Abstract
This chapter reviews common and novel rehabilitation strategies provided to older patients with dizziness and imbalance. The overview provides a description of the role of rehabilitation providers in screening older adults with complaints of dizziness using specific assessment tools related to risk of falling and quality of life. We also provide a description of the role of rehabilitation providers in treating older adults with dizziness using common vestibular rehabilitation exercises and present theories related to functional recovery for specific vestibular disorders. Also, the overview provides a description of promising innovative rehabilitation strategies and technologies that might enhance recovery of older adults with vestibular disorders.
Keywords
Dizziness, Elderly, Novel rehabilitation technologies, Vestibular rehabilitation
Introduction
Dizziness is a common problem in the elderly (65 years and older), with a prevalence between 13% and 38% depending on the population studied. Dizziness affects the lives of older adults and is associated with restrictions in activities of daily living, worsening of cognitive status, fear of falling, and an increased risk of falling. Dizziness and its relationship to falls are of particular concern because falls pose a serious threat for older adults. Of older adults who fall, 10% sustain a major injury, including head injury, hip fractures, or dislocation. Of those who fracture their hip, 20% die within 1 year. Such consequences not only suggest the disabling nature of dizziness and imbalance but also demonstrate the detrimental repercussions of dizziness in older adults.
Dizziness is an imprecise term used by patients to describe symptoms of vertigo, syncope, lightheadedness, disequilibrium, and other non-specific sensations. Each of these terms is defined and linked to a host of diagnoses listed in Table 19.1 . Dizziness may stem from central disorders and/or peripheral vestibular disorders. Central disorders that give rise to dizziness include cerebrovascular disease/vertebrobasilar insufficiency, multiple sclerosis (MS), Parkinson disease (PD), tumors, normal-pressure hydrocephalus, and global atrophy. Although central disorders appear in only 8% of patients with dizziness, they are strong predictors of falls, with more than 50% of patients with central disorders falling more than twice a year. Of patients with central disorders and history of frequent falls, 12%–42% sustain head injury or hip fracture.
| Symptom | Description of Symptom | Associated Pathologies |
|---|---|---|
| Vertigo | Illusion of movement of the body or spinning of the environment Cause: peripheral or central vestibular disorder |
|
| Syncope | Loss of consciousness that is not associated with illusion of movement Cause: vascular disorder |
|
| Disequilibrium | Sensation of imbalance without illusion of movement or loss of consciousness Cause: visual/somatosensory impairment |
|
| Other nonspecific forms | Vague floating sensation that does not follow the description of any other form. Cause: not particular to a specific system |
|
a People with complete bilateral vestibular lesion do not complain of dizziness. Their chief complaint is “oscillopsia,” which is often described as visual jumping or environment moving.
Dizziness may also stem from peripheral vestibular disorders. In contrast to central disorders, peripheral disorders are considered the principle cause of dizziness, appearing in 40%–50% of patients with dizziness. Peripheral vestibular disorders constitute a host of diagnoses ( Table 19.1 ), with benign paroxysmal positional vertigo (BPPV) being the most common. Peripheral disorders result in recurrent falls in approximately 25% of patients, and up to 10% of these patients sustain serious injuries.
It is worth noting that dizziness can stem from a combination of peripheral and central disorders in 20%–40% of patients. In addition, dizziness may occur from causes unrelated to the vestibular system, such as cardiovascular disorders, medication and polypharmacy, age-related structural deterioration of the vestibular system, and psychogenic disorders.
Many types of dizziness, when assessed appropriately, can be managed with vestibular rehabilitation exercises (VREs). VREs may be blended with novel technologies such as virtual reality or the Nintendo Wii system. VREs have been shown to improve dizziness, quality of life, and postural control and reduce the risk of falling.
In the next sections, the role of rehabilitation providers in screening, assessing risk of falling, assessing quality of life, and managing patients with dizziness is illustrated. Also, VREs and theories related to functional recovery of certain conditions of dizziness are discussed. In addition, novel rehabilitation technologies for older adults with dizziness are described.
