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CC BY 4.0 · Arq Neuropsiquiatr 2024; 82(11): s00441790568
DOI: 10.1055/s-0044-1790568
Original Article

The effect of proprioceptive vestibular rehabilitation on sensory-motor symptoms and quality of life

Efeito da reabilitação vestibular proprioceptiva nos sintomas sensório-motores e qualidade de vida
Gülfem Ezgi Özaltın 
1   Inonu University, Faculty of Health Sciences, Physiotherapy and Rehabilitation Department, Malatya, Türkiye.
,
Burcu Talu 
1   Inonu University, Faculty of Health Sciences, Physiotherapy and Rehabilitation Department, Malatya, Türkiye.
,
Tuba Bayındır 
2   Yüksek İhtisas Unıversity, Medicalpark Ankara Hospital, Ear Nose and Throat Clinic, Ankara, Türkiye.
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Abstract

Background Peripheral vestibular hypofunction (PVH) is characterized by balance and gait disorders and vestibulo-autonomic findings. The vestibular system and proprioceptive system work together to regulate sensorimotor functions. Vestibular exercises are effective in PVH, but their superiority over each other is still unclear.

Objective This study aims to examine the effect of proprioceptive vestibular exercises on patients with PVH.

Methods 30 individuals with unilateral PVH were assigned to 3 groups. Group 1 received proprioceptive vestibular rehabilitation, group 2 received standard vestibular rehabilitation. Both groups were given standard vestibular exercises as home exercises. No exercise was applied to the group 3. Patients were evaluated in terms of balance, functional mobility, posture, sensory profile, and quality of life.

Results Although there was a significant intra-group difference in balance, functional mobility, and quality of life results in all groups (p < 0.05), the difference between groups was generally in favor of group 1 (p < 0.05). There was a significant difference between the groups in the posture analysis results (p < 0.05), while there was a significant difference in the 1st group (p < 0.05). There was a significant difference between the groups in the results of sensory sensitivity, sensory avoidance, and low recording (p < 0.05). There was no significant difference between the groups in sensory-seeking results (p > 0.05). There was a significant difference in quality of life between and within groups (p < 0.05).

Conclusion Proprioceptive vestibular rehabilitation is an effective method in PVH. We think that our study will guide clinicians and contribute to the literature.

Trial registration NCT04687371.


 

Resumo

Antecedentes A hipofunção vestibular periférica (HVP) é caracterizada por distúrbios do equilíbrio e da marcha e achados vestíbulo-autonômicos. O sistema vestibular e o sistema proprioceptivo trabalham juntos para regular as funções sensório-motoras. Os exercícios vestibulares são eficazes na HVP, mas sua superioridade entre si ainda não está clara.

Objetivo Este estudo tem como objetivo examinar o efeito de exercícios vestibulares proprioceptivos em pacientes com HVP.

Métodos Trinta indivíduos com HVP unilateral foram divididos em três grupos. O grupo 1 recebeu reabilitação vestibular proprioceptiva, o grupo 2 recebeu reabilitação vestibular padrão. Ambos os grupos receberam exercícios vestibulares padrão como exercícios caseiros. Nenhum exercício foi aplicado ao grupo 3. Os pacientes foram avaliados quanto a equilíbrio, mobilidade funcional, postura, perfil sensorial e qualidade de vida.

Resultados Embora tenha havido uma diferença significativa intragrupo nos resultados de equilíbrio, mobilidade funcional e qualidade de vida em todos os grupos (p < 0,05), a diferença entre os grupos foi geralmente a favor do grupo 1 (p < 0,05). Houve diferença significativa entre os grupos nos resultados da análise postural (p < 0,05), embora tenha havido diferença significativa no 1° grupo (p < 0,05). Houve diferença significativa entre os grupos nos resultados de sensibilidade sensorial, esquiva sensorial e baixo registro (p < 0,05). Não houve diferença significativa entre os grupos nos resultados de busca sensorial (p > 0,05). Houve diferença significativa na qualidade de vida entre e dentro dos grupos (p < 0,05).

Conclusão A reabilitação vestibular proprioceptiva é um método eficaz na HVP. Acreditamos que nosso estudo orientará os médicos e contribuirá para a literatura.

Registro de teste NCT04687371.


