructions. According to the ﬁnd-

The analyzed variables in the selected studies included:

20,30,32,33 20 ings of this study, the movement restrictions after ORM do

vertigo, positional nystagmus and postural

33 not inﬂuence outcomes. These data are in concordance with

balance, the number of necessary maneuvers for remission 37

31,32 the international guideline elaborated by Fife et al., which

of symptoms and the quality of life by Dizziness Handicap

31,33 classiﬁed movement restrictions as ‘‘Recommendation U,’’

Inventory (DHI) score, and functionality by the Vestibular

30,34 therefore, there are not enough data to support its use in

Disorders Activities of Daily Living scale (VDADL).

clinical practice.

31 33

Only the studies of André et al. and Ribeiro et al.

Discussion evaluated quality of life after management of BPPV. They

concluded that the Epley maneuver improves patient’s DHI

The increment of older population around the world score, which indicates that this procedure is effective to

will require special attention government health services. decrease the impact of the vertiginous symptoms. Similar

Comorbidities related to the aging process underlined by the ﬁndings are found after the treatment of people with VPPB

deﬁcit in physiological, cognitive and social functions, con- in other age groups.

tribute to the development of diseases in multiple biological According to number of maneuvers, the studies that used

systems. BPPV is the most common cause of vestibular ver- ORM varied from 1 to 3 maneuvers in general. Four studies

20,32,33

tigo and one of the otoneurological conditions that has applied 1 --- 3 maneuvers in the same session. Tw o

the highest prevalence in the geriatric population, lead- studies performed one maneuver per session with a range

ing to strong impact on the health and quality of life of of 1 --- 3 maneuvers (sessions) among groups and concluded

35 30,31

these individuals. Non-pharmacological alternatives for its that the ORM was effective for symptom remission.

treatment, including the ORM, represent an important ther- Korn et al. suggest that consecutive maneuvers in the

apeutic opportunity as a result of absence of side effects same session seem to be more effective than only one

risks commonly seen in older people. maneuver per session. On the other hand, Kasse et al.

Effectiveness of Otolith Repositioning Maneuvers and Vestibular Rehabilitation 113 (VR)

and

EG of

score CG 3

a 6

the

5.8% months;

VR.

negative to

of in

living 6

ﬁnal

0.001).

rate after

in nystagmus)

0.001).

the scores p

< the

present

obtained ( remission pre-treatment (negative

daily

p Rehabilitation cure (

in conclude

post-treatment and

to of

obtained

maneuver

remission;

remission in compared

CG recurrence

VDADL not

EG personalized

remission

EG in vertigo noticed of

patients

after recurrence

total

did

5% nystagmus

of of

0.553). 5 (no from Vestibular

subgroup was

activities

spontaneous continued

months; compared =

signiﬁcant 3.8%

had

differences

vertigo symptoms

6 p 6

difference group in

77% (

received only CG

and

life

test and

of of had

and 21.1%

decrease beneﬁt

and/or to treatment.

the

patients test end, in

patients was were

of (ORM) 94.2% 57.7% 34.6%

Phase: patients the 0.01). 0.009).

Phase:

statistically

VDADL quality < <

18 At G1: G2: G3: A 64% p p

recurrence ( symptoms; in ( - phase. Signiﬁcant months. - positive success There of between Dix-Hallpike maneuvers improvement compared study. - performance symptoms Seven experimental - There 2nd Dix-Hallpike), Results - - Signiﬁcant - 1st who Maneuvers of

days); no

during

month). not days

h); of 60

1 end

mg/d CG:

30 week. groups did

exercises

consecutive for exercises a

week,

the

symptom

(10

12/12 a and

(after

VR symptoms, who

both

1---3. 1 --- 3

de : : Repositioning of

remission until times after

(EG) Cooksey ORM 3

sleeping

mg from in

maneuver);

or sessions

weeks. and week

2 2

antagonists Otolith

: pharmacotherapy month. weeks months

supervised

before remission 1 4 --- 6 5 6 per a maneuvers maneuvers of

(Epley (SLM).

received

: : :

and treatment. of of

spontaneous

get

participants Participants ORM ORM Calcium no treatment.