The Role of the Rehabilitation Provider in Evaluating Patients With Dizziness
The evaluation of older adults with dizziness by rehabilitation providers generally includes screening, assessment of fall risk, and assessment of quality of life.
Screening
Because dizziness stems from many causes, rehabilitation providers need to work with physicians and other healthcare providers to determine the cause and recommend the optimal treatment strategy. To do that, rehabilitation providers can screen patients with dizziness using a classification system that places the patients into three groups: red flags, yellow flags, and green flags. Red flag screening involves assessing patients with dizziness for signs, symptoms, or symptom behavior indicative of serious pathologies ( Table 19.2 ). Yellow flag screening involves assessing patients for the presence of behavioral or nonbehavioral disorders. Behavioral disorders that may be associated with dizziness include panic disorders, phobic disorders, and depression. Nonbehavioral disorders include PD, stroke, head injuries, MS, migraine (not common among older adults with dizziness), and musculoskeletal disorders. Green flags indicate patients whose dizziness stems from primarily peripheral vestibular disorders, and the assessment involves determining whether the patient has BPPV, unilateral vestibular hypofunction, or bilateral vestibular loss.
Symptoms in patients with dizziness that may indicate the presence of serious pathology
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a Symptoms that occur in the period between the triggering factor and the onset of dizziness and include lightheadedness, pallor, salivation, blurred vision, or increased heart rate.
This screening process of dizziness can aid the rehabilitation provider and the physician in determining the best management strategy. For red flags, patients are less likely to benefit from VREs; these patients require specialized, often urgent medical attention that could involve medication or surgery. For yellow flags, patients may benefit from VREs; however, the effect of VREs may be lessened or delayed because of the presence of concomitant disorders, vestibular/ocular motor impairment, or catastrophic emotional reaction to dizziness. As such, the concomitant disorders or impairments should be treated as the patient is receiving VREs, which would likely improve the results of VREs. For green flags, patients are more likely to benefit from VREs, and as such, rehabilitation providers may treat these patients independently. If an acute vestibular hypofunction is identified (within 4 weeks), a medical referral for consideration of steroids is advised.
Assessment of Falling Risk and Quality of Life in Older Adults
The rehabilitation provider uses a multidimensional assessment of fall risk and quality of life. The assessment starts with history taking to identify frequent fallers (i.e., more than twice a year), use of medication(s) associated with increased fall risk, fear of falling, and functional limitations in daily living activities. The assessment continues by identifying physical factors related to falls, such as visual acuity, cognitive status, need for an assistive device, balance, orthostatic vital signs, sensation, and fallers’ vital signs. Fallers’ vital signs include gait speed, gait variability, the stop walking when talking test, and the Timed Up and Go (TUG) test.
Similar to measuring blood pressure and body temperature to screen for general health status, gait speed can also be used to assess general health status and disability in older adults. Age-appropriate gait speed is reflective of health status because gait requires body support, muscle power, coordination, and timing. Thus the interaction of these factors to produce an adequate gait speed can be viewed as a proxy for effective interaction of the musculoskeletal, nervous, and cardiopulmonary systems.
When testing gait speed, it is important to specifically attend to gait fluctuations during slow walking; such fluctuations are predictive of falls. Also, it is important to observe whether a patient stops walking when talking because such behavior is linked to fall-related anxiety. Gait speed is a suitable measure to assess fall risk and quality of life because it provides quick, inexpensive, and reliable information regarding quality of life and risk of falling. Therefore improvement in gait speed has been shown to be a good indicator of treatment effectiveness, and slowing of gait speed can indicate a worsening medical condition.
