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  • Study: Vestibular Rehab Works Via Both Conventional and Modified Protocols

    Vestibular rehabilitation (VR) improves balance control among elderly individuals with dizziness, but there isn't a clear winner when it comes to whether physical therapists (PTs) should use a conventional or modified VR protocol, according to a new study.

    The research, recently published online in The American Journal of Physical Medicine & Rehabilitation (abstract only available for free), aimed to find out not only if VR actually improved outcomes for older individuals with chronic dizziness due to vestibular disorders, but if one protocol was better than another. For purposes of this study, researchers compared the Conventional Cawthorne and Cooksey protocol (CCC), which authors write "consists basically of eye, head, and trunk exercises," with a "multimodal" Cawthorne and Cooksey protocol (MCC), which they describe as an approach that adds "flexibility, cognition, sensory interaction, and muscle strength exercises" to the mix.

    A total of 82 older individuals with chronic dizziness were divided into 2 groups that participated in 16 VR sessions over a 2-month period (2 50-minute sessions per week for 8 weeks). Both the CCC and MCC protocols consisted of 4 stages, with 1 week focused on exercises performed while lying down and the remaining 3 weeks focused on exercises performed while standing and walking. Participants also received educational information on VR and falls prevention, as well as instructions for daily home exercises.

    In assessing outcomes posttreatment (8 weeks) and 3 months later, researchers relied on the Dynamic Gait Index (DGI) as the primary measure, but they used several secondary measures to get a more complete picture: the timed up-and-go test (TUG)—both TUGcognitive and TUGmanual—the sit-to-stand test, the multidirectional functional reach test, the Romberg and sensorial Romberg tandem and unipedal stance tests, and a hand-grip strength test using a manual hydraulics dynamometer.

    They found that both groups showed a significant improvement in DGI scores, with an average increase of 2.8 points on the 24-point scale between baseline and posttreatment. Additionally, with the exception of the forward functional reach test, the Romberg sensorial (eyes open), and the unipedal stance (eyes closed), "the remaining secondary outcomes showed significant differences between evaluation periods." The gains were sustained at the 3-month follow-up.

    While mostly comparable, researchers noted that the MCC protocol resulted in "superior" results in 2 static balance tests—the Romberg sensorial (eyes closed) and the unipedal stance (left, eyes open), and that the approach may be "preferable to the CCC protocol for patients with worse baseline assessments of those measurements."

    The improvements in test scores, however, didn't necessarily translate into fewer falls for this group. Authors cite 2 possible reasons for the lack of change: first, the treatment duration "was less than recommended by falls prevention guidelines," and, second, the balance improvement itself may prompt individuals to expose themselves to "challenging activities and environments that were avoided in the past."

    Still, they write, VR resulted in improvements in static and dynamic balance control, a result that "reveals the importance of exercises in general for vestibular compensation and to restore body balance."

    As to which protocol to use, authors conclude that "it is up to the physiotherapist to choose which protocol is more suitable … considering the patient's balance assessment, the resources available, the therapeutic setting, and patient preference."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Editor's Note: Don't forget Falls Prevention Awareness Day, September 23, 2015. APTA offers a wealth of resources on balance and falls, most of them accessible via the association's Balance and Falls webpage. Offerings range from consumer-focused information including a video, a PT's guide to falls, handouts on falls prevention and physical therapy and the balance system (members-only .pdfs), to PT- and PTA-focused information on how to develop community events on balance, falls, and exercise. Members can also access several continuing education courses related to falls at the Balance and Falls page, and the PTNow evidence-based practice resource includes a clinical practice guideline on falls and fall injuries in the older adult and a clinical summary on falls risk in community-dwelling elderly people.

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