Vestibular disorders can significantly limit an individual’s ability to function adequately in everyday life.1 Vestibular disorders manifest as a variety of signs and symptoms, including dizziness, vertigo, oscillopsia, and imbalance.2 These symptoms affect individuals physically and psychologically, with negative consequences on activities of daily living (ADL) and quality of life (QoL).2–4

About 40% of older adults cease certain ADL due to dizziness.5 Among 15 ADL, walking close to home was considered the most difficult task to perform by older adults with vestibular disorders.6 Environmental factors (poor lighting, supermarket aisles, and crowded places) can elicit symptoms.1,7 Therefore, around 18.5% of those with vestibular disorders avoid leaving their homes.5 Even during symptom remission, patients are worried about the next episode, preventing movements and performing certain tasks.4 These constraints contribute to the high prevalence of low self-confidence, disability, anxiety, depression, and social isolation in individuals with vestibular disorders.3

Each patient is unique, because the same disease can affect their lives differently.8 Therefore, patient-reported outcomes or self-perceived measures, i.e., health perceptions, QoL, and functional status, are important tools to assess debilitating effects related to vestibular disorders.3 These measures capture patients’ personal experience, which is the main goal for improvement in clinical interventions.8

Vestibular rehabilitation (VR) has been used as a treatment to reduce/eliminate symptoms, improve independence in ADL, and increase self-confidence in patients with vestibular disorders.9 A systematic review with meta-analysis10 supports the use of VR to improve subjective measures of dizziness in people with chronic unilateral peripheral vestibular disorder compared with no treatment. However, no conclusions could be made when different VR protocols were compared.10 Another systematic review of VR determined that while randomized clinical trials with samples of older adults are scarce, positive effects with reduction in vestibular symptoms were reported.11

Despite the positive results of the Cawthorne & Cooksey VR protocol,11 this intervention does not incorporate exercises using different bases of support, strength, or dual tasks, which reflect components required to perform daily activities. In previously published data from this clinical trial, reporting on objective balance control variables, we described that a multimodal VR protocol resulted in superior improvements for two static balance tests (Romberg Sensorial Eyes Closed and Unipedal Stance Left Eyes Open) when compared to the conventional protocol.12 This current paper focuses on reporting patient-related outcomes of QoL, emotional data, and functional capacity. The purpose of this study was to compare the effects of the conventional Cawthorne & Cooksey with the multimodal Cawthorne & Cooksey protocols on patient-reported outcomes in older adults with vestibular disorders after the two-month treatment period and the three-month follow-up. A secondary aim was to investigate clinical factors associated with the primary outcome score.

This is a single-blind, randomized controlled trial with a three-month follow-up period (trial registration: ACTRN12610000018011). The study was approved by the Universidade Federal de São Paulo (UNIFESP), Sao Paulo, Sp, Brazil, Research Ethics Committee (no. 1658/09). Details concerning the trial project are described in publications on its study protocol,13 process evaluation14 and effects on balance.12 No deviation from the original design was made after the trial commencement.

Between March 2010 and February 2012, 144 patients with chronic dizziness were referred to VR. Of these patients, 62 were excluded for various reasons, and 82 were eligible for the trial and then randomly assigned to the multimodal (n = 42) or conventional (n = 40) groups. During the clinical trial, 12 patients were withdrawn from the study. Fig. 1 shows the trial flowchart.

Figure 1.

Trial flowchart.

(0.39MB).

Both groups consisted primarily of women (conventional: 67.5%; multimodal: 76.2%) with advanced age (conventional: 74.1 ± 5.9 years old; multimodal: 74.4 ± 6.8 years) and diagnosis of peripheral topographic vestibular disorder (conventional: 47.5%; multimodal: 52.4%). Sample characteristics, the DHI scores, and scores on secondary outcomes were similar between the VR groups (Table 1 and Table 2).

There was no between-group difference on the primary outcome, DHI- total score, after VR (MD: −0.7 95%CI: −9.2, 7.8) and at three-month follow-up (MD: −1.6 95%CI: −9.5, 6.2), i.e. no interaction (differences between group and time points of assessment) (Table 2). In the within-group analysis significant time effects were observed in DHI total score and subscales, i.e., both groups improved after rehabilitation. The post-hoc test showed changes in DHI total score and subscales between baseline and post-treatment and no significant changes between post-treatment and follow-up.

For all secondary outcomes, the between-group analyses showed no differences in changes between VR groups for all time points of assessment (Table 2). The within-group analysis showed significant improvement from baseline to after treatment, which was maintained between post-treatment and follow-up for both VR protocols and for all secondary outcomes (Table 2).

At baseline, nine (22.5%) of the participants in the conventional protocol and 16 (38.1%) of those in the multimodal protocol group presented severe handicap according to a DHI score of ≥60 points. After VR, both groups showed a significant decrease in the number of participants with a severe DHI score (conventional: n = 2, 5.0%, McNemar p = 0.02; multimodal: n = 6, 14.3%, McNemar p = 0.006), which was maintained at follow-up (McNemar p = 1.00) (Table 3). No differences were observed between the VR groups for DHI severity at baseline (Chi-square, p = 0.154), post-treatment (Chi-square, p = 0.265) and follow-up (Chi-square, p = 0.313).