 

Keywords

Exercise - Vertigo - Physical Therapy Services - Postural Balance

Palavras-chave

Exercício Físico - Vertigem - Serviços de Fisioterapia - Equilíbrio Postural

INTRODUCTION

Peripheral vestibular hypofunction (PVH) is a disorder that occurs when the structures responsible for the peripheral vestibular system, such as the semicircular canals in the inner ear, otolith organ, or vestibular nerve, are affected. It is difficult to estimate the prevalence or incidence of PVH with certainty. “National Health and Nutrition Examination Survey” data between 2001 and 2004 showed that 35.4% of adults living in the United States had vestibular dysfunction and this rate increased with age.[1]

The disease is primarily characterized by postural instability, visual blurring caused by head movements, balance disorder, vertigo, and gait disturbance. At the same time, neurovegetative symptoms (vomiting, sweating, nystagmus, etc.) occur as the vestibulo-autonomic pathways involved in providing visceral control are affected.[2] It negatively affects the individual's quality of life. Appropriate treatment is important in relieving symptoms. Exercise therapy has been accepted as the primary approach because medical treatments are not used in the long term and surgery is the last option.[3] [4] For the applied rehabilitation program to be more effective, it is necessary to understand the physiology and pathophysiology of the vestibular system well. Most of the vestibular signals involved in maintaining balance and postural control are processed in the brainstem and cerebellum, along with proprioceptive and visual information. Specifically, head movements directly stimulate the vestibular system, but during neck movements, the vestibular system and proprioceptive system work together to capture the position of the head and body in space and ensure continuity of postural control. Vestibular and proprioceptive system integration is vital to ensure balance and posture. Many exercise approaches have been developed so far within the scope of vestibular rehabilitation (VR), but there is no consensus on their superiority over each other.[5]

The proprioceptive system's effect, which is closely related to the vestibular system, during exercises has not been investigated so far. This study aims to examine the effects of proprioceptive vestibular exercises on balance, functional mobility, posture, sensory profile, and quality of life in patients with vertigo due to PVH.


 

METHODS

This randomized controlled prospective single-blind (participant-blind) study was conducted between December 2020 and July 2021 in the ear, nose, and throat outpatient clinic of a university hospital and the physiotherapy and rehabilitation unit of a private hospital. Following institutional permissions, ethics committee approval was obtained (Research Protocol Code: 2020/190). The study was registered with Clinical Trials under protocol number NCT04687371 and was conducted by the Declaration of Helsinki. All individuals who agreed to participate in the research had an “Informed Consent Form” signed.

Inclusion criteria

Patients were between the ages of 18–65, diagnosed with unilateral PVH according to the clinical examinations or otoneurological tests performed by an otorhinolaryngology physician, had vertigo, and agreed to participate in the study. Exclusion criteria; Patients with neurological, orthopedic, and circulatory system problems that may cause severe hearing/visual impairment-loss, vertigo, dizziness, and balance disorders, patients with severe hypertension/diabetes, patients who have previously been included in a vestibular rehabilitation program, patients using medications that may negatively affect the treatment, patients with benign paroxysmal positional vertigo (BPPV), patients with acute attacks, and patients with central vestibular pathology. Patients who refused to participate in the clinical study, who could not comply with the training program, who abandoned the treatment, and who received different diagnoses that could disrupt the treatment during the study were excluded from the study.

The research population was determined to be 2 hospitals using the cluster sampling method. Patients who agreed to participate in the study and met the inclusion criteria were randomized from the relevant population using the “research randomizer” computer program and assigned to groups in this way. For the appropriate sample size, at least 9 subjects were recruited in each group to ensure that the change in the average DHI (dizziness handicap inventory) score after proprioceptive vestibular training in patients with vertigo was 27, with α = 0.05 and 1-β (power) = 0.80 in the power analysis performed before the start of the study. Was calculated as required.[6]


 

Intervention

Following the pre-treatment evaluation, the patients were given proprioceptive vestibular exercise for 8 weeks, 4 days a week, 30 minutes a day, under the supervision of a physiotherapist for 32 sessions; group 1 was given proprioceptive vestibular exercise; Standard vestibular rehabilitation was applied to group 2. Additionally, 1 set of standard vestibular rehabilitation home exercise programs was applied every day of the week. Group 3 was not given any treatment and was asked to continue its daily life. The evaluation was made before and after 8 weeks of treatment in all groups.

