Vestibular Rehabilitation for Peripheral Vestibular Hypofunction

Acknowledgements

Chief Editor: Reda Kamel1

General Secretary: Ahmed Ragab2

General Coordinator: Baliegh Hamdy3

Scientific Board: Ashraf Khaled,4 Mohamed Ghonaim,5 Mahmoud Abdel Aziz,6 Tarek Ghanoum,7 Mahmoud Yousef8

Assembly Board: Soha Mekki,9 Abir  Omara,10 Sara Fawzan11

Grading Board (In alphabetical order): Abeir Dabbous,7 Enass Sayed,12 Enaas Kolkaila,13 Eman Mostafa Basiouny,14 Mona Elakkad,15Mona Mourad,11 Mohamed Salama,12 Mostafa Youssif,16 Naema Ismail,17 Nashwa Nada,13 Reham Rafei,15 Rabab Koura,14 Radwa Mahmoud,16Salwa Mahmoud,10 Tarek El Dessouky,14 Trandil ElMehallawi13, Magdy ElHossieny Ebrahim Elewa18

Reviewing Board: Alaa Abousetta,19  Mohamed El-Badry,20  Nagwa Hazzaa21

1Otorhinolaryngology Department,  Faculty  of  Medicine/ Cairo  University,  2Otorhinolaryngology Department,  Faculty  of  Medicine/ Menofia University, 3Otorhinolaryngology Department, Faculty of Medicine/ Menia University, 4Otorhinolaryngology Department, Faculty of Medicine/ Beni-Suef University, 5Otorhinolaryngology Department, Faculty of Medicine/Mansoura University, 6Otorhinolaryngology Department, Faculty of Medicine/ Tanta University, 7Audiovestibular Medicine Unit, Otorhinolaryngology Department, Faculty of Medicine/ Cairo University, 8Phoniatrics Unit, Otorhinolaryngology Department, Faculty of Medicine/ Ain Shams University, 9Audiovestibular Medicine Unit, Otorhinolaryngology Department, Faculty of Medicine/ Zagazig University, 10 Audiovestibular Medicine Unit,  Otorhinolaryngology Department/  Hearing and Speech Institute, 11Audiovestibular Medicine Unit, Otorhinolaryngology Department, Faculty of Medicine/Alexandria University,

12Audiovestibular Medicine Unit, Otorhinolaryngology Department, Faculty of Medicine/ Asuit University, 13Audiovestibular Medicine Unit, Otorhinolaryngology Department, Faculty of Medicine/ Tanta University, 14Audiovestibular Medicine Unit, Otorhinolaryngology Department, Faculty of Medicine/ Bani-suif University, 15Audiovestibular Medicine Unit, Otorhinolaryngology Department, Faculty of Medicine/ Fayoum University, 16Audiovestibular Medicine Unit, Otorhinolaryngology Department, Faculty of Medicine/ Suhag University,

17Audiovestibular Medicine Unit, Otorhinolaryngology Department, Faculty of Medicine/ AlAzhar University, 18Physiotherapy and rehabilitation department, Zagazig University 19Audiovestibular Medicine,Unit, Otorhinolaryngology Department, Faculty of Medicine/ Suez canal University. 20Audiovestibular Medicine, Unit, Otorhinolaryngology Department, Faculty of Medicine/ Menia University. 21Audiovestibular Medicine, Unit, Otorhinolaryngology Department, Faculty of Medicine/ Ain shams University.

Sincere thanks extend to the secretaries: Samar Hussein and Eman Ragab, as well as the editor: Mohamed Salah

Abbreviations

AECPG: Adapted Egyptian Clinical practice guideline.

APTA: American physical therapy association.

VRT:  Vestibular rehabilitation therapy.

BSA: British society of audiology

BVH: Bilateral vestibular hypofunction.

CBT: Cognitive behavioral therapy.

GSE: Gaze stabilizing exercises.

IGE: international guidelines for education

VR: Visual reality

VOR: Vestibulo-ocular reflex.

UVH: Unilateral vestibular hypofunction.

Executive Summary

Audio-Vestibular medicine physicians prescribe the proper therapy plan that could be performed in collaboration with physiotherapist, Clinicians should offer vestibular rehabilitation to patients with acute or subacute UVH. (Strong recommendation), In acute cases; patient might first take symptomatic treatment to control acute symptoms, anxiety and autonomic complaints to be able to start the VRT. Also Clinicians are (strongly recommended) to offer vestibular rehabilitation to patients with chronic UVH and BVH.  Clinicians should not offer saccadic or smooth-pursuit exercises in isolation; as they are not specific exercises for gaze stability to individuals with unilateral or bilateral vestibular hypofunction (strong recommendation). Clinicians may provide targeted exercise techniques to accomplish specific goals appropriate to address identified impairments, activity limitations, and participation restrictions (strong recommendation). Clinicians may prescribe static and dynamic balance exercises and prescribe weekly clinic visits plus a home exercise program of gaze stabilization exercises (strong recommendation). Clinicians should offer supervised vestibular physical therapy in individuals with peripheral UVH and BVH (strong recommendation). Clinicians may use achievement of primary goals, resolution of symptoms, normalized balance and vestibular function, or plateau in progress as reasons for stopping therapy; objective and subjective outcome measures could be used, also Patient’s age and physical capabilities should be considered. (Strong recommendation). Clinicians may evaluate factors that could modify rehabilitation outcomes (strong recommendation). Clinicians should offer vestibular rehabilitation therapy to persons with peripheral vestibular hypofunction with the intention of improving quality of life (Strong recommendation).

