Indian Journal of Public Health Research & Development, April-June 2018, Vol.9, No. 2 113 response is related to the time required for the cupola
to be deflected by the pull of endolymph. The increase in Vertigo is related to the relative deflection of cupola.
The decrease in Vertigo as position in maintained is due to cessation of endolymph movement5. In case of BPPV after Viral neuronitis, Head trauma or Stapedectomy the particles which evoke vertigo might be blood cells, phagocytes and endothelial debris. Vertigo is precipitated by certain critical positions of head, usually occurring when the patient lies flat with the head turned to affected side (Hallpike Maneