Vestibular rehabilitation following the removal of an ...cise, balance training, or specific ves-tibular rehabilitation treatments such as adaptation exercises, habitu-ation exercises

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For citation purposes: Passier L, Doherty D, Smith J, McPhail SM. Vestibular rehabilitation following the removal of an acoustic neuroma: a systematic review of randomized trials. Head Neck Oncol. 2012 Sep 9;4(2):59.

Copyright © 2012 OA Publishing London

AbstractIntroductionAn acoustic neuroma (also known as vestibular schwannoma) is an in-tracranial tumour of the vestibular nerve that is commonly treated by surgical resection. Following resec-tion, patients may experience a range of symptoms that include deficits in gaze stability, mobility and balance. Vestibular rehabilitation may be use-ful in reducing the severity and mini-mizing the impact of these symptoms.ObjectiveTo systematically review the clinical trial evidence for the effectiveness of vestibular rehabilitation interventions following resection of an acoustic neuroma and provide a concise syn-thesis useful for informing clinical re-habilitation of this patient population.Data sourcesElectronic databases including Cochrane, PubMed, CINAHL, Embase and AUSThealth were searched with no time restriction. Search terms included combinations of MeSH terms (‘acous-tic neuroma’, ‘vestibular schwannoma’, ‘acoustic neurinoma’, ‘acoustic neuri-lemoma’, ‘acoustic neurilemmoma’ or ‘acoustic schwannoma’) and (‘reha-bilitation’, ‘physiotherapy’ ‘physical therapy’, ‘adaptation’, ‘habituation’, ‘balance’, ‘exercise’ or ‘gaze stability’).

Vestibular rehabilitation following the removal of an acoustic neuroma: a systematic review of randomized trials

L Passier1, D Doherty1, J Smith1, SM McPhail2,3*

Study selectionRandomized clinical trials of rehabili-tation approaches following surgical resection of acoustic neuroma among adults were included. Studies with mixed populations that included bi-lateral vestibular loss or vestibular dysfunction of central or unknown aetiology were excluded. The 591 hits were screened by title, abstract and then full text by two independent researchers who reached a consen-sus on the eligibility of each study (a third researcher was available to arbitrate but was not required). Six clinical trials fulfilled the inclusion criteria.Data extractionThe characteristics of each study including the trial design, sample, intervention, outcome measures and summary of results were extracted and tabulated.Data synthesisMethodological quality was indepen-dently assessed by two researchers using the Physiotherapy Evidence Database scale. The heterogeneity of both interventions and outcome measures did not allow a valid meta-analysis.ConclusionThere is some evidence to support the use of adaptation exercises for this clinical group. Clinical trial evi-dence does not support the use of habituation exercises alone, although when combined with adaptation ex-ercises and balance and gait training, habituation exercises may have some benefit. Further research is required to determine the optimal combina-tion of vestibular rehabilitation inter-ventions as well as the volume and timing of interventions.

ReviewBackgroundAn acoustic neuroma (also known as vestibular schwannoma) is an intra-cranial tumour of the vestibular nerve that is most commonly treated by surgical resection. Following re-section, patients may experience a range of symptoms that include defi-cits in gaze stability, mobility and balance. The incidence and functional impact of these symptoms have varied across previous reports1–4. Although compensation through parallel sys-tems and central processing usually occurs relatively quickly post-surgery, these impairments can be long last-ing1,5,6. Deficits in measures of bal-ance and mobility have been found in patients at least three months post-resection of an acoustic neuroma who have not undergone vestibular rehabilitation6. Similarly, deficits in gaze control have been found in pa-tients at least three months post- resection of an acoustic neuroma5. Vestibular rehabilitation may be use-ful in reducing the severity and mini-mizing the impact of these symptoms.

A broad Cochrane review of the evidence for vestibular rehabilitation in patients with symptomatic unilat-eral vestibular dysfunction found evidence supporting the use of ves-tibular rehabilitation for symptom resolution and improvement of func-tion7. This review included multiple diagnostic groups including benign paroxysmal positional vertigo, ves-tibular neuritis, Meniere’s disease including endolymphatic hydrops, perilymphatic fistula, unilateral laby-rinthectomy or neurectomy (acoustic or vestibular). It compared vestibular rehabilitation to placebo or sham or

* Corresponding author Email: [email protected] Physiotherapy Department, Princess Alexandra

Hospital, Ipswich Road, Brisbane, Australia2 Centre for Functioning and Health Research,

Buranda Plaza, Corner Ipswich Road and Cornwall Street, Buranda, Brisbane, Australia

3 Queensland University of Technology, School of Public Health and Social Work and Institute of Health and Biomedical Innovation, Kelvin Grove, Brisbane, Australia



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usual care, vestibular rehabilitation to other kinds of management such as pharmacological and surgical in-terventions and one form of vestibu-lar rehabilitation to another form of vestibular rehabilitation. The review considered vestibular rehabilitation to include a variety of interventions including adaptation exercises, ha-bituation exercises, substitution ex-ercises and balance and gait training activities. Although the review con-cluded that there is moderate evi-dence for vestibular rehabilitation following surgical removal of an acoustic neuroma, there was consid-erable variation in the outcomes of the reported studies, making it diffi-cult to achieve clinical guidance for optimal rehabilitation protocols, in-cluding which elements of vestibular rehabilitation are the most effective for this diagnostic group.

The aim of this manuscript is to provide a systematic review of clini-cal trial evidence for vestibular reha-bilitation interventions following resection of an acoustic neuroma and provide a concise synthesis useful for informing clinical rehabilitation of this patient population.

Search strategyThis review investigated an acoustic neuroma, also known as vestibular schwannoma, acoustic schwannoma, acoustic neurilemoma or acoustic neu-rinoma. Searches were performed in April 2011 in the following data-bases: Cochrane, PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase and AUSThealth. Search syntaxes are pre-sented in Appendix 1.

Study selectionA conventional four-stage approach for the identification of studies fulfill-ing the inclusion and exclusion crite-ria was adopted by two researchers (Figure 1). A third member of the re-search team was available to arbi-trate any disagreement between the two researchers, but his intervention

was not required. Studies were screened by title; non-relevant arti-cles and duplicates were removed. Article abstracts were then screened and the articles that did not fulfil the inclusion criteria were excluded. Finally, the full texts of the remaining articles were examined and articles that fulfilled the inclusion criteria were included in the review.

Inclusion and exclusionThe population being investigated was adults following the resection of an acoustic neuroma. Studies with mixed populations that included bi-lateral vestibular loss or vestibular dysfunction of central or unknown aetiology were excluded. Studies were included if the sample com-prised only post-resection of acoustic neuroma patients or a mixed diagno-sis, which included patients post- resection of an acoustic neuroma and patients with unilateral vestibular

loss with pathophysiological presen-tation and mechanism of recovery comparable with post-acoustic neu-roma resection. Only studies using randomized-controlled trial method-ologies were considered eligible for inclusion.

