Dizziness is among the most prevalent complaints for which people seek medical help and the incidence of dizziness increases with age.Dizziness represents a diagnostic and treatment challenge for clinicians because it is a subjective sensation, can refer to a variety of symptoms (unsteadiness, spinning, a sense of movement or lightheadedness), and has a multitude of potential contributory factors.Dizziness is often related to vestibular pathology which is treated effectively with vestibular exercises. Unfortunately, a significant proportion of dizzy patients (2 - 40%) never receive a diagnosis for the cause of their dizziness. Successful management of dizziness is critical because dizziness is a major risk factor for falls in older adults. The goal f this study is to develop novel, exercise interventions for older adults with non-vestibular dizziness. There are parallels between the naturally occurring loss of vestibular function with age and the results of pathological loss of vestibular function - both in complaints of dizziness and in an increased risk for falls. Our question, then, is whether the same exercises that are beneficial for patients with vestibular pathology are beneficial for older patients with dizziness but normal vestibular function. It has been established that vestibular exercises decrease dizziness and improve postural stability in patients with vestibular hypofunction. It is unclear, however, if vestibular exercises are beneficial for older individuals with dizziness who are at ris for falls, but do not have vestibular pathology. Yardley et al. found that vestibular rehabilitatio reduced symptoms and increased postural stability in individuals with a primary complaint of dizziness. A limitation of these studies was that the majority of patients did not have a specific diagnosis for the underlying cause of their dizziness. Thus, it is unclear whether vestibular exercises were effective because the patients had undiagnosed vestibular pathology or whether vestibular exercises were an effective exercise approach for patients without vestibular pathology. Given the increased incidence of falls with age and the associated morbidity, the results of this study will be relevant to a substantial number of veterans.
Specific Aim 1 : Examine the extent to which vestibular exercises enhance rehabilitation outcomes in older adults with dizziness without vestibular pathology. We hypothesize that vestibular exercises will reduce symptoms and fall risk and improve gaze and postural stability to a greater extent than placebo exercises.
Specific Aim 2 : Determine the degree to which symptom improvement and fall risk reduction are retained after the intervention is completed. We hypothesize that the benefits of vestibular exercises will be retained after discharge as measured by visual analog scale, balance-related confidence scale, dynamic gait index, and gait speed, and that retention of improvements will be correlated with home exercise compliance.
Specific Aim 3 : Determine factors that influence rehabilitation outcomes. We hypothesize that exercise compliance will predict rehabilitation outcomes and that improved gaze stability will predict reduced fall risk. Older adults (n = 70) with non-vestibular dizziness (i.e., normal vestibular function, defined as normal horizontal semicircular canal and otolith function) who have been referred to physical therapy for balance and gait impairments will be randomized to receive 1) vestibular exercises or 2) placebo eye movement exercises. All subjects will receive standard gait and balance training. Outcome measures include: 1-3) visual analog scale measures of subjective complaints of dizziness, disequilibrium, and percent of time that dizziness interferes with activities;4) disability;5) balance-related confidence;6) visual acuity during head movement as a measure of gaze stability;7) dynamic gait index as a measure of fall risk;8) preferred gait speed;9) sensory organization test as a measure of postural stability. Outcome measures will be assessed at baseline, discharge, and 1-month and 6-months post-discharge from physical therapy.
Relevance of Proposed Research to VA Patient Care Mission: This research directly addresses the mission of the VA by attending to quality-of-life mandates. The number of Veterans age 85 years and older has tripled this decade (VetData, 2010). Older Veterans, particularly those over 85, are among the most vulnerable of the veteran population and are at highest risk for suffering fall-related injuries. An estimate of outpatient costs to the VA in 2001 for fall-related injuries as nearly $3.3 million for the initial visit alone (Luther, 2005). The potential for large economic savings by reducing falls incidence, thus fall-related injuries, is evident. Given the increased incidence of falls with age and the morbidity associated with falls, the results of this study willbe relevant to a substantial number of veterans. The proposed study has the potential to develop novel rehabilitation approaches to reduce the risk of falls in older veterans with dizziness. This project will contribute to improved quality of life and containment of health care costs in the elderly.