Phase: Pharmacotherapy. Cawthorne

Phase: not

frequency frequency:

weeks. EG: CG: The G1: G2: G3:

did - Flunarizine each 5 Follow-up protocol VR intervention. Number (Gingko-Biloba---40 underwent program. VR Follow-up symptoms 2nd - (CG). achieve Follow-up resolution. - maneuvers CG: Number - Follow-up: - 1st EG: - people.

effectiveness

the

elderly

test test. test

during during in

measures Intervention

about

during

(BPPV) Vertigo: Positional Functionality Vertigo: Functionality

trials Reported Electronystagmo- Reported

(2) (2) Dix-Hallpike Dix-Hallpike Dix-Hallpike graphy (1) (1) - nystagmus: - (VDADL) - (VDADL) (1) Outcome in

Vertigo

clinical

3.4 4.5

(60---78) (61---82) (71---80) ± ± Positional

(70---78) (72---79)

controlled

74.2 69.3 (mean-median) 74.5 70.5 73 74.5 75

CG: G2: Age years G3: CG: EG: G1: EG: Paroxysmal

randomized 19 8 28 8 52 52 52 canal not

Benign EG: EG: G1: PC-BPPV Did G2: G3: PC-BPPV CG: CG: specify the Sample

from

10) data /

of 4/10)

treatment (PEDro: 4

(PEDro: 10) / al. the

al.

Synopsis in et al.

States Kingdom et

(PEDro:

exercises Resende Salvinelli (2004) United (2003) Brazil (2003) United Table Author Year Country Angeli

114 Ribeiro KF et al. 3

the 4 13 all 3

the

to in

not

1 DHI for the and

the

and

was

number

yet by in while based

for EG found 28.6% after

from

when CG (3---6)

in of physical

the decrease 4

was

negative

median higher, the on

in weeks,

difference was

ranged effective in

evaluated

improvement was 13 the

failure

necessary was

groups;

number procedure EG

0.001).

0.009);

(1---6)

treatment was

= all

test 3

p after p the rate the difference while

the

( progressive

( in

aspects a of

ORM in

after EG

was signiﬁcant for

EG G2

maneuvers

improvement CG, CG. signiﬁcant signiﬁcant, all

treatment

maneuvers

in G1 to the

the

with in

groups;

used

the the of of

was

in in median Dix-Hallpike recurrence period. groups. treatment

score. showed

drugs all

Number Statistically Signiﬁcant Independent The The There The

week comorbidities seniors CG number of (2---6) - gradient, between statistically after maneuver treatment - patients. - in observed (3---7) - compared DHI - aspects Results - - - hours

session 48

neck Mini per

VR + +

for 3 vertigo. per

evaluations to of

week.

one 1

: : maneuver) maneuver); maneuver)

times between maneuver) restrictions maneuver)

remission 2

weeks

13 maneuvers maneuvers time

(Epley (Epley (Epley

: (Epley (Epley

of of informed.

Postural up

+ ORM ORM ORM maneuver;

complete

not ORM ORM

frequency

G1: G2: G3:

session. VR Follow after brace vibrator Number until - CG: Number was - Follow-up: EG: Intervention -

test; test;

Brazilian of aspects

measures by

symptoms: questionnaire.

Dix-Hallpike Clinical Dix-Hallpike Number

VAS;

(3) (2) (2) Vertigo---evaluated by DHI maneuvers. and referred (1) (1) Outcome in

median not

did the

(65---76) (65---78) group

(60---91) 73

(mean-median) 69 by

age provide CG: years Age Authors EG: 67.2

7 7 23 15 15

G1: EG: PC-BPPV G2: G3: PC-BPPV Ductolithiasis CG: Sample ) 10) / 2 Continued

al. (

al.

et 10)

/ et 1

(PEDro:

Ribeiro (2016) Brazil Table Author Year Country André (PEDro: 7 (2010) Brazil

Effectiveness of Otolith Repositioning Maneuvers and Vestibular Rehabilitation 115 VDADL, all

in in

group Maneuver. were

all

group

life dynamic

in Scale;

were

groups groups of

group’s there

within

improvement signiﬁcantly

balance within

differences Liberatory both Analog

In groups signiﬁcant balance

was

quality

regarding

no between group. balance,

group.

Visual and

tests. Semont standing

signiﬁcant

there

measures. experimental found parameters

However,

between signiﬁcant

all standing

VAS, the

control SLM,

in the no dynamic

were

the differences Conversely,

symptoms groups. Index; balance However,

outcome

intragroup

experimental were

regarding

differences Gait

majority

both

No Concerning There

Rehabilitation; the dynamic between balance comparisons, dizziness signiﬁcant aspects. found improvement showed tests - - differences for improved. Results -

Dynamic VR

DGI,

Vestibular session.

balance VR,

per

week.

1 --- 3

a Inventory; canal;

times maneuver) maneuver)

2 weeks

: Handicap posterior

13 maneuvers

: (Epley the (Epley

ORM ORM Dizziness

frequency

CG: VR Follow-up Number EG: Vertigo DHI,

03;

by and

Positional

Group of

measures Intervention

G3,

02; Postural Quality computadorized VAS;

Paroxysmal

posturography (3) DGI; (2) Vertigo---evaluated by life---evaluated (1) DHI. balance---evaluated by Outcome Group in

Benign

G2,

01;

(72---76)

PC-BPPV,

(65---78)

Group

73.5 (mean-median) 69

G1, scale;

CG: Age years EG:

Living group;

7 7 canal not

Daily

EG: Did CG: specify the Sample of control

CG,

) Activities

group;

10) / 7 Continued

al. ( Disorders

1 (PEDro:

experimental

Vestibular (2016) Brazil Table Author Year Country Ribeiro EG,

116 Ribeiro KF et al.

Table 2 Methodological analysis by PEDro score of clinical trials about the effectiveness of Otolith Repositioning Maneuvers

(ORM) and Vestibular Rehabilitation (VR) exercises in the treatement of Benign Paroxysmal Positional Vertigo (BPPV) in elderly

people.