InterventionsThe review considered vestibular re-habilitation interventions that could include walking or gait training, exer-cise, balance training, or specific ves-tibular rehabilitation treatments such as adaptation exercises, habitu-ation exercises and substitution strategies. The authors found that this treatment is primarily delivered by physical therapists, although they may have also been delivered by other suitably qualified profession-als. Adaptation exercises use the er-ror signal created by retinal slip to induce adaptation of vestibulo- ocular reflex8. The ×1 and ×2 viewing

Data sourcesComputer search results Cochrane database (n = 1) PubMed (n = 291) Embase (n = 253) CINAHL (n = 37) AUSThealth (n = 9)

Outcome: 591 ar�cles

591 �tles screened Outcome: 77 ar�cles

Duplicates removed Outcome: 48 ar�cles

48 abstracts screened Outcome: 8 ar�cles

8 full text screened Outcome: 6 ar�cles

6 ar�cles included in final review

Excluded 514 ar�cles

Excluded 29 duplicates



Figure 1: Literature search and number of articles excluded at each stage dur-ing study selection.

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post-operative vestibular rehabilita-tion intervention or a randomized-controlled trial design.

HeterogeneityThere was considerable diversity in methodological rigour between the six randomized-controlled trials. Quality scores using the PEDro scale ranged from 3–7 (Table 1). An inade-quate description of whether an intention-to-treat analysis was con-ducted and failure to specify the eligibility criteria were common limi-tations of the included investigations. Assessments were blinded in four of

total of 591 hits. Screened by title, 514 were removed at this stage as they were not relevant to this review. A further 29 were duplicates and were removed. Abstracts of the 48 re-maining articles were then screened and eight were identified as poten-tially fulfilling the inclusion criteria. The full text of these eight articles was then retrieved and assessed for eligibility, with two further articles removed as they did not fulfil the in-clusion criteria. For investigations of acoustic neuroma patients, the most common reason for the exclusion of articles was the absence of either a

paradigms8 are commonly used adap-tation exercises. In the ×1 viewing paradigm, the visual target is station-ary and, while maintaining visual fix-ation on the target, the patient moves the head back and forth. In the ×2 viewing paradigm, the target and head are moved in opposite direc-tions, again keeping the target in focus throughout. Both paradigms are generally performed using both a near and a far target. Habituation exercises use repeated exposure to provocative movements to produce a reduction in symptoms8. Substitution exercises rely on the utilization of other strategies, such as vision and somatosensory cues, to compensate for the loss of function8.

Data extraction and quality assessmentThe characteristics of each study including the trial design, sample, in-tervention, outcome measures and summary of results were extracted and tabulated. The methodological quality of the included studies was independently assessed by two re-searchers, after which the results were compared and a consensus was reached. A third researcher was avail-able to arbitrate any unresolved as-sessment disagreements. Each study was rated using the Physiotherapy Evidence Database (PEDro) scale. This scale consists of a checklist of 11 items designed to evaluate the meth-odological quality of clinical trials and has evidence to support its valid-ity and reliability for this purpose9–12. One item (eligibility criteria) relates to external validity and is not used in the calculation of the total PEDro score, which ranges between 0 and 10. The heterogeneity of both interven-tions and outcome measures used in the clinical trials did not allow a valid meta-analysis.

Search resultsAn overview of the literature search and study selection is shown in Figure 1. The searches returned a

Table 1 Quality scores (PEDro* scale) for included randomized trialsPEDro scale items Cakrt

et al., 2010

Cohen et al., 2002

Herdman et al., 1995

Herdman et al., 2003

Mruzek et al., 1995

Vereeck et al., 2008

1. Eligibility criteria specified†

0 1 0 1 0 0

2. Randomization 1 1 1 1 1 1 3. Allocation

concealed0 0 0 0 0 0

4. Groups similar at baseline

0 1 1 1 1 1

5. Blinding of subjects

0 0 0 1 0 0

6. Blinding of therapists

0 0 0 0 0 0

7. Blinding of assessors

0 1 1 1 0 1

8. Adequate follow-up

0 0 1 1 0 1

9. Intention-to-treat analysis‡

0 0 0 0 0 0

10. Between groups statistical comparison

1 1 1 1 1 1

11. Point and variability measures

1 1 1 1 1 1

Total 3 5 6 7 4 6*Range 0–10 points. †Eligibility criteria are related to external validity and not used in the cumulative total. ‡Intention-to-treat analysis may have been undertaken, but was not explicitly stated for all included studies. PED, Physiotherapy Evidence Database



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all of which reported positive find-ings. One of these17 found an im-provement in postural stability and reduction in the complaint of dis-equilibrium with the performance of adaptation exercises in the acute post-operative period (day 3–6). A further study by the same lead au-thor13 reported improvement in gaze stability in a mixed population of patients with unilateral vestibular hypofunction that included patients 2–17 weeks post-resection of an acoustic neuroma. A customized pro-gramme of vestibular rehabilitation that included both adaptation and habituation exercises was found to improve postural control, particu-larly in patients older than 50 years of age18.

Effect of ambulation and balance retrainingThree13,14,18 of six studies included ambulation (walking or gait) and balance training as a component of vestibular rehabilitation. Of the re-maining three studies, two16,17 in-cluded only ambulation training and one15 included only balance training. In four of the studies13,14,17,18, ambula-tion or balance was included in both the control and intervention groups. This did not allow conclusions to be drawn about the effect of these inter-ventions from those studies. One study18 implemented balance train-ing as part of a multi-faceted vestibu-lar rehabilitation intervention and although positive findings were re-ported, it was difficult to attribute improvement to any one facet of the intervention, such as ambulation and balance retraining exercises. Only one study15 specifically examined balance retraining in the acute post-operative period (day 5–14). This study found that patients who under-took balance retraining with visual biofeedback demonstrated better compensation and postural control than patients who performed bal-ance rehabilitation without visual biofeedback cues.

measured in five studies, although with variation in utilization, for ex-ample some studies considered the six Sensory Organisation Test condi-tions,14,15,17 while others considered only one of the six conditions16 or used a composite score14. Two stud-ies17,18 considered clinical measures of balance and gait and one study13 did not include any measures of pos-tural control or balance.

Effect of habituation exercisesThree studies14,16,18 included habitua-tion exercises in the interventions. One study16 implemented habituation exercises as the only primary inter-vention. Findings from this study did not demonstrate a benefit from ha-bituation exercises in the first week post-resection of an acoustic neu-roma for balance, vestibulo-ocular reflex function or spatial orientation. The other two studies14,18 investi-gated habituation exercises in con-junction with balance training. One of these14 reported findings that were similar to the habituation-only inves-tigation; however, the reduction in both motion sensitivity and self- perceived dizziness handicap was suggestive of more rapid improve-ment post-surgery. In contrast, the other reported early vestibular reha-bilitation including habituation, bal-ance and gaze stability exercises resulted in improved postural control for patients older than 50 years of age18. This discrepancy in findings across studies could be due to the ad-dition of gaze stability exercises alone or a combined effect of gaze stability exercises with habituation exercises and balance training. Alternatively, the difference may be reflective of the customization of ves-tibular rehabilitation programmes in one study18 compared with the pre-scriptive approach used in the other two studies14,16.