Group 1 (proprioceptive vestibular rehabilitation)

This program was created by the researcher based on evidence-based guidelines.[3] Ground changes, speed changes, and weight changes were used along with vestibular rehabilitation exercises to strengthen the targeted proprioceptive system.[7] [8] [9] When patients could not tolerate the exercise, it remained at the same level and progressed when tolerance was achieved. Postural smoothness was achieved during all exercises. The exercises applied are shown in [Table 1].

Table 1

Proprioceptive vestibular exercises

Positions

Exercises

How to Make

Difficulty level

Supine

Postural smoothness, respiratory control, and relaxation

In the supine position, the neutral position of the pelvis, spine, and head was demonstrated based on the kinetic chain. Breathing and relaxation exercises were performed in this position.

–

Bridging

Bridging while maintaining postural smoothness in the supine position

First on two legs, then on one leg, First on stable ground, then on unstable ground (Bobath ball)

Gaze stabilization

4 point targets were determined within the visual field. First, he was asked to look at these points with his head fixed and his eyes moving. Then a single point was determined and a command was given to keep the eyes fixed and the head moving.

Metronome used for speed (50 bpm-120 bpm)

Balance exercises

Cat camel and cross-arm leg extension exercises were given

Eyes open, eyes closed

Sitting

Gaze stabilization

Four target points (right, left, up, down) were determined within the visual field. First, he was asked to look at these points with his head fixed and his eyes moving. Then a single point was determined and a command was given to keep the eyes fixed and the head moving.

Metronome used for speed (50 bpm-120 bpm)

Stand up bent over

The patient was asked to stand up and sit down again by picking up an object from the floor in a sitting position.

It progressed from stable ground to unstable ground (bobath ball).

First slow then fast

Functional reaching

The patient was asked to pick up the ball extended from different directions in a sitting position

While sitting first on stable ground and then on unstable ground, First slow, then fast, Increased the weight of the gun used (0.5 kg, 1 kg, 1.5 kg.)

Spinning in a swivel chair

While sitting on the chair with the head flexed at 30°, the chair was rotated by the physiotherapist.

First slow then fast

Standing

Sitting to standing and 360° vertical rotation

The patient was asked to bend over from her seat, stand up, turn 360 ° around herself, and sit down again.

On hard ground, on soft ground, Eyes open, eyes closed

Static dynamic balance exercises

Static and dynamic balance exercises while standing

First on hard ground, then on soft ground, First on two legs, then on one leg, Eyes open, eyes closed, focusing on visual video

Standing on the balance board

First standing in front of the mirror and then focusing on the prepared visual video

While standing on the balance board, a weight was hung on both ends of a stick and the weight was gradually increased.

Walking

Forward walking

Walking forward on flat ground

In the wide area, narrow area, and tandem position First on hard ground, then on soft ground, Eyes open, eyes closed, First slow then fast

Walking with head movements

Turning your head left, right, up, and down on a flat surface; walking by reading the writings on the wall

First in a wide area, then in a narrow area, then in a tandem position

First on hard ground, then on soft ground, First slow then fast

Walking with an obstacle

Walking on flat ground by jumping over obstacles of different heights and making a figure of eight between obstacles

First hard then soft ground, First slow then fast

Walking with functional activity

Catching and throwing the ball from different directions while walking on flat ground

First hard ground, then soft ground, Ball weight gradually increased (0.5 kg, 1 kg, 1.5 kg), First slow then fast

Going up and down stairs

Stair climbing and descending exercises

First on hard ground, then on soft ground, Eyes open, eyes closed, First, slow then fast

 

Group 2 (standard vestibular rehabilitation)

The control group used the Cawthorne-Cooksey protocol, which consists of eye, head, and trunk exercises while sitting, standing, and walking.[10] The exercises were repeated every day at home under the same sensory conditions as the last session in the clinic.


 

Group 3 (control)

The patients were not given any exercise and were asked to continue their daily lives.