More than half of the patients reached clinical improvement in the DHI (decreased score of ≥18 points) with VR (conventional: n = 22, 55.0%; multimodal: n = 24, 57.1%), and there were no significant differences in changes between protocols (Chi-square, p = 0.845). All participants in the study were used to determine factors that could predict improvement in DHI, with no variables identified (Table 4).

This randomized clinical trial showed that the addition of multimodal exercises did not lead to greater improvement to patient-reported outcomes than the conventional Cawthorne & Cooksey protocol in older adults with chronic dizziness attributed to vestibular disorders. All five patient-reported outcomes evaluated in this trial improved in both groups following treatment and changes remained after a short period. In this clinical trial, only self-perception measures were chosen, since the cause (dizziness) and consequences (functional incapacity) under investigation are subjective phenomena. It is important to highlight that the self-perceived measures consider the patient’s perspective on their performance,28 and sometimes this perception differ from those of health care professionals and/or family members. Regardless of whether the patient’s responses were over or underestimated compared to actual performance, it is imperative to recognize the way patients feel about the interference of dizziness in their daily lives. Patient performance in a daily activity is not only a matter of being physically able, it is important that older adults feel capable and that the task has meaning when performed.

A systematic review and meta-analysis10 of treatment for chronic unilateral peripheral vestibular hypofunction, which including five clinical trials, determined a standardized mean difference between groups of −0.8 (95% CI: −1.0, −0.6) on the DHI (scale 0 to 4), which means approximately 20 points (scale 0–100) in favor of the experimental group versus the control group without treatment. However, differences were non-significant for the DHI when comparing different VR protocols,10 which is consistent with our results that showed improvement for both groups. One study29 reported that the practice of any type of exercise (light or heavy) among older people with dizziness could reduce the risk of low QoL. Thus, more than the type of VR protocol, encouraging exercise in this population can lead to benefits in QoL and in other problems that come with the dizziness symptom, such as avoiding activities, fear of falling, and depression.

In our trial, the sample characteristics of sex, age, and otoneurologic diagnosis, had no association with DHI clinical improvement. According to the Evidence-Based Clinical Practice Guideline from the American Physical Therapy Association (APTA) older adults have the same potential for improvement with vestibular rehabilitation than adults.30 Another study31 with older adults was also unable to determine any association between QoL using the DHI with the type of dizziness (i.e., rotatory or non-rotatory), post-caloric nystagmus assessment, and topographic vestibular diagnosis. The QoL, in patients with dizziness, is so impaired that it seems to be independent of any specific dizziness characteristics or etiology.32 Because QoL is a multidimensional measure, it is improbable that only one characteristic could affect it as a whole.

All outcomes changed with intervention, and improvement was sustained after three months of follow-up. Any benefit acquired by older adults after an exercise program will last depending on continuous participation in the recommended treatment.33 After supervised exercise therapy, it is important that patients with chronic conditions learn how to self-manage their symptoms.

In this trial, the use of home exercise through a booklet to complement the VR protocols is in accordance with the literature recommendations for the treatment of patients with dizziness.30,34 APTA recommend that patients with chronic peripheral disorders under supervised VR sessions should also perform home exercises, at least 20 min per day.30 A VR booklet presents good cost-effectiveness and can help patients with chronic dizziness cope with their symptoms.34

We altered the conventional Cawthorne & Cooksey protocol to provide more functional task-based exercises for older people, without compromising the benefits of the standard protocol, i.e., low cost, easy to administer, well-tolerated by patients. For vestibular compensation and transfer benefits to everyday life, exercises should incorporate daily situations instead of unattractive laboratory situations.35 Since both protocols presented changes in self-perceived measures, we recommend that the therapist consider the patient’s assessment and preferences when choosing the exercises. Older adults are a heterogeneous population, and complaints of dizziness are unique to each patient, as are the behavioral strategies for recovery, so developing an exclusive VR protocol that works for all patients is highly unlikely.35

Limitations of this research can be that patients and therapists were not blinded to the protocol provided, interviewer presence can bias the patient reports and no genuine control group (placebo or no intervention) was used. It is not feasible to blind those doing or delivering exercises. All tests-questionnaires, even those that are objectives, can be bias with patient learning. Regarding a non-intervention group, our sample of patients had a chronic condition that can worsen over time, so denying them treatment would be unethical.

This manuscript is the final report of a comprehensive clinical trial12–14 regarding the effects of VR on older people with chronic dizziness due to vestibular disorders. Patients with dizziness often make considerable adjustments to their lives to continue performing ordinary tasks. VR can offer patients a way to overcome negative feelings (depression, anxiety, fear), decrease limitations in their activities, and regain confidence in their balance and sense of self-control.36 Herein, we have shown that, regardless of the protocol used, VR can change patient-reported outcomes (dizziness intensity, dizziness-related symptoms, depression, fear of falling, and independence in daily activities) in older people. However, a more functional task-based exercises, i.e. multimodal exercises, did not result in better outcome than a more conventional VR program. Further studies should compare the number of sessions per week (one session versus two) and supervised versus booklet home-based exercises in this population.

The authors declare no conflicts of interest.

This study was supported by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), Brazil.