Introduction, scope and audience

➡️Introduction

Vestibular rehabilitation therapy (VRT) is a specialized form of physical therapy used to treat vestibular disorders or symptoms characterized by dizziness, vertigo and trouble with balance, posture and vision.

➡️Scope:

Providing evidence-based recommendations regarding appropriate VRT protocol to use in the treatment of individuals with acute, sub-acute, and chronic unilateral and bilateral peripheral vestibular hypofunction.

➡️Target audience:

Audio vestibular medicine physician are those who prescribe the proper therapy plan, ENT for appropriate referral and physiotherapist could perform physiotherapy under supervision of audio vestibular medicine physician.

Methods

➡️Methods of development

➡️Stakeholder Involvement: Individuals who were involved in the development process. Included the above-mentioned Audio vestibular medicine Chief Manager,  Audio vestibular medicine Executive Manager, Assembly Board, Grading Board and Reviewing Board.

➡️Search method

Electronic database searched:‎

Pubmed, Medline, Medscape, WebMD, Google Scholar

➡️Keywords:‎

Vestibular rehabilitation therapy, peripheral vestibular disorders, adults.

The adaptation cycle passed over: set-up phase, adaptation phase (Search and screen, assessment: currency, content, quality & /decision/selection) and finalization phase that included revision and external reviewing.

➡️Time period searched: from 2009 t0 2022

➡️Results

Three national Audio Vestibular Medicine consultants reviewed the guidelines available.

The American physical therapy association (APTA) guidelines gained the highest scores as regards currency, contents and quality and were thus adopted then adapted

It was graded by seventeen experts and reviewed by three expert reviewers to improve quality, gather feedback on draft recommendations.

The external review was done through a rating scale as well as open-ended questions.

➡️Setting: Primary, secondary and tertiary care centers & hospitals, and related specialties.

Interpretation of strong and conditional recommendations for an intervention

WHO handbook for guideline development – 2nd ed.Chapter 10, page 129

The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to Decision frameworks (GRADE Working Group 2013)

Recommendations

The  following  statements  and  flowchart  were  adapted from the Guidelines from Vestibular   Rehabilitation   for   Peripheral   Vestibular hypofunction:  An  updated  clinical  practice  guideline from the academy of neurologic physical therapy of the American physical therapy association (APTA) 2022. which received the highest scores as regards the currency, contents, and quality.

Recommendations statements

Research needs

1-Researchers should explore delivery of VPT using technology, telehealth, or self-teaching methods as an alternative for some individuals and identify individual-level factors that impact the use of technology on rehabilitation outcomes and patient satisfaction.

2-There is a paucity of research on the effectiveness of vestibular rehabilitation in children. Randomized controlled studies are needed to determine the effect of GSE on gaze stability, gross motor abilities, and postural control in children with UVH and BVH.

3- Researchers need to investigate whether there is critical dosage or time points for person versus telehealth/remote supervision.

4-Researchers need to investigate added value of high technology methods (VR) to traditional methods of VRT.

5- Researchers should examine the concept of return to work. Areas for study include job requirements that may be difficult for individuals with vestibular hypofunction, job modification or assistive technology to allow return to work, criteria for return to work or disability assignment, and indicators for return to safe driving.

Monitoring and evaluating the impact of the guideline

Monitoring/ Auditing Criteria

Audio vestibular physician should be able to:

· Acquire patient full medical history.

· Differentiate between UVH and BVH.

· Differentiate between peripheral and central causes of imbalance

· Apply customized VRT.

· Counseling the patient and/or family member.

· Periodic assessment for VRT effectiveness.

Updating of the guideline

Updating Procedure:

Any recommendation of this guideline will be updated when new evidence that could potentially impact the current evidence base for this recommendation is identified. If no new reports or information are identified for a particular recommendation, the recommendation will be revalidated. The focus will be on recommendations supported by very-low- or low certainty evidence and where new recommendations or a change in the published recommendations may be needed.

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Annexes

Editorial Independence:

· This guideline was developed without any external funding.

· All the guideline development group members have declared that they do not have any competing interests.

Annex 1: Guideline Flowchart 

Annex 2: Tables of appraisal of selected guidelines: Content (table 1), Quality (table 2) and Currency (table 3) of the selected guidelines.

Assessment of Content