 

 

Measures

Balance

The Tinetti Balance and Gait Test was used to evaluate the patients' balance. The total score is 28 points, 16 for balance and 12 for walking. Activities specified in test 2: performing the specified movement correctly; 1: performing the specified movement with compensations; 0: scoring as not performing the specified movements.[11]


 

Functional mobility

The time Up and Go test (TUG) was used. The test was started in a normal-height chair with a back support and no arm support. A distance of 3 m (m) was determined. Initially, the patient sat on the chair leaning back with his feet in full contact with the ground. Then, he was asked to get up from the chair without support, walk a distance of 3 m, return, and sit on the chair again. The time taken was recorded in seconds.[12]


 

Posture analysis

Posturzone application was used. This free application was used with camera-equipped IOS software to run in compatibility mode.[13] Head lateral tilt, the difference between both shoulders, and the difference between both pelvises were recorded in degrees. Measurements were taken before and after treatment, and a decrease in the difference was considered an improvement.


 

Sensory profile

Adolescent/Adult Sensory Profile developed from Dunn's sensory processing model was used. The lower the neurological threshold, the more the nervous system can be stimulated and the greater the response of the nervous system. The higher the neurological threshold, the later the nervous system can be stimulated and the less it responds. The behavioral part is also related to the response to the perceived sensation. In line with these behavioral patterns, Dunn's model consists of 4 quadrants: sensory sensitivity, sensory avoidance, low register, and sensory seeking. The Turkish validity and reliability of the questionnaire were determined by Üçgül et al. It was made by.[14] At the end of the test, individuals are evaluated as “much less than most people,” “less than most people,” “similar to most people,” “more than most people,” and “much more than most people.” The individual scores between 5–75 in each section. The higher the score, the more characteristics the individual displays within that sensory processing pattern.[15]


 

Quality of Life

Evaluated by the “Dizziness Handicap Inventory” (DHI). It is a 25-question survey that measures the functional, physical, and emotional effects of dizziness.[16]


 

 

Statistical analysis

Statistical Package for Social Sciences (SPSS) 26.0 program was used in the statistical analysis of the data. The suitability of numerical data to normal distribution was analyzed using the “Shapiro-Wilk Test” and histogram graphics. Numerical data analyzed and found to be suitable for normal distribution were defined with arithmetic mean (x̄) and standard deviation (SD); Categorical data were expressed as percentages (%) and numbers (n). One-way ANOVA test was used to compare between groups in cases where normality and homogeneity were ensured in the data that was found to be suitable for normal distribution. Appropriate Chi-square tests were used to compare categorical variables between groups. A comparison of individuals' pre- and post-treatment values in terms of groups was made with a two-way analysis of variance with repeated measurements. A Post Hoc test with Bonferroni correction was used for pairwise group comparisons of the measurements that showed differences. The Mc Nemar test and Marginal Homogeneity test were used in the initial and final evaluation of categorical variables within the group. The significance level of all analyses was accepted as p < 0.05.


 

 

RESULTS

In the study, 70 patients with vertigo due to unilateral PVH were evaluated for eligibility. It was conducted with 34 patients who met the inclusion criteria and agreed to participate in the study. During the treatment period, 4 patients were excluded for various reasons and the study was completed with a total of 30 patients ([Figure 1]).

Zoom
Figure 1 Flow diagram(CONSORT).

A comparison of the demographic and clinical characteristics of the groups is shown in [Table 2]. It was observed that there was no significant difference in age, height, weight, and BMI values between the groups (p > 0.05).

Table 2

Comparison of patient's demographic and clinical characteristics

Group 1 (n = 10)

x̄ ± ss

Group 2 (n = 10)

x̄ ± ss

Group 3 (n = 10)

x̄ ± ss

p [a]

Age (year)

41.40 ± 12.24

40.4 ± 6.58

41.9 ± 8.46

0.936

Length (m)

1.67 ± 0.11

1.67 ± 0.84

1.68 ± 0.10

0.992

Weight (kg)

69.8 ± 10.89

72.7 ± 11.98

72.6 ± 11.07

0.811

Body mass index

24.90 ± 3.06

25.97 ± 4.37

25.81 ± 3.79

0.794

Sex

Female

6 (%60)

5 (%50)

4 (%40)

0.670

Male

4 (%40)

5 (%50)

6 (%60)

Education status

Primary education

5 (%50)

3 (%30)

6 (%60)

0.590

Second education

2 (%20)

4(%40)

4(%40)

University

3(%30)

3(%30)

1(%10)

Smoker

Yes

0 (%0)

3 (%30)

3 (%30)

0.153

No

10 (%100)

7 (%70)

7 (%70)

Alcohol

Yes

0 (%0)

0 (%0)

0 (%0)

*

No

10 (%100)

10 (%100)

10 (%100)

Affected side

Right

6 (%60)

5 (%50)

7 (%70)

0.659

Left

4 (%40)

5 (%50)

3 (%30)

Time to a diagnosis (months)

0–3

4 (%40)

4 (%40)

6 (%60)

0.582

3–6

2 (%20)

2 (%20)

3 (%30)

>12

4 (%40)

4 (%40)

1 (%10)

Notes: aOne-way ANOVA; X ± SD: mean ± standart deviation; *p-value could not be calculated because there was no data.


A comparison of the patient's clinical symptoms before and after treatment is shown in [Table 3].

Table 3

Comparison of patients' clinical symptoms

Group 1

n = 10 (%)

P

Group 2

n = 10 (%)

p [a]

Group 3

n = 10 (%)

p [a]

Nausea T1

Yes

10 (100)

 

 

0.002 [a]

7 (70)

 

 

0.031 [a]

10 (100)

 

 

0.031 [a]

No

0 (0)

3 (30)

0 (0)

Nausea T2

Yes

0 (0)

1 (10)

4 (40)

No

10 (100)

9 (90)

6 (60)

Sweat T1

Yes

3 (30)

 

 

0.250[a]

5 (50)

 

 

0.125[a]

8 (80)

 

 

0.063[a]

No

7 (70)

5 (50)

2 (20)

Sweat T2

Yes

0 (0)

1 (10)

3 (30)

No

10 (100)

9 (90)

7 (70)

Headache T1

Yes

9 (90)

 

0.004 [a]

9 (90)

 

1.000[a]

10 (100)

 

 

_*[a]

No

1 (10)

1 (10)

0 (0)

Headache T2

Yes

0 (0)

8 (80)

10 (100)

No

10 (100)

2 (20)

0 (0)

Nistagmus T1

Yes

8 (80)

 

 

0.008 [a]

3 (30)

 

 

1.00[a]

9 (90)

 

 

0.500[a]

No

2 (20)

7 (70)

1 (10)

Nistagmus T2

Yes

0 (0)

2 (20)

7 (70)

No

10 (100)

8 (80)

3 (30)

Attack frequency T1

<1 per month

0 (0)

 

 

 

 

0.002[b]

0 (0)

 

 

 

 

0.002[b]

0 (0)

 

 

 

 

0.046[b]

1 in 15 Days

1 (10)

0 (0)

2 (20)

1 per week

2 (20)

3 (30)

5 (50)

>3 per week

7 (70)

7 (70)

3 (30)

Attack frequency T2

<1 per month

9 (90)

3 (30)

0 (0)

1 in 15 Days

1 (10)

6 (60)

6 (60)

1 per week

0 (0)

1 (10)

1 (10)

>3 per week

0 (0)

0 (0)

3 (30)

Attack severity T1

Light

0 (0)

 

 

_*[b]

0 (0)

 

 

0.002[b]

0 (0)

 

 

0.025[b]

Middle

2 (20)

2 (20)

2 (20)

High

8 (80)

8 (80)

8 (80)

Attack severity T2

Light

10 (100)

2 (20)

0 (0)

Middle

0 (0.00)

8 (80)

7 (70)

High

0 (0.00)

0 (0.00)

3 (30.00)

Abbreviations: T1, Initial assessment; T2, Last assessment.


Notes: aMc-Nemar Test; bMarginal Homogeneity Test; *p-value could not be calculated because both variables are the same.


There was a significant difference between groups in balance, functional mobility, posture, sensation, and quality of life results ([Table 4]).