The TUG test is often used to assess a person’s ability to rise from a chair, ambulate, and turn, which can be difficult for individuals with central and/or peripheral vestibular disorders. The time (in seconds) required to perform the test is strongly correlated with functional mobility. People who can complete the TUG within 20 seconds are found to be independent in transfer tasks such as moving from the wheelchair to a bed, and have sufficient gait speed (0.5 meters/second) for limited community mobility. Podsiadlo and Richardson reported that people who walk very slowly (0.5 meters/second) were not able to ambulate freely in the community. Older adults who took 13.5 seconds or longer to perform the TUG test were classified as frequent fallers, with an overall correct prediction rate of 90%. Also, people who required more than 13.5 seconds to perform the TUG were 3.7 times more likely to have reported a fall in the previous 6 months. The sensitivity of the TUG test for fall prediction in persons with vestibular disorders is 80%, and the specificity is 56% for those who score greater than 11.1 seconds on the test. Generally, slow completion of the TUG test is associated with an increased impairment of function and warrants referral for rehabilitation, particularly if symptoms listed in Table 19.3 are present.
| Positive Dix-Hallpike test Positive Romberg test Dizziness with movement of the head Dizziness associated with neck pain Slow gait History of falling two or more times within the past 6 months Inability to rise from a chair without using arm support Fear of falling that prohibits the person from participating in activities of interest Arrhythmic gait |
The Role of the Rehabilitation Provider in Treating Patients With Dizziness
Dysfunction in the vestibular system can result in dizziness, postural imbalance, increased risk of falling, and ultimately a lower quality of life. To rehabilitate the vestibular system, VREs are commonly recommended ( Table 19.4 ). Currently, VREs are utilized by various practitioners but mainly physical therapists specializing in vestibular physical therapy.
| Type of the Exercise | Reason for the Exercise | Description |
|---|---|---|
| Vestibulo-ocular reflex (VOR) adaptation exercises | Help the central nervous system to adapt to a change or loss in the vestibular system input | VOR × 1: The patient moves the head to both sides (yawing or pitching) while keeping his eyes fixed on a stationary target ( Fig. 19.1 ) VOR × 2: The head and the hand holding the target are moving in opposite directions with the eyes fixated on the target |
| Habituation exercises | Involves repeated exposure to a provoking stimulus or movement so the pathologic response to the stimulus is reduced | The therapist selects movements that provoke the patient’s symptoms, and the patient repeats these motions until the patient no longer reacts adversely to the stimuli |
| Substitution exercises | Help patients improve one channel of sensory input (vision, somatosensory, proprioception) by blocking sensory inputs from the other two channels | To challenge proprioception, the patient closes the eyes and tries to maintain balance while standing |
| Optokinetic stimulation | Can help to desensitize people who are very sensitive to motion in the periphery and also who are motion sensitive | Example: Have the patient sitting and spin an umbrella about 1 m away from them in a circle while they look at the center of the umbrella |
Improvements in a variety of areas after VREs have been reported regardless of patient age. VREs were found to be effective in patients with vestibular disorders (even with a history of symptoms lasting over 20 years), patients with PD, patients with anxiety and depression, and in postsurgical patients, such as after removal of an acoustic neuroma.
After VREs, patients show dramatic improvements in their perception of dizziness, ability to perform activities of daily living, emotional status, and improved static and dynamic balance. Positive effects of VREs are reported to occur as early as 3 weeks after initiation of therapy; for those who do not receive VREs, improvement may take as long as 3 months. This suggests that VREs expedite improvement.
The effect of VREs on gait and balance may be significantly enhanced if the performance of VREs is closely monitored ; if VREs are combined with flexibility, cognition, sensory interaction, and muscle strength exercises ; or if VREs are combined with canalith repositioning maneuvers when appropriate. Combining VREs with other interventions might be preferred when a patient has a concomitant disorder or a poorer baseline status; this combination can be achieved without increasing the number of treatment visits.