Effect of adaptation exercisesThe effect of adaptation exercises was investigated in three studies14,17,18,

six investigations. Two studies13,14 also included some patients with unilat-eral vestibular loss not caused by an acoustic neuroma, and all studies had small sample sizes (range, n = 15–65).

A variety of intervention types and duration were reported in the studies including adaptation exercises, ha-bituation exercises, range of motion exercises, balance training, walking, general instruction and social rein-forcement (Table 2). The intervention period in three studies15–17 was lim-ited to the acute post-operative period (day 1–14). In one study18, the inter-ventions commenced in the acute post-operative period (day 3–5) and continued until 12 weeks post-sur-gery. In another14, the interventions were commenced the day after hos-pital discharge and continued until eight weeks post-surgery. Follow-up periods ranged from six days post-operatively17 to 12 months18.

Monitoring of adherence to the intervention protocol varied across the studies. Observations of adher-ence were noted in five studies13,15–18 by the therapist treating each patient daily or through the use of a diary or a calendar. However, only one study13 described the level of adherence to the prescribed intervention and con-sidered a patient to be compliant if he/she completed more than 50% of the prescribed exercises.

There was considerable variation in the outcome measures used across the studies (Table 2). Patients in all except one study13–16,18 underwent tests of vestibular function such as calories, rotary chair testing and quantified dynamic visual acuity be-fore the surgery or interventions. Only three studies13,14,16 used any vestibular functions test as an out-come measure. The investigators in one trial17 decided against the use of some clinical assessment items (Table 2) because of the acuity of their participants and the potential risk of adverse events with more vigorous testing early in the post- operative period. Posturography was

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Tabl

e 2

Sum

mar

y of

stud

y de

sign

s, sa

mpl

es, i

nter

venti

ons,

out

com

e m

easu

res a

nd re

sults

of i

nclu

ded

stud

ies

Stud

ySt

udy

desi

gn a

nd

popu

latio

nIn

terv

entio

nO

utco

me

mea

sure

sSu

mm

ary

of re

sults

Cakr

t et

al.,

20

10

• RC

T•

Patie

nts u

nder

goin

g re

mov

al o

f ve

stibu

lar

schw

anno

ma

• Co

ntro

l gro

up

(n =

8)

• In

terv

entio

n gr

oup

(n =

9)

• In

terv

entio

n: D

ay

5–14

pos

t-sur

gery

• As

sess

men

t: pr

e-op

erati

ve, d

ay 5

an

d da

y 14

pos

t-su

rger

y

Cont

rol:

Reha

bilit

ation

with

out v

isual

bio

feed

back

• Id

entic

al e

xerc

ises t

o th

e in

terv

entio

n gr

oup

Inte

rven

tion:

Reha

bili t

ation

usin

g vi

sual

bio

feed

back

•

Shift

ing

cent

re o

f pre

ssur

e on

forc

e pl

atfor

m w

ith v

isual

targ

ets o

n m

onito

r sc

reen

Both

gro

ups:

Vesti

bula

r ada

ptati

on e

xerc

ises f

or

vesti

bula

r-ocu

lar r

eflex

•

×1 v

iew

ing

ex w

ith n

ear a

nd fa

r tar

get,

horiz

onta

lly a

nd v

ertic

ally

Dura

tion

of tr

eatm

ents

: In

crea

sed

grad

ually

from

min

utes

day

5

post

-sur

gery

, up

to 4

0 m

inut

es o

n th

e da

y of

disc

harg

e (d

ay 1

4 or

15

post

-sur

gery

)

• Po

stur

ogra

phy

– Ce

ntre

of

foot

pre

ssur

e pa

ram

eter

s du

ring

the

Clin

ical

Test

fo

r Sen

sory

In

tera

ction

of

Bal

ance

co

nditi

ons

(1–4

)

Firm

surf

ace

with

eye

s clo

sed:

Con

trol

and

inte

rven

tion

grou

ps si

mila

r

Foam

surf

ace

with

eye

s clo

sed:

Sta

tistic

ally

sign

ifica

nt

impr

ovem

ent i

n in

terv

entio

n gr

oup

in 5

out

of 7

cen

tre

of fo

ot p

ress

ure

para

met

ers (

p va

lues

0.0

08–0

.027

)

Sum

mar

yTh

ese

findi

ngs i

ndic

ate

visu

al b

ased

reha

bilit

ation

tr

eatm

ent i

mpr

oved

pos

tura

l con

trol

bett

er th

an

reha

bilit

ation

with

out v

isual

feed

back

Cohe

n

et a

l.,

2002

• RC

T•

Patie

nts s

ched

uled

fo

r res

ectio

n of

AN

(n

= 3

1)•

Cont

rol g

roup

(n

= 1

5)•

Inte

rven

tion

grou

p (n

= 1

6)•

Inte

rven

tion:

Day

1

post

-sur

gery

to

disc

harg

e da

y 5–

6 po

st-s

urge

ry•

Asse

ssm

ent:

pre-

oper

ative

, di

scha

rge,

ap

prox

imat

ely

3, 7

an

d 13

wee

ks p

ost-

surg

ery

Cont

rol:

Atten

tion

from

labo

rato

ry a

ssist

ant

• Ar

ousa

l and

psy

chol

ogic

al su

ppor

tIn

terv

entio

n:Se

en b

y th

erap

istDa

y 1:

• Pa

ssiv

e ra

nge

of m

otion

of h

ead

and

neck

in y

aw, p

itch

and

roll

whi

le ly

ing

sem

i rec

lined

in b

ed, y

aw li

mite

d by

dr

essin

g siz

e to

ope

rate

d sid

eDa

y 2

and

3:

• Pa

ssiv

e ra

nge

of m

otion

with

hea

d aw

ay fr

om b

ed fo

r ful

l ran

ge o

f moti

on;

activ

e ra

nge

of m

otion

as f

ast a

s po

ssib

le•

Perfo

rmed

sitti

ng in

bed

or c

hair

if po

ssib

leDa

y 3:

•

Pass

ive

rang

e of

moti

on w

ith h

ead

away

from

bed

for f

ull r

ange

of m

otion

;

• Ro

tary

cha

ir te

sting

– ve

stibu

lar-

ocul

ar re

flex

• Su

bjec

tive

verti

go in

tens

ity

and

freq

uenc

y•

Dyna

mic

po

stur

ogra

phy

– Se

nsor

y or

gani

satio

n te

st•

Path

inte

grati

on

test

Verti

go in

tens

ity a

nd fr

eque

ncy:

No

signi

fican

t diff

eren

ce b

etw

een

grou

ps

Vesti

bula

r-ocu

lar r

eflex

(VO

R) :

No

signi

fican

t effe

ct o

f age

, lev

el o

r ver

tigo

or

expe

rimen

tal g

roup

on

VOR

gain

, sym

met

ry o

r as

ymm

etry

Sens

ory

orga

nisa

tion

test

(Con

ditio

n 5)

:N

o sig

nific

ant d

iffer

ence

bet

wee

n ex

perim

enta

l gro

ups

Path

inte

grati

on:

No

signi

fican

t diff

eren

ce b

etw

een

expe

rimen

tal g

roup

s

Sum

mar

yN

o ev

iden

ce fo

r ves

tibul

ar re

habi

litati

on d

urin

g ac

ute

post

-ope

rativ

e w

eek

in te

rms o

f im

prov

ed V

OR

func

tion,

bal

ance

and

spati

al o

rient

ation

Rate

of c

ompe

nsati

on re

late

d to

tum

our s

ize(C

ontd

.)