Table 4

Comparison of patients' balance, functional mobility, posture, sensory profile, and quality of life results

Group 1

(n = 10)

x̄ ± SS

Group 2

(n = 10)

x̄ ± SS

Group 3

(n = 10)

x̄ ± SS

p [a]

Analysis of variance in repeated measurements

F

p [b]

Groups

1 and 2

Groups

1 and 3

Groups

2 and 3

Tinetti Balance

T1

7.60 ± 3.97

6.70 ± 3.97

5.10 ± 2.92

0.46

8.488

0.001

1.000

0.414

1.000

T2

15.10 ± 0.87

11.20 ± 2.69

8.10 ± 2.42

0.001

0.001

0.001

0.010

p

0.001

0.001

0.001

Tinetti Gait

T1

7.60 ± 2.59

8.00 ± 1.56

8.50 ± 1.77

0.265

T2

11.60 ± 0.69

10.80 ± 1.03

11.00 ± 1.05

0.222

P

0.001

0.001

0.001

Tinetti Total

T1

15.20 ± 6.14

14.70 ± 5.35

13.60 ± 435

0.805

6.612

0.005

1.000

1.000

1.000

T2

26.70 ± 1.25

22.00 ± 2.98

19.10 ± 2.92

0.001

0.001

0.001

0.047

p

0.001

0.001

0.001

TUG

T1

11.43 ± 2.87

10.23 ± 2.13

11.35 ± 2.01

0.459

6.85

0.004

0.800

1.000

0.901

T2

7.97 ± 1.03

9.10 ± 1.24

10.14 ± 0.97

0.001

0.084

0.001

0.128

p

0.001

0.034

0.024

Neck Tilt (°)

T1

0.63 ± 0.17

0.59 ± 0.19

0.66 ± 0.16

0.675

62.659

0.001

1.00

1.00

1.00

T2

0.11 ± 0.12

0.55 ± 0.19

0.67 ± 0.19

0.001

0.001

0.001

0.402

p

0.001

0.289

0.789

Shoulder (°)

T1

1.67 ± 0.51

1.61 ± 0.55

1.57 ± 0.48

0.911

65.342

0.001

1.000

1.000

1.000

T2

0.15 ± 0.15

1.52 ± 0.52

1.57 ± 0.48

0.001

0.001

0.001

1.000

p

0.001

0.401

1.000

Pelvic (°)

T1

1.46 ± 0.58

1.29 ± 0.48

1.23 ± 0.44

0.584

26.590

0.001

1.00

0.964

1.00

T2

0.27 ± 0.30

1.20 ± 0.50

1.23 ± 0.44

0.001

0.001

0.001

1.00

p

0.001

0.490

1.000

Sensory sensitivity

T1

49.70 ± 3.43

49.20 ± 3.70

46.00 ± 2.86

0.042

15.20

0.001

1.000

0.061

0.126

T2

39.10 ± 2.33

40.60 ± 4.62

45.10 ± 2.60

0.001

0.975

0.001

0.017

p

0.001

0.001

0.499

Sensation Avoiding

T1

40.30 ± 4.29

41.20 ± 3.29

42.20 ± 5.47

0.638

7.712

0.002

1.000

1.000

1.000

T2

32.90 ± 5.64

37.50 ± 4.06

40.90 ± 4.48

0.003

0.121

0.003

0.370

p

0.001

0.002

0.250

Low Registration

T1

34.80 ± 5.09

38.00 ± 5.47

37.90 ± 4.45

0.287

7.206

0.003

1.000

0.044

1.000

1.000

T2

27.70 ± 4.24

32.70 ± 4.44

36.70 ± 4.16

0.001

0.001

0.140

p

0.001

0.001

0.296

Sensation Seeking

T1

32.60 ± 5.81

33.80 ± 7.80

31.20 ± 7.39

0.715

T2

40.10 ± 6.11

38.90 ± 7.72

34.40 ± 7.63

0.194

p

0.001

0.003

0.047

Quality of life

(DHI)

T1

69.00 ± 16.95

72.4 ± 10.57

73.8 ± 13.67

0.735

62.148

0.001

1.00

1.00

1.00

T2

10.4 ± 6.16

33.4 ± 7.54

61.8 ± 11.17

0.001

0.001

0.001

0.001

p

0.001

0.001

0.001

Abbreviations: T1, Initial assessment; T2, Last assessment.


Notes: aOne way ANOVA; bgroup-time interaction.