The Effect of Vestibular Rehabilitation on Various Conditions
Table 19.5 summarizes conditions that improve with vestibular rehabilitation and positive outcomes that were found with each condition. Theories that underlie why vestibular rehabilitation may be effective are described in Table 19.6 .
| Patient Diagnosis | Noted Improvement With Vestibular Physical Therapy |
|---|---|
| Benign paroxysmal positional vertigo | Subjective report of vertigo, nystagmus, quality of life |
| Unilateral vestibular disorders | Fall risk, vision, balance, quality of life |
| Chronic peripheral vestibular dysfunction | Vestibulo-ocular reflex gain and dizziness, standing balance, emotional status (i.e., anxiety) |
| Bilateral vestibular dysfunction | Postural control, gait speed, dizziness, vision |
| Vestibular neuritis | Ocular torsion (i.e., nystagmus), postural control, ambulation skills and gait |
| Post-acoustic neuroma resection | Postural control, dizziness, motion sensitivity |
| Meniere’s disease | Self-report of symptoms, balance, dizziness, motion sensitivity |
| Anxiety associated with vestibular disorder | Anxiety, subjective report, postural control, presence of nystagmus, and ability to cope with dizziness |
| Cervical vertigo | Postural stability, decreased neck pain, intensity of dizziness, postural sway |
| Head injury | Gait improved, postural stability, less dizziness, gaze stability |
| Cerebellar disease and dysfunction | Self-perception of symptoms, postural control, gait, decreased risk of falling |
| Multiple sclerosis | Subjective report of dizziness and postural control |
| Parkinson’s disease | Subjective complaint of vertigo |
| Theory | Brief Description | Function | Malfunction | Exercises |
|---|---|---|---|---|
| Vestibulo-ocular reflex (VOR) adaptation | A reflex mediated by a three-neuron arc:
| Enables stabilization of a visual image on the retina during head movement Produces an eye movement of equal velocity to head movement but in the opposite direction. When the head moves to the right, the eyes instantaneously move to the left at the same speed of the head. This ratio of eye movement velocity opposite to head movement velocity is referred to as VOR gain | The eyes are not moving in the opposite direction of the head with the same speed as the head. The image stabilization on the retina during head movement is affected resulting in corrective eye movements | VOR × 1 and VOR × 2 ( Fig. 19.1 ). It is believed that these exercises decrease symptoms of dizziness and improve function in elderly patients with vestibular hypofunction |
| Cervicoocular reflex (COR) | Eye movement induced by neck stimulation during trunk rotation while the head is stationary | Interacts with the VOR to drive eye movement based on input from cervical proprioceptors | The COR may be adaptable in some but not all people with vestibular hypofunction. This response is called for when needed, although not all patients have the ability to utilize the COR | Body moving with the head stable |
| Vestibulo-spinal reflex (VSR) | Input regarding body position is sent from semicircular canals and vestibular nuclei to medial and lateral vestibulospinal tracts | Stabilize the body via increasing extensor muscle activity on the side to which the head is turned with concomitant flexion activity on the other side | Inability to maintain balance | Balance training and gait exercises |
| Sensory reweighting | Sensory reweighting consists of:
| There are three sensory modalities through which the body maintains balance or controls posture | When somatosensation, vision, or vestibular function is lost or impaired, the central nervous system readjusts to become more reliant on the remaining intact modalities | During vestibular rehabilitation the patient is repeatedly exposed to various sensory information so the brain can optimize postural responses to maintain balance |
Peripheral Vestibular Disorders
Benign paroxysmal positional vertigo
Even though dizziness is very common among older adults, it seems that BPPV is underestimated in this population , possibly because the majority of older adults (61%) do not report dizziness unless they are asked. This is concerning because older adults with BPPV have a higher prevalence of falls compared to those without BPPV. These findings suggest that older adults should be screened for dizziness even if they do not report it as a symptom.
Clinically, BPPV can be easily identified by provoking symptoms using the Dix-Hallpike test (see Chapter 9 ). If BPPV is noted, patient referral to clinicians who are trained in canalith repositioning procedures (CRPs) is warranted. Based on strong evidence, CRPs are reported to be very effective in treating symptoms of BPPV and improving the perception of verticality. Shepard and Telian reported complete resolution of symptoms in 100% of their population after performing CRPs. If CRPs do not resolve patients’ symptoms, it is likely that another type of VRE would improve symptoms; a combination of the CRPs and VREs may also improve outcomes.