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ciati

on fo

r Med

ical

Eth

ics (

AME)

eth

ical

rule

s of d

isclo

sure

.

Review

Tabl

e 2

(Con

tinue

d)St

udy

Stud

y de

sign

and

po

pula

tion

Inte

rven

tion

Out

com

e m

easu

res

Sum

mar

y of

resu

lts

Cohe

n

et a

l.,

2002

activ

e ra

nge

of m

otion

as f

ast a

s pos

sible

• Pe

rform

ed si

tting

in c

hair

• Co

mm

ence

d tr

unk

mov

emen

ts in

all

plan

es, c

ombi

ned

with

upp

er li

mb

reac

hing

mov

emen

ts re

quiri

ng p

atien

t to

turn

and

look

whi

lst re

achi

ng•

Wal

king

if to

lera

ted

Day

4 an

d 5:

•

Activ

e ra

nge

of m

otion

hea

d w

hile

sitti

ng•

Wal

king

long

er d

istan

ces f

rom

3 to

10

m a

s tol

erat

ed w

ith a

ugm

ente

d he

ad m

ovem

ents

in p

itch

and

yaw

Da

y 5

or 6

: •

Disc

harg

e at

surg

eon’

s disc

retio

n ba

sed

on m

edic

al st

atus

and

safe

mob

ility

. Bo

th g

roup

s:•

Patie

nts s

een

2× d

aily

• Du

ratio

n gr

adua

lly in

crea

sed

as

tole

rate

d fr

om 5

min

utes

of t

reat

men

t da

y 1

to 3

0 m

inut

es d

ay b

efor

e di

scha

rge

Herd

man

et

al.,

19

95

• RC

T•

Patie

nts s

ched

uled

fo

r res

ectio

n of

AN

(n

= 1

9)•

Cont

rol g

roup

(n

= 8

)•

Inte

rven

tion

grou

p (n

= 1

1)•

Inte

rven

tion:

co

mm

ence

d da

y 3

post

-sur

gery

• As

sess

men

t:

pre-

oper

ative

, dai

ly

post

-sur

gery

Cont

rol:

Smoo

th p

ursu

it ex

erci

ses (

with

out h

ead

mov

emen

t) p

erfo

rmed

:•

in b

oth

verti

cal a

nd h

orizo

ntal

di

recti

ons

• in

stan

ding

and

sitti

ng•

for 1

min

ute

each

, five

tim

es p

er d

ay,

for t

otal

of 2

0 m

inut

es p

er d

ayIn

terv

entio

n:Ex

erci

ses t

o in

crea

se v

estib

ular

gai

n (×

1 vi

ewin

g pa

radi

gm (h

orizo

ntal

and

ver

tical

he

ad m

ovem

ents

mai

ntai

ning

visu

al

fixati

on) p

erfo

rmed

:•

on n

ear t

arge

t (ar

ms l

engt

h) o

r far

ta

rget

(acr

oss t

he ro

om)

• in

stan

ding

and

sitti

ng

• VA

S fo

r ve

rtigo

and

di

sequ

ilibr

ium

• Ro

mbe

rg•

Qua

litati

ve g

ait

anal

ysis

• O

culo

mot

or te

st–

Spon

tane

ous

nyst

agm

us–

Gaze

evo

ked

nyst

agm

us–

VOR

to sl

ow

and

horiz

onta

l he

ad th

rust

s

Verti

go:

No

diffe

renc

e be

twee

n gr

oups

Dise

quili

briu

m:

At d

ay 1

–4 p

ost-s

urge

ryth

ere

was

no

diffe

renc

e be

twee

n gr

oups

At d

ay 5

and

6 p

ost-s

urge

ry th

e in

terv

entio

n gr

oup

expe

rienc

ed le

ss d

isequ

ilibr

ium

than

con

trol

gro

up

(p <

0.0

5)

Rom

berg

:At

day

3, 2

5% o

f con

trol

and

64%

of i

nter

venti

on g

roup

co

uld

perf

orm

with

eye

s clo

sed

At d

ay 6

, 57%

of c

ontr

ol a

nd 8

0% o

f int

erve

ntion

gro

up

coul

d pe

rfor

m w

ith e

yes c

lose

d

Page 7 of 13

Com

petin

g in

tere

sts:

non

e de

clar

ed. C

onfli

ct o

f int

eres

ts: n

one

decl

ared

.Al

l aut

hors

con

trib

uted

to th

e co

ncep

tion,

des

ign,

and

pre

para

tion

of th

e m

anus

crip

t, as

wel

l as r

ead

and

appr

oved

the

final

man

uscr

ipt.

All a

utho

rs a

bide

by

the

Asso

ciati

on fo

r Med

ical

Eth

ics (

AME)

eth

ical

rule

s of d

isclo

sure

.



Review

• fo

r 1 m

inut

e ea

ch, fi

ve ti

mes

per

day

, fo

r a to

tal o

f 20

min

utes

a d

ayBo

th g

roup

s:Am

bula

tion

• Po

stur

ogra

phy

– Pe

ak to

pea

k an

terio

r–po

ster

ior

sway

– To

tal s

way

pa

th–

Freq

uenc

y of

sw

ay

Qua

litati

ve g

ait a

naly

sis:

At d

ay 3

, all

subj

ects

had

wid

e ba

se o

f sup

port

, m

inim

al–m

oder

ate

atax

ia a

nd re

duce

d he

adm

ovem

ent.

Thre

e of

8 in

con

trol

gro

up a

nd 3

of 1

1 in

th

e in

terv

entio

n gr

oup

need

ass

istan

ce o

f one

per

son

for s

afe

ambu

latio

nAt

day

6, a

ll of

the

cont

rol g

roup

and

40%

of

inte

rven

tion

grou

p w

ere

cons

ider

ed to

hav

e an

abn

orm

al g

ait.

All o

f the

con

trol

and

50%

of

inte

rven

tion

grou

p ha

d so

me

atax

ia o

r ata

xia

with

hea

d tu

rns w

hilst

wal

king

No

signi

fican

t diff

eren

ce b

etw

een

gait

on d

ay 6

pos

t-op

erati

vely

and

any

pre

-ope

rativ

e cl

inic

al a

sses

smen

t

Gaze

evo

ked

nyst

agm

us (r

oom

ligh

t):

At d

ay 3

, 88%

of t

he c

ontr

ol a

nd 9

1% o

f the

inte

rven

tion

grou

p ha

d ga

ze e

voke

d ny

stag

mus

At d

ay 6

, 71%

of t

he c

ontr

ol a

nd 7

3% o

f the

inte

rven

tion

grou

p ha

d ga

ze e

voke

d ny

stag

mus

VOR

(clin

ical

) to

slow

hea

d ro

tatio

ns:

At d

ay 3

, 25%

of t

he c

ontr

ol a

nd 5

5% o

f the

inte

rven

tion

grou

p ha

d cl

inic

ally

nor

mal

VO

RAt

day

6, 2

9% o

f the

con

trol

and

73%

of t

he in

terv

entio

n gr

oup

had

clin

ical

ly n

orm

al V

OR

Post

urog

raph

y:

At d

ay 3

, the

re w

as n

o di

ffere

nce

in p

eak

to p

eak

sway

be

twee

n pr

e- a

nd p

ost-s

urge

ry m

easu

res o

n te

sts

1–3

for c

ontr

ol o

r int

erve

ntion

gro

ups.

The

re w

as a

di

ffere

nce

(p <

0.0

5) b

etw

een

pre-

and

pos

t-sur

gery

on

test

s 4–6

for b

oth

cont

rol a

nd in

terv

entio

n gr

oups

.At

day

6, t

here

was

no

diffe

renc

e be

twee

n pr

e- a

nd

post

-sur

gery

on

test

s 1–3

for c

ontr

ol o

r int

erve

ntion

gr

oups

. The

re w

as a

sign

ifica

nt d

iffer

ence

(p <

0.0

2)

betw

een

pre-

and

pos

t-sur

gery

on

test

4–6

for t

he

cont

rol g

roup

. The

re w

as a

sign

ifica

nt d

iffer

ence

(p

< 0

.04)

bet

wee

n pr

e- a

nd p

ost-s

urge

ry fo

r tes

t 5 a

nd

6 bu

t no

diffe

renc

e on

test

4 fo

r int

erve

ntion

gro

up

Sum

mar

y:Ve

stibu

lar a

dapt

ation

exe

rcise

s dur

ing

the

initi

al p

ost-

surg

ical

per

iod

faci

litat

es ra

te o

f rec

over

y of

pos

tura

l(C

ontd

.)



Page 8 of 13

Com

petin

g in

tere

sts:

non

e de

clar

ed. C

onfli

ct o

f int

eres

ts: n

one

decl

ared

.Al

l aut

hors

con

trib

uted

to th

e co

ncep

tion,

des

ign,

and

pre

para

tion

of th

e m

anus

crip

t, as

wel

l as r

ead

and

appr

oved

the

final

man

uscr

ipt.

All a

utho

rs a

bide

by

the

Asso

ciati

on fo

r Med

ical

Eth

ics (

AME)

eth

ical

rule

s of d

isclo

sure

.

Review

Tabl

e 2

(Con

tinue

d)St

udy

Stud

y de

sign

and

po

pula

tion

Inte

rven

tion

Out

com

e m

easu

res

Sum

mar

y of

resu

lts

stab

ility

, dec

reas

es e

xper

ienc

e of

dise

quili

briu

m a

nd

impr

oves

VO

R cl

inic

ally

Herd

man

et

al.,

20

03

• RC

T•

Patie

nts w

ith

unila

tera

l ves

tibul

ar

loss

refe

rred

to

labo

rato

ry fo

r as

sess

men

t

• Co

ntro

l gro

up

(n =

8)

• In

terv

entio

n gr

oup

(n =

13)

• In

terv

entio

n:

4–5

wee

ks

• As

sess

men

t: pr

e-in

terv

entio

n,

2-w

eek

inte

rval

s aft

er c

omm

enci

ng

inte

rven

tion

Cont

rol:

Vesti

bula

r neu

tral

exe

rcise

s•

Sacc

adic

eye

mov

emen

ts w

ith h

ead

stati

onar

y ag

ains

t a fe

atur

eles

s sur

face

Gait

and

bala

nce

exer

cise

s•

Excl

udin

g ex

erci

sed

inco

rpor

ating

hea

d m

ovem

ents

Inte

rven

tion:

Adap

tatio

n ex

erci

ses

(×1

and

×2 v

iew

ing

para

digm

s)Ey

e–he

ad e

xerc

ises t

o ta

rget

Gait

and

bala

nce

exer

cise

s

Both

gro

ups:

Hom

e pr

ogra

mm

e•

perf

orm

ed e

xerc

ises 4

–5×

daily

for a

to

tal o

f 20–

30 m

inut

es

• pl

us 2

0 m

inut

es b

alan

ce a

nd g

ait

exer

cise

s

• Dy

nam

ic v

isual

ac

uity

– Pr

edic

tabl

e he

ad

mov

emen

t (s

ubje

ct

mov

es h

ead)

– U

npre

dict

able

he

ad

mov

emen

t (a

sses

sor

mov

es h

ead)

• VA

S fo

r visu

al

blur

ring

Dyna

mic

visu

al a

cuity

cha

nge:

Ther

e w

as n

o ch

ange

in d

ynam

ic vi

sual

acu

ity p

redi

ctab

le

or u

npre

dict

able

in th

e co

ntro

l gro

up. T

here

was

sig

nific

ant i

mpr

ovem

ent (

p <

0.01

) in

dyna

mic

visu

al

acui

ty p

redi

ctab

le in

the

inte

rven

tion

grou

p w

ith 1

2 of

13

subj

ects

retu

rnin

g to

nor

mal

for a

ge. I

nter

venti

on g

roup

al

so h

ad si

gnifi

cant

impr

ovem

ent (

p <

0.01

) in

dyna

mic

vi

sual

acu

ity u

npre

dict

able

O

nly

exer

cise

type

con

trib

uted

sign

ifica

ntly

(p =

0.0

09)

to c

hang

e in

dyn

amic

visu

al a

cuity

pre

dict

able

and

for

50.5

% o

f cha

nge

in d

ynam

ic v

isual

acu

ity u

npre

dict

able

VAS

for v

isual

blu

rrin

g:Th

ere

was

a si

gnifi

cant

redu

ction

in v

isual

blu

rrin

g fo

r co

ntro

l (p

= 0.

02) a

nd in

terv

entio

n gr

oup

(p =

0.0

3)

Sum

mar

yTh

e re

cove

ry o

f gaz

e st

abili

ty d

urin

g pr

edict

able

hea

d m

ovem

ents

and

to a

less

er e

xten

t unp

redi

ctab

le

head

mov

emen

ts, c

an b

e fa

cilita

ted

with

ves

tibul

ar

reha

bilit

ation

exe

rcise

s. Im

prov

emen

t occ

urs i

n <5

wee

ksM

ruze

k et

al.,

19

95

• RC

T•

24 p

atien

ts

sche

dule

d fo

r un

ilate

ral v

estib

ular

ab

latio

n•

Cont

rol g

roup

, (n

= 8

)•

Inte

rven

tion

gr

oup

1 (n

= 8

)•

Inte

rven

tion

gr

oup

2 (n

= 8

)•

Inte

rven

tion:

co

mm

ence

d da

y 1

po

st-h

ospi

tal

disc

harg

e

Cont

rol G

roup

:Ra

nge

of m

otion

pro

gram

me

• Sh

ould

er, e

lbow

, hip

, kne

e an

d an

kle

rang

e of

moti

on e

xerc

ises p

erfo

rmed

in

sitting

pos

ition

• N

o he

ad a

nd n

eck

moti

ons

Soci

al re

info

rcem

ent

• En

cour

agem

ent a

nd p

raise

for

parti

cipa

ting

in e

xerc

ises

• 3–

5 m

inut

e ph

one

calls

, 1–2

tim

es

per w

eek—

rem

inde

d to

do

exer

cise

s,

rein

forc

ed c

ompl

ianc

e an

d en

cour

aged

to

con

tinue

pro

gram

me

• 10

–15

min

ute

mee

tings

with

ph

ysio

ther

apist

dur

ing

follo

w-u

p te

sting

• Dy

nam

ic

post

urog

raph

y–

Sens

ory

Org

anisa

tion

Test

• M

otion

Se

nsiti

vity

Q

uotie

nt•

Dizz

ines

s Ha

ndic

ap

Inve

ntor

y•

Rota

ry c

hair

– As

ymm

etry

in

dex

Sens

ory

orga

nisa

tion

test

:In

terv

entio

n gr

oup

2 pe

rfor

med

sign

ifica

ntly

bett

er

(p =

0.0

13) t

han

the

cont

rol g

roup

on

sens

ory

orga

nisa

tion

test

con

ditio

n tw

o at

five

wee

ks p

ost-

surg

ery.

The

re w

ere

no o

ther

sign

ifica

nt d

iffer

ence

s

Moti

on se

nsiti

vity

quo

tient

:At

7 w

eeks

pos

t-sur

gery

bot

h in

terv

entio

n gr

oups

had

sig

nific

antly

less

(p =

0.0

3) m

otion

sens

itivi

ty th

an th

e co

ntro

l gro

up

Dizz

ines

s han

dica

p in

vent

ory:

At 8

wee

ks p

ost-s

urge

ry, i

nter

venti

on g

roup

1 h

ad

signi

fican

tly le

ss (p

= 0

.05)

phy

sical

disa

bilit

y th

an th

e co

ntro

l gro

up

Page 9 of 13

Com

petin

g in

tere

sts:

non

e de

clar

ed. C

onfli

ct o

f int

eres

ts: n

one

decl

ared

.Al

l aut

hors

con

trib

uted

to th

e co

ncep

tion,

des

ign,

and

pre

para

tion

of th

e m

anus

crip

t, as

wel

l as r

ead

and

appr

oved

the

final

man

uscr

ipt.

All a

utho

rs a

bide

by

the

Asso

ciati

on fo

r Med

ical

Eth

ics (

AME)

eth

ical

rule

s of d

isclo

sure

.



Review

• As

sess

men

t:

With

in 1

mon

th

pre-

oper

ative

, da

y 5

post

-sur

gery

, th

en 2

, 5 a

nd 7

w

eeks

pos

t-sur

gery

se

ssio

ns—

prog

ress

disc

usse

d,

ques

tions

ans

wer

ed, v

erba

l en

cour

agem

ent o

ffere

d

Subj

ects

wer

e gi

ven

no in

stru

ction

abo

ut

parti

cipa

ting

in a

ny re

gula

r acti

vity

but

m

ay h

ave

rece

ived

gen

eral

inst

ructi

on

from

the

phys

icia

n

Inte

rven

tion

1:Ve

stibu

lar r

ehab

ilita

tion

• Ha

bitu

ation

exe

rcise

s •

Bala

nce

exer

cise

s•

Daily

wal

king

pro

gram

me

Soci

al re

info

rcem

ent

• As

per

con

trol

gro

up

Inte

rven

tion

2:•

Vesti

bula

r reh

abili

tatio

n •

As p

er in

terv

entio

n gr

oup

1

All g

roup

s:Co

mm

ence

d as

hom

e pr

ogra

mm

e on

the

day

after

hos

pita

l disc

harg

eIn

stru

cted

to p

erfo

rm

• 15

-min

ute

sess

ions

, tw

ice

per d

ay•

daily

wal

k (g

roup

s 1 a

nd 2

onl

y)

Asym

met

ry in

dex:

No

signi

fican

t diff

eren

ce b

etw

een

grou

ps. A

sym

met

ry

at se

ven

wee

ks p

ost-s

urge

ry w

as c

lose

to p

re-s

urge

ry

leve

ls

Sum

mar

yPa

tient

s can

effe

ctive

ly c

ompe

nsat

e irr

espe

ctive

of t

he

ther

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in

moti

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perc

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d di

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andi

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for p

atien

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artic

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ves

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ar re

habi

litati

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ests

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e ra

pid

and

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aps m

ore

com

plet

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ry in

thes

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tient

s

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eck

et a

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2008

• RC

T •

57 p

atien

ts fo

r re

secti

on o

f AN

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ntro

l gro

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roup

>5

0 ye

ars (

n =

11)

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terv

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n gr

oup

<50

year

s (n

= 16

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rven

tion

grou

p >5

0 ye

ars (

n =

15)

• In

terv

entio

n:

com

men

ced

post

-op

erati

vely

and

Cont

rol:

(gen

eral

inst

ructi

ons)

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lyIn

form

ation

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ruct

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wal

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at a

t tab

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atch

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read

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nd

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spor

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rmal

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ven

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bala

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berg

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am)

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arpe

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lim

b st

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med

up

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go te

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ait

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nam

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ait

inde

x

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e in

terv

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etter

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than

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gro

up o

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l tes

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t all

asse

ssm

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ynam

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ait I

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acut

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d (1

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d st

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alan

ce a

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ndem

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t in

the

follo

w-u

p pe

riod

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2 m

onth

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6 w

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pos

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, bal

ance

mat

ched

per

surg

ery

mea

sure

s in

the

inte

rven

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grou

p. A

t 12

wee

ks p

ost-

surg

ery,

the

inte

rven

tion

grou

p pe

rfor

med

bett

er th

an

pre-

surg

ery

At 1

yea

r pos

t-sur

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, the

inte

rven

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grou

p sti

ll pe

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med

bett

er th

an p

re-s

urge

ry

(Con

td.)