 

DISCUSSION

The data obtained from this study show that proprioceptive vestibular rehabilitation exhibits more positive results on balance, functional mobility, posture, sensory profile, and quality of life compared with standard exercises in individuals with PVH.

One of the most important functions that restrict daily living activities in vestibular disorders is balance disorder. One of the first and most frequently used programs created for VR is the Cawthorne Cooksey exercises.[17] Although Cawthorne Cooksey exercises provide positive results in this sense, they may be considered lacking in terms of simultaneous management of visual and proprioceptive information, stages of balance exercises, and other motor components.[18] The recovery rate was higher in the group that received proprioceptive vestibular rehabilitation exercises compared with the other two groups. We think that this situation is caused by decreased vestibular system function and increased somatosensory stimuli during exercises. It has been determined that there are various treatment approaches for patients with vestibular hypofunction, but the underlying cause of improvement is not fully understood.[19] In our study, we think that proprioceptive stimulation, which replaces the missing vestibular input through habituation, adaptation, and substitution exercises, increases motor learning skills and affects balance more positively than others.

With impaired balance, functional limitations occur. Since the vertical movement of the head is excessive during walking, there is a significant decrease in visual acuity during walking, and a deterioration in normal walking patterns and speed is observed.[20] In this sense, the general principles of the exercises are to prevent vertigo and functional limitations by managing vestibulo-ocular reflex (VOR) and vestibulo-spinal reflex (VSR).[21] In our study, we saw that the averages of all three groups improved in the measurements taken after the treatment. We can say that the difference between the groups stems from group 1. Layman et al. It has been suggested that cervical vestibular evoked myogenic potential (cVEMP) latencies have a significant relationship with walking speed in healthy individuals and that saccular signaling contributes to head stabilization and postural gait via the sacculocolic reflex.[22] [23] Saccular function, which normally increases with head movements during walking, is decreased in PVH patients. In our study, we think that extravestibular inputs, different head movements, activities requiring attention and different speed parameters added to walking exercises may have provided the integration of the proprioceptive system and vestibular system in two ways; We think that, first, it may have contributed to the vestibular system adjusting the desired movement speed, and second, it improved the slow movement strategy it created to prevent falls due to the general feeling of imbalance.

Pathology occurring in the vestibular system may cause incorrect processing of sensory inputs in the central nervous system and incorrect tonic and phasic muscle activation. As a result, posture disorders and a tendency to spinal deformity can be mentioned.[24] [25] There have been studies suggesting that there are morphological changes in the vestibular organs of scoliosis patients and that functional anomalies of the vestibular organ may also cause scoliotic changes.[26] [27] According to the measurements taken at the end of the treatment, there was a significant improvement in head, shoulder, and pelvis positions in the group that received proprioceptive vestibular rehabilitation exercises, while the improvement in the other groups did not reach the level of significance. The vestibulo-cerebellar system receives information from both otolith organs and semicircular canals. Purkinje fibers here inhibit the neurons in the lateral vestibular nucleus and, together with the VOR and VSR, ensure the preservation of postural smoothness.[25] [28] It can be said that the proprioceptive vestibular rehabilitation we applied in our study improved the vestibulospinal reflex, created compensatory results for the impaired vestibular system, and accordingly improved body posture.

Many studies have been conducted examining postural control and postural sway values in patients with vestibular insufficiency, but no study examining posture analysis has been found.[18] [29] To the best of our knowledge, our study is the first study conducted in this sense. We think it will be a guide for clinicians.

