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Physiotherapy works - Vestibular rehabilitation

File 118509Vestibular rehabilitation (VR) is effective in reducing dizziness and vertigo and associated falls and improving quality of life in people with disorders involving balance mechanisms

Good balance is essential for daily life, from getting out of bed to crossing the road. A healthy balance system uses information from the brain, inner ears, eyes, and joints, and enables people to see clearly when moving their head. (1)

Balance disorders and dizziness are a growing public health concern across all age groups. Prevalence increases with age and these disorders are some of the most common complaints reported to GPs by older patients.(1) Untreated, they result in worsening unsteadiness, loss of confidence and anxiety, difficulty with concentration and memory, inactivity, loss of independence, an increased risk of falls and costly falls-related injuries. (1) (2)

What causes dizziness?

Size of the problem

  • Almost 1 in 4 adults under 65 years report dizziness or vertigo, often causing occupational difficulties or preventing employment but less than 25 per cent had received treatment(10)
  • About 20 per cent with vestibular vertigo avoid leaving the house and 41 per cent require sick leave(7)
  • Over 38 per cent of those aged over 85 years fall annually; half in combination with dizziness or blackouts
  • 2.4 per cent lifetime prevalence of BPPV alone, with only 8 per cent receiving effective treatment.(8-10)

The most common form of dizziness and balance disorder is BPPV (Benign Paroxysmal Positional Vertigo), a disorder of the inner ear resulting in episodes of intense dizziness on certain head movements.

Other causes include side effects from medication or alcohol, brain disorders such as stroke, concussion or cerebellar degeneration, cardiac problems and anxiety.

What is vestibular rehabilitation?

VR is an exercise-based programme to encourage the central nervous system to compensate for problems in the inner ear. Following thorough examination, specialist physiotherapists develop personalised exercise-based management plans including home exercise programmes.

A management plan may include:

  • Eye and head movement exercises(2)
  • Exercises to improve standing balance and walking(3)
  • Specific techniques to reposition fragments in the inner ear which cause dizziness in BPPV(2)
  • Education and advice on activities of daily living to improve confidence & function
  • Advice on falls reduction/prevention.

Significant improvement is achieved in:

  • 80 per cent of patients with unilateral vestibular loss (e.g. labyrinthitis, acoustic neuroma surgery)(3)
  • 80 per cent of patients with BPPV after one treatment session(4)
  • Patients with a central cause (e.g. stroke) may show some improvement
  • Use of VR in concussion,(5) migraine,(6) and nonspecific balance loss of the elderly may be helpful.

Physiotherapists are ideally placed to provide early screening and intervention to minimise the impact on daily life of balance and dizziness disorders.

Specialist physiotherapists provide personalised VR programmes which are clinically effective reducing distressing symptoms and improving quality of life.

Case study

Cost of ill health

  • 80 per cent of unexplained fallers attending A&E had possible vestibular loss, 41 per cent had vertigo, with 30-40 per cent admitted to hospital (11)
  • Fallers use more than 4 million bed-days, cost the NHS £2.3 billion and incur total costs including social-care of £5.6 billion.(12) Costs per faller are £1,720, rising to £8,600 for those seeking medical care (13)
  • The costs of BPPV are significant; American healthcare costs to diagnosis BPPV alone approach $2 billion (14)
  • Untreated dizziness/balance disorders may lead to anxiety, avoidance strategies and increased risk of falling, impacting further on resources.(8, 15)

Over a six month period, the introduction of an award-winning Specialist Physiotherapy and Audiology service for patents referred with balance/dizziness disorders at Aintree Hospitals, Liverpool, has reduced waiting times and achieved excellent patient satisfaction. 80 per cent of patients are now managed exclusively in physiotherapy led clinics with 52 per cent assessed, diagnosed and treated in one session.

References

1.Sturnieks DL, St George R, Lord SR. Balance disorders in the elderly. NeurophysiolClin. 2008 Dec;38(6):467­-78.

2. Bhattacharyya N, Baugh RF, Orvidas L, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2008 Nov;139(5 Suppl4):S47-­81. http://oto.sagepub.com/content/139/5_suppl/S47.full.pdf

3. Hillier Susan L, McDonne llM. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database of Systematic Reviews. 2011(2):Art. No.: CD005397. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005397.pub3/abstract005397.pub3/abstract

4. Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 1992 Sep;107(3):399-­404.

5. Alsalaheen BA, Mucha A, Morris LO, et al. Vestibular rehabilitation for dizziness and balance disorders after concussion. Journal of Neurologic PhysicalTherapy : JNPT. 2010 Jun;34(2):87­-93.

6. Gottshall KR, Moore RJ, Hoffer ME. Vestibular rehabilitation for migraine­ associated dizziness. The International Tinnitus Journal. 2005;11(1):81­-4.

7. Neuhauser HK, Radtke A, von Brevern M, et al. Burden of dizziness and vertigo in the community. Archives of Internal Medicine. 2008;168(19):2118-­24. http://dx.doi.org/10.1001/archinte.168.19.2118

8. von Brevern M, Radtke A, Lezius F, et al. Epidemiology of benign paroxysmal positional vertigo: a population based study. Journal of Neurology, Neurosurgery, and Psychiatry. 2007 Jul;78(7):710­-5. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2117684/pdf/710.pdf

9. Stevens KN, Lang IA, Guralnik JM, et al. Epidemiology of balance and dizziness in a national population: findings from the English Longitudinal Study of Ageing. Age and Ageing. 2008 May1, 2008;37(3):300-­5. http://ageing.oxfordjournals.org/content/37/3/300.abstract

10. Collerton J, Kingston A, Bond J, et al. The personal and health service impact offalls in 85 year olds: cross­-sectional findings from the Newcastle 85+ cohort study. PloS one. 2012;7(3):e33078. http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0033078

11. Pothula VB, Chew F, Lesser TH, et al. Falls and vestibular impairment. Clinical Otolaryngology and Allied Sciences. 2004 Apr;29(2):179-­82. URL: http://onlinelibrary.wiley.com/doi/10.1111/j.0307-7772.2004.00785.x/abstract

12. Tian Y, Thompson J, Buck D, et al. Exploring the system -wide costs of falls in older people in Torbay. London: The King’s Fund;2013. URL: http://www.kingsfund.org.uk/publications/exploring-system-wide-costs-falls-older-people-torbay

13. Craig J, Murray A, Mitchell S, et al. The high cost to health and social care of managing falls in older adults living in the community in Scotland. Scottish Medical Journal. [in press]

14. Neuhauser HK. Epidemiology of vertigo. Current Opinion in Neurology. 2007 Feb;20(1):40­-6.

15. Yardley L, Redfern MS. Psychological factors influencing recovery from balance disorders. Journal of Anxiety Disorders. 2001;15(1):107­-19.

Further information

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