Page 10 of 13

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Tabl

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(Con

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Inte

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com

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Sum

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spita

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, 3, 6

, 9

and1

2 w

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6

and

12 m

onth

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st-s

urge

ry

Inte

rven

tion:

(c

usto

mize

d ve

stibu

lar r

ehab

ilita

tion)

Pre-

oper

ative

lyIn

form

ation

Post

-ope

rativ

ely

Sam

e as

con

trol

gro

ups p

lus

Basic

exe

rcise

s•

Com

men

ced

day

3–5

post

-sur

gery

• Su

perv

ised

wal

king

with

dec

reas

ing

base

of s

uppo

rt, i

ncor

pora

te h

ead

mov

emen

ts, t

read

mill

wal

king

Post

-disc

harg

e fo

llow

-up

cust

omize

d ho

me

prog

ram

me

• 5

activ

ities

incl

udin

g ga

ze st

abili

ty a

nd

moti

on se

nsiti

vity

, bal

ance

and

wal

king

• Pe

rform

ed 3

× da

ily, t

otal

30

min

/day

Patie

nts <

50 y

ears

: N

o sig

nific

ant e

ffect

of e

xper

imen

tal g

roup

on

test

s

Sum

mar

yFo

r pati

ents

>50

yea

rs e

arly

cus

tom

ized

vesti

bula

r re

habi

litati

on re

sulte

d in

bett

er p

ostu

ral c

ontr

ol th

an

gene

ral i

nstr

uctio

ns o

nly

For p

atien

ts <

50 y

ears

gen

eral

inst

ructi

ons m

ay b

e en

ough

; how

ever

, som

e yo

unge

r pati

ents

may

ben

efit

from

a v

estib

ular

reha

bilit

ation

pro

gram

me

Page 11 of 13

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Review

Study limitationsThere were a number of limitations evident from this review of random-ized-controlled trials. In addition to the presence of only a small number of randomized studies, all had small sample sizes. Most of the studies in-vestigated vestibular rehabilitation interventions within the first two weeks post-operatively, with only two14,18 continuing interventions for eight and 12 weeks, respectively. Only one study18 included six- and 12-month follow-up assessments, making it difficult to speculate about the long-term effect of vestibular rehabilitation interventions on the patient group. The heterogeneity in interventions across studies and the outcome measures used did not allow valid meta-analyses. Greater consistency of outcome measures used and standardized time-frames for application of the measures in fu-ture studies will aid the interpreta-tion of pooled results across clinical trials and allow stronger conclusions to be drawn.

Compliance with exercise proto-cols is another important consider-ation that was not adequately reported across the trials. Vestibular rehabilitation interventions include exercises that may induce symptoms of dizziness and related discomfort. Patients may not adhere to treatment protocols to avoid discomfort (or for other reasons). It is likely that some level of adherence to the ves-tibular rehabilitation intervention is a pre-requisite to its effectiveness. Non-compliance with exercises is likely to adversely affect the findings of a study and careful monitoring is warranted. This is perhaps easier among inpatients than community-based patients. It is possible for fu-ture studies to mandate a minimum level of compliance with the inter-vention protocol if the aim is to inves-tigate the direct response to the vestibular rehabilitation intervention. However, if the aim of a trial is to inves-tigate the feasibility and effectiveness

exercises in combination with other vestibular rehabilitation interven-tions such as adaptation exercises, gait and balance training may pro-mote more rapid recovery18.

For patients older than 50 years of age, customized vestibular reha-bilitation incorporating adaptation, habituation, balance and mobility im-proved outcomes18. For most patients younger than 50 years of age, a sim-ple exercise programme may be suf-ficient18, although it may be necessary to screen for patients likely to require more customized or intensive reha-bilitation. The Romberg test with closed eyes performed on the third post-operative day was identified as a potential indicator of such patients17. Interestingly, age was not a predictor of recovery13,16,17 following resection of an acoustic neuroma.

Findings from this review have provided a more focused analysis of the clinical trial evidence for vestibu-lar rehabilitation following resection of an acoustic neuroma than that reported in the 2007 Cochrane re-view of vestibular rehabilitation7. None of the studies of vestibular re-habilitation following resection of an acoustic neuroma included in the Cochrane review were included in a comparative analysis between forms of vestibular rehabilitation. It is possible that the variability in the findings of the Cochrane review is a result of considering vestibular reha-bilitation interventions collectively rather than isolating techniques to determine which approach is the most effective. This is in contrast with this systematic review, which considered the different types of vestibular rehabilitation interven-tions or combinations of interven-tions. A more detailed analysis of the randomized-controlled trials investi-gating vestibular rehabilitation fol-lowing the resection of an acoustic neuroma has provided greater in-sight into the efficacy of various com-ponents of vestibular rehabilitation interventions.

Effect of social reinforcement and attention and instructionThe effect of social reinforcement on post-operative recovery was investi-gated in one study14, which found no statistically significant difference in outcomes between treatment and control groups. However, a trend to-wards reduced emotional scores on the Dizziness Handicap Inventory our weeks post-operatively was evi-dent. The small sample size (n = 24) for this three group trial (8 per group) indicated that a Type 2 error may have occurred.

ConclusionMain findingsThe six investigations included in this systematic review have provided some empirical evidence to support the use of vestibular rehabilitation following resection of an acoustic neuroma. The heterogeneous quality of clinical trial reporting, the inter-ventions evaluated and the outcome measures used helped the authors to draw reserved conclusions on the effectiveness of the vestibular reha-bilitation interventions that were evaluated. Overall, there appears to be evidence for the use of adaptation exercises13,17,18, at least in the acute post-operative period.

Current clinical trial evidence does not support the use of habituation exercises in isolation following resection of an acoustic neuroma. Differences in the findings between the two studies of habituation exercises14,16 may be attributed to the outcome measures used. One study14 used the Motion Sensitivity Quotient19, a measure of motion-induced dizzi-ness, and the Dizziness Handicap Inventory20, a measure of self-perceived disability due to vestibular dysfunction. The inclusion of the Motion Sensitivity Quotient in the other study16 may have yielded a dif-ferent result. A salient finding from this study, though, is that habituation exercises did not produce a change in vestibulo-ocular reflex. Habituation



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e de

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onfli

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one

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anus

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and

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the

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bide

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Review

10. Foley NC, Bhogal SK, Teasell RW, Bureau Y, Speechley MR. Estimates of quality and reliability with the physio-therapy evidence-based database scale to assess the methodology of randomized controlled trials of pharmacological and nonpharmacological interventions. Phys Ther. 2006 Jun;86(6):817–24.11. Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M. Reliability of the PEDro scale for rating quality of random-ized controlled trials. Phys Ther. 2003 Aug;83(8):713–21.12. Moseley AM, Herbert RD, Sherrington C, Maher CG. Evidence for physiotherapy practice: a survey of the Physiotherapy Evidence Database (PEDro). Aust J Physiother. 2002;48(1):43–9.13. Herdman SJ, Schubert MC, Das VE, Tusa RJ. Recovery of dynamic visual acu-ity in unilateral vestibular hypofunction. Arch Otolaryngol Head Neck Surg. 2003 Aug;129(8):819–24.14. Mruzek M, Barin K, Nichols DS, Burnett CN, Welling DB. Effects of vestib-ular rehabilitation and social reinforce-ment on recovery following ablative vestibular surgery. Laryngoscope. 1995 Jul;105(7 Pt 1):686–92.15. Cakrt O, Chovanec M, Funda T, Kalitová P, Betka J, Zverina E, et al. Exercise with visual feedback improves postural stabil-ity after vestibular schwannoma surgery. Eur Arch Otorhinolaryngol. 2010 Sep; 267(9):1355–60.16. Cohen HS, Kimball KT, Jenkins HA. Factors affecting recovery after acoustic neuroma resection. Acta Otolaryngol. 2002 Dec;122(8):841–50.17. Herdman SJ, Clendaniel RA, Mattox DE, Holliday MJ, Niparko JK. Vestibular adaptation exercises and recovery: acute stage after acoustic neuroma resection. Otolaryngol Head Neck Surg. 1995 Jul; 113(1):77–87.18. Vereeck L, Wuyts FL, Truijen S, De Valck C, Van de Heyning PH. The effect of early customized vestibular rehabilita-tion on balance after acoustic neuroma resection. Clin Rehabil. 2008 Aug;22(8): 698–713.19. Shepard NT, Telian SA. Programmatic vestibular rehabilitation. Otolaryngol Head Neck Surg. 1995 Jan;112(1):173–82.20. Jacobson GP, Newman CW. The devel-opment of the Dizziness Handicap Inventory. Arch Otolaryngol Head Neck Surg. 1990 Apr;116(4):424–7.

outcomes and where the greatest benefit can be achieved.