Angeli et al. Resende Salvinelli André et al. Ribeiro Ribeiro

2003 et al. 2003 et al. 2004 2010 et al. 2016 et al. 2016

1. Eligibility criteria were Yes Yes Yes Yes Yes Yes

speciﬁed

2. Subjects were randomly Yes Yes No Yes Yes Yes

allocated to groups

3. Allocation was concealed No No No No Yes Yes

4. The groups were similar at Yes Yes No No Yes Yes

baseline regarding the most

important prognostic indicators

5. There was blinding of all No No No No No No

subjects

6. There was blinding of all No No No No No No

therapists who administered the

therapy

7. There was blinding of all No No No No Yes Yes

assessors who measured at least

one key outcome

8. Measures of at least one key Yes No Yes No Yes Yes

outcome were obtained from

more than 85% of the subjects

initially allocated to groups

9. All subjects for whom outcome No No No No No No

measures were available

received the treatment or

control condition as allocated

or, where this was not the case,

data for at least one key

outcome was analyzed by

‘‘intention to treat’’

10. The results of between-group Yes Yes Yes Yes Yes Yes

statistical comparisons are

reported for at least one key

outcome

11. The study provides both point No Yes Yes No Yes Yes

measures and measures of

variability for at least one key

outcome

Score 4/10 4/10 3/10 2/10 7/10 7/10

conducted a quasi-experimental study in 33 older patients improvement referring to functionality by performing ther-

with BPPV and performed the ORM only once per session, apeutic exercises; however, there are not reports denoting

then repeated weekly until symptoms and nystagmus improvements in BPPV symptoms and signs (vertigo and

disappeared (remission), and also concluded that ORM nystagmus). Angeli et al. also used VR exercises in elderly

was effective. Therefore, despite ORM being an effective people with BPPV and randomly assigned the patients into 2

intervention for BPPV in elderly regardless of the protocol groups in the ﬁrst part of the study: ORM and no treatment.

performed by the studies, it is not possible to propose After one month, those patients who did not respond to

a standard number of maneuvers, or if they should be treatment were enrolled in the second part of the study and

performed in the same session or in different ones. were treated with an individualized combination of ORM

Only one study that did not use ORM as therapeutic and VR, and then reevaluated 3 months later. The authors

proposal was found, but its main intervention was VR concluded that the maneuvers are more effective compared

exercises for an elderly sample. They applied Cawthorne to no treatment, and VR exercises can be added to ORM to

and Cooksey exercise protocols associated to Gingko- improve results in the treatment of BPPV in elderly people.

Biloba in experimental group and only drug intervention Furthermore, Angeli et al. observed a considerable rate

in the control group. The authors obtained signiﬁcant of symptoms recurrence in elderly who only underwent ORM

Effectiveness of Otolith Repositioning Maneuvers and Vestibular Rehabilitation 117

and they suggest that VR exercises can decrease recurrence standard protocol. There is a lack of robust methodological

rate of BPPV. They stated that this protector effect can be studies that used VR in this population, thus it is not

more evident in elderly people. The study conducted by possible to conclude that this intervention is effective. It

Ribeiro et al. also aimed to verify the recurrence rate seems that the movement restrictions after maneuver do

between the group that performed only ORM and the group not inﬂuence results. Overall, there is sparse evidence from

that performed VR associated to ORM, but there was not sta- methodologically robust clinical trials that have examined

tistically signiﬁcant difference between the groups. Some the effects of ORM and VR exercises for treating BPPV in the

studies have shown that VR exercises in younger and older elderly population. Randomized controlled clinical trials

patients with BPPV are more effective alone when compared with comprehensive assessment of symptoms, quality of

40,41 24

to no treatment or placebo treatment. Silva et al. ana- life, function and long-term follow up are warranted.

37,42

lyzed two international guidelines and considered VR

exercises as possibly effective, becoming a secondary option

Conﬂicts of interest

in the treatment of BPPV.

The majority of selected articles provide short-term

The authors declare no conﬂicts of interest.

results ranging from 4 weeks to 13 weeks post-follow up.

Only the study of Salvinelli et al. presented a longer follow

up of six months and they observed a higher rate of symp- References

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43 18

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