Special consideration must be taken into account when testing or treating older adults with BPPV. Because skilled or self-administered repositioning maneuvers typically require approximately 30 degrees of neck extension and 45 degrees of neck rotation, patients with spine conditions must be addressed cautiously. Patients with neck or low back pain should have cervical or lumbar support during CRP because limited neck or trunk mobility can be affected by quick and unanticipated movements, which might reproduce the patient’s pain. Patients with osteoporosis or Paget’s disease are at risk for pathologic fractures. Most importantly, patients with severe rheumatoid arthritis must be treated with great care because ligamentous laxity, especially within the upper cervical spine, is very common, and moving the neck beyond normal limits may cause serious injury or a lesion to the spinal cord. Thus it is important to screen patients with BPPV for these conditions before beginning testing or intervening.
Chronic unilateral vestibular dysfunction
Patients with chronic unilateral vestibular dysfunction are good candidates for VREs and have a good prognosis. Ninety percent of patients dramatically improve or completely recover postural control and disability status after rehabilitation, provided that the patient has no central disorders. Improvements in these patients were reported in dizziness symptoms, postural control, as well as physical and emotional status after VREs.
Improvements after VREs are correlated with plasticity and compensation mechanisms in the central nervous system (CNS). This correlation between VREs and plasticity is expressed as changes in the vestibulo-ocular reflex (VOR), enhanced balance and reduced “retinal slip” or apparent motion of visual images. Improvements in dizziness, postural control, and quality of life have been reported in patients with chronic vestibular disorders after receiving a combination of VREs and visual stimuli by digital images. Based on strong evidence, using VREs for patients with unilateral or bilateral vestibular hypofunction is suggested in a recent practice guideline.
Bilateral vestibular dysfunction
Although full recovery of symptoms does not occur in patients with bilateral vestibular dysfunction, patients can benefit from VREs. Improvements in these patients have been reported in gait speed, stair negotiation, and postural stability. Patients with bilateral vestibular loss fall more frequently than others with vestibular loss and age-matched controls. As a result, exercise programs are designed to decrease the likelihood of falling and to minimize the risk of injury from falling. Patients with bilateral vestibular loss should also receive specific instruction regarding how to get up off the floor after a fall.
Vestibular neuritis
VREs can assist the patient with vestibular neuritis to recover functional abilities after an episode. The aim of VREs is to promote neural plasticity in the CNS and to accelerate central compensation via adaptation of the VOR and through enhancement of vestibulospinal reflexes and distal somatosensory optimization ( Table 19.4 ).
After administration of VREs for patients with vestibular neuritis, Strupp et al. reported faster recovery of postural stability in stance, vestibulospinal compensation, and earlier resumption of normal daily activities (e.g., playing tennis or returning to work) compared with a control group. Also, early VREs seem to produce satisfactory outcomes in performing daily functions within 2 months on average.
Meniere’s disease
Patients with Meniere’s disease may benefit from referral to vestibular rehabilitation providers during the inactive phase of the disease to receive support and education about the disease process. The rehabilitation provider assesses the patient’s current balance abilities and strength and provides advice regarding how to prevent falls during an active attack of the disease. Patients with Meniere’s disease and vertigo receiving medical therapy or minimally invasive techniques may benefit from VREs to improve balance and dizziness symptoms associated with the disease and its effects on the involved vestibular system. Exercises such as gaze stabilization, visual acuity, and static and dynamic postural exercises were found to have some positive effect on balance function and gait.
Functional dizziness (functional movement disorder)
Functional dizziness refers to changes in the functioning of the organ system rather than structural defects. Functional dizziness includes phobic postural vertigo disorder, chronic subjective dizziness, and persistent postural-perceptual dizziness. In neurotology clinics, functional dizziness is reported in 10% of patients with vestibular symptoms. Functional dizziness is not the same as psychogenic comorbidities (e.g., anxiety and depression) that may occur concomitantly with structural defects of the vestibular system. Compared with functional dizziness, the prevalence of psychogenic comorbidities is reported to be higher among patients with BPPV (51%), bilateral vestibular loss (24%), and vestibular neuritis (37%).