Abbreviations list CINAHL, Cumulative Index to Nursing and Allied Health Literature; PEDro, Physiotherapy Evidence Database.

AcknowledgementSteven M McPhail was supported by the National Health and Medical Research Council Early Career Award.

References1. Tufarelli D, Meli A, Labini FS, Badaracco C, De Angelis E, Alesii A, et al. Balance im-pairment after acoustic neuroma surgery. Otol Neurotol. 2007 Sep;28(6):814–21.2. Lynn SG, Driscoll CL, Harner SG, Beatty CW, Atkinson EJ. Assessment of dysequi-librium after acoustic neuroma removal. Am J Otol. 1999 Jul;20(4):484–94.3. Kane NM, Kazanas S, Maw AR, Coakham HB, Torrens MJ, Morgan MH, et al. Functional outcome in patients after exci-sion of extracanalicular acoustic neuro-mas using the suboccipital approach. Ann R Coll Surg Engl. 1995 May;77(3): 210–6.4. El-Kashlan HK, Shepard NT, Arts HA, Telian SA. Disability from vestibular symptoms after acoustic neuroma resec-tion. Am J Otol. 1998 Jan;19(1):104–11.5. Hirvonen TP, Aalto H, Pyykkö I. Decreased vestibulo-ocular reflex gain of vestibular schwannoma patients. Auris Nasus Larynx. 2000 Jan;27(1):23–6.6. Choy NL, Johnson N, Treleaven J, Jull G, Panizza B, Brown-Rothwell D. Balance, mobility and gaze stability deficits re-main following surgical removal of ves-tibular schwannoma (acoustic neuroma): an observational study. Aust J Physiother. 2006;52(3):211–6.7. Hillier SL, Hollohan V. Vestibular reha-bilitation for unilateral peripheral vestib-ular dysfunction. Cochrane Database Syst Rev. 2007 Oct;(4):CD005397.8. Herdman S. ‘Vestibular rehabilitation’. Physical therapy diagnosis for vestibular disorders 3rd ed. Philadelphia: FA Davis Company; 2000. pp228–308.9. de Morton NA. The PEDro scale is a valid measure of the methodological quality of clinical trials: a demographic study. Aust J Physiother. 2009;55(2): 129–33.

of a vestibular rehabilitation protocol in clinical settings, compliance levels are likely to be relevant to clinical practice. Such a study could report the level of compliance and conduct analyses on an intention-to-treat ba-sis, as well as reporting sub-group analyses for patients who did adhere to the protocol. This would be valu-able for informing clinical practice and for the development of interven-tions to promote optimal adherence to vestibular rehabilitation protocols in clinical settings.

Future researchThere are several key priorities for future research. Randomized-controlled trials with larger sample sizes and more rigorous methodolo-gies are needed to investigate the ef-fects of each element of vestibular rehabilitation, as well as when used in combination with comprehensive vestibular rehabilitation program with patients following resection of an acoustic neuroma. Conducting clinical trials with factorial designs offers a useful approach to make these comparisons. Elements of ves-tibular rehabilitation worthy of in-vestigation on their own or in combination include adaptation ex-ercises, habituation exercises, bal-ance training and gait retraining. Investigation of intervention param-eters such as the timing and duration of interventions as well as the mini-mum and optimal ‘dosage’ require-ment to achieve effectiveness should be considered. The effects of educa-tion and social reinforcement also re-quire further investigation. Finally, the development of a clinical predic-tion rule(s) from empirical data would be useful to aid clinical staff in identifying those patients at risk of adverse outcomes and those who are likely to benefit from vestibular reha-bilitation. This would allow limited healthcare resources for this clinical population to be focused on those patient subgroups at risk of poor

Page 13 of 13

Com

petin

g in

tere

sts:

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clar

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onfli

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ts: n

one

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and

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tion

of th

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anus

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t, as

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l as r

ead

and

appr

oved

the

final

man

uscr

ipt.

All a

utho

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bide

by

the

Asso

ciati

on fo

r Med

ical

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ics (

AME)

eth

ical

rule

s of d

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sure

.



Review

Appendix 1 Search syntaxesDatabase Search syntaxCochrane Acoustic neuroma or vestibular schwannoma or acoustic schwannoma or acoustic neurilemoma or acoustic

neurinomaPubMed (acoustic neuroma OR vestibular schwannoma OR acoustic neurinoma OR acoustic neurilemoma OR acoustic

neurilemmoma OR acoustic schwannoma) AND (physiotherapy OR physical therapy OR rehabilitation OR adaptation OR habituation OR balance OR exercise OR gaze stability)

Limits: Humans, All Adult: 19+ yearsEmbase (acoustic neuroma.mp. or exp acoustic neurinoma/) or (exp acoustic neurinoma/ or exp neurilemoma/ or

exp vestibular schwannoma/ or exp neuroma/) and ([physiotherapy.mp. or PHYSIOTHERAPY/] or [physical therapy.mp.]) or ([rehabilitation or adaptation or habituation or gaze stability or balance or exercise].mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer])

limit to (human and [adult <18 to 64 years> or aged <65+ years>])CINAHL ([MH Neuroma, Acoustic+] and [acoustic neuroma or acoustic schwannoma or acoustic neurinoma or acoustic

neurilemoma or acoustic neurilemmoma or vestibular schwannoma]) and ([MH Physical Therapy+] or [physical therapy or physiotherapy or rehabilitation or adaptation or habituation or gaze stability or balance or exercise])

Limit: Human; Age Groups: All AdultAUSThealth (‘acoustic neuroma’ or ‘vestibular schwannoma’ or ‘acoustic neurinoma’ or ‘acoustic neurilemoma’ or

‘acoustic neurilemomma’ or ‘acoustic schwannoma’) and (physiotherapy or ‘physical therapy’) or rehabilitation or exercise or ‘gaze stability’ or adaptation or habituation or balance)

Documents

Vestibular rehabilitation following the removal of an ...cise, balance training, or specific ves-tibular rehabilitation treatments such as adaptation exercises, habitu-ation exercises