The underlying cause of symptoms such as loss of balance, postural control, vegetative symptoms, and insufficiency in daily living activities that occur with the disease may be due to many sensory deficiencies. When studies in the literature were examined, it was seen that sensory organization tests were frequently used to evaluate the sensory organization of people with vestibular loss. The sensory organization test is a valuable tool that measures sensory input (proprioceptive, vestibular, and visual) and how it is used in patients with PVH.[30] However, it has limitations.[31] In addition to problems such as loss of balance and dizziness, which significantly affect the quality of life of patients, there is also the interference of visceral sensations that reveal vegetative symptoms.[2] [32] [33] Considering that this type of different senses may be affected, we wanted to examine the effect of vestibular rehabilitation on the sensory profile. In the first measurements taken from the patients, the average of the sensory sensitivity and sensory avoidance values was determined to be “higher than most people” in all groups. Looking at this situation, we can say that the neurological threshold value of patients with peripheral vestibular insufficiency is low. This shows that the physiological response to afferent stimuli is strong and the habituation ability is weak. Individuals have difficulty focusing on a single behavior among many sensory inputs and avoid disturbing environments. After the treatment, it was observed that it fell within the “similar to most people” norm range, especially in groups 1 and 2. Contrary to our expectations, the first measurements taken from the patients at low recording values were close to the upper limit of the normal range in group 1, while they were determined to be “more than most people” in groups 2 and 3. After treatment, it was recorded as “similar to most people” in groups 1 and 2. Individuals with low recording characteristics in the sensory processing process are stated to have a high neurological threshold level. Questions about low registration include “I trip or bump into things,” etc. Since it consists of questions that require caution such as these values may be close to the normal limit or slightly higher in the first measurements we took from the patients. Sensory seeking was determined to be “similar to most people and less so” in the first and second measurements taken. Since individuals' neurological threshold level toward sensory stimuli is low, it can be said that they show fewer features within this sensory processing pattern.

Our study, it was aimed to achieve plasticity in the vestibulo-autonomic reflex as well as in VSR and vestibulocollic reflex after vestibular rehabilitation. The improvement in the untreated group can be explained by the central compensation mechanism. The better results in the treatment groups can be explained by the strengthening of vestibulo-autonomous reflex connections and the development of plasticity in vestibular synapses as a result of stimulation of the vestibular nerve, which activates the vestibular system. It is observed that postural and vegetative symptoms are eliminated and individuals enter into normal/near-normal sensory patterns. To our knowledge, our study is the first to examine the effect of vestibular rehabilitation on sensory processing patterns in patients with PVH. We emphasize the importance of considering sensory processing patterns as well as options specific to motor symptoms in treatment.

It is known that there is a high correlation between the severity of vestibular disorder and the individual's quality of life. Studies conducted in this context have provided moderate to strong evidence for the effectiveness of vestibular rehabilitation.[34] However, there is no consensus on the superiority of different exercise protocols. Measurements taken at the end of our study showed improvement in DHI scores in all three groups. While the recovery rate in group 2 was similar to the results in the literature, measurements taken from group 1 showed a higher level of improvement. We think that the proprioceptive vestibular rehabilitation we applied in our study positively affects the central nervous system compensation, improves physical and clinical symptoms, and accordingly increases the quality of life of the patients.

Our study has some limitations. One of the important limitations is that the individuals who participated in the study stopped working for various reasons and the Covid-19 pandemic experienced during the study delayed reaching the sample size.

In conclusion, this study offers a new perspective on vestibular rehabilitation exercises. This study proves the effectiveness of proprioceptive vestibular rehabilitation. Posture analysis and sensory profile in patients with vestibular disorders have not been examined so far. We think that this study will be a guide to better investigate this issue in future studies and will also contribute to clinicians.


 

 

Conflict of Interest

There is no conflict of interest to declare.

Authors' Contributions

GEÖ: conceptualization, data curation, formal analysis, ınvestigation,methodology, project administration, supervision, visualization, writing – original draft, writing – review & editing; BT: conceptualization, methodology, supervision, writing – original draft, writing – review & editing; TB: conceptualization, visualization, writing – original draft, writing – review & editing.


Editor-in-Chief: Hélio A. G. Teive.


Associate Editor: Adriana Bastos Conforto.



Address for correspondence

Gülfem Ezgi Özaltın

Publikationsverlauf

Eingereicht: 06. Juni 2024

Angenommen: 08. August 2024

Artikel online veröffentlicht:
24. September 2024

© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution 4.0 International License, permitting copying and reproduction so long as the original work is given appropriate credit (https://creativecommons.org/licenses/by/4.0/)

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Bibliographical Record
Gülfem Ezgi Özaltın, Burcu Talu, Tuba Bayındır. The effect of proprioceptive vestibular rehabilitation on sensory-motor symptoms and quality of life. Arq Neuropsiquiatr 2024; 82: s00441790568.
DOI: 10.1055/s-0044-1790568

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Figure 1 Flow diagram(CONSORT).