Whether the patient has functional dizziness or a vestibular defect with associated psychogenic comorbidities, treatment should include a combination of VREs, psychological therapy, and possibly antidepressant medication. This combination of interventions has been shown to improve self-reported dizziness symptoms and postural control.
Postsurgical conditions
The use of VREs aids in optimizing results both before and after ablative vestibular surgery and acoustic neuroma resection. A rehabilitation program is recommended especially if reduction of dizziness-related symptoms (e.g., vertigo or postural instability) after the surgery does not match the surgeon’s expectations. After surgery, dizziness can be the result of incomplete or delayed postoperative compensation. Instead of proceeding to additional surgery, a trial of VREs is advised when incomplete compensation is suspected. Receiving VREs after surgery has been shown to reduce self-reported dizziness, nystagmus, disequilibrium, and motion sensitivity and improve postural and dynamic stability. These improvements can occur as early as 1–3 weeks after the postsurgical VREs.
A few reports have suggested that preoperative VREs may hasten patients’ recovery after ablative surgery. Preoperative VREs that include movement of the head help patients avoid postoperative vertigo and symptoms of acute vestibular loss. A preoperative VRE program starts 14 days before the surgery and continues into the first weeks after surgery. Preoperative VREs can improve postural stability for up to 6 months after ablative surgery.
Central Vestibular Disorders
Patients who complain of dizziness due to central disorders or mixed central and peripheral disorders are harder to treat with VREs than those with only peripheral disorders.
Parkinson’s disease
Falls are reported in 38%–68% of patients with PD. In 12% of patients with PD, the cause of a fall is attributed to dizziness. Thirteen percent of patients living with PD who fall sustain a fracture. The risk of a fall and the report of dizziness in patients with PD can be significantly reduced by VREs. Vestibular exercises are believed to play a key role in plasticity and compensation mechanisms within the central vestibular system. Vestibular rehabilitation for patients with PD seems to be effective in improving self-reported dizziness, activities of daily living, gait speed, balance, and, most importantly, the risk of falling. Such improvements seem to persist at least 1 year after the rehabilitation program.
Falls in patients with PD can be caused by impairments other than dizziness, such as tremor, freezing, retropulsion, and rigidity. Loss of postural reflexes is a cardinal manifestation of PD and likely represents complex interruption of signals within and between several body systems. In any case, falls in patients with PD should be assessed and addressed, and in addition to consideration of personal safety issues, management should include balance and muscle strengthening exercises, which may be combined with vestibular rehabilitation if necessary.
Multiple sclerosis
Dizziness is a common complaint of patients with MS. Vertigo is the initial symptom in approximately 5% of patients with MS; 50% of patients with MS experience dizziness at some time during the disease course. After rehabilitation, improvements in self-reported dizziness, the TUG test, gait speed, and postural and dynamic balance have been reported in patients with MS.
However, dizziness is not the only important clinical manifestation in patients with MS. Other symptoms such as fatigue, muscle weakness, sensory abnormalities, visual impairment, and depression occur in patients with MS. Consideration of these symptoms along with dizziness is likely to improve treatment outcomes.
Head injuries
Head injuries are commonly associated with reports of dizziness or vertigo, especially in older adults. Dizziness may result from hemorrhage of the brainstem or the brain if trauma is severe. If trauma is mild and there are no fractures or hemorrhage, dizziness may be caused by damage to the inner ear or vestibular nerve or may be attributed to concussion, posttraumatic BPPV, or perilymphatic fistula. Dizziness related to head injuries can persist for 6 months or more after the event.
Dizziness after head injury is predictive of delayed recovery, particularly if the patient has vestibulo-ocular dysfunction. This could be due to injury of the CNS, which can impair compensatory mechanisms in the central vestibular system. Dizziness caused by head injuries can be effectively treated with vestibular rehabilitation. After head injury, patients who developed unilateral vestibular dysfunction had improved self-reported dizziness and postural stability after participation in a vestibular rehabilitation program. However, careful consideration of comorbid symptoms (e.g., muscle tone abnormalities, lack of coordination, cognitive impairment, concussive symptoms of fatigue, fogginess, headache) optimizes the results of an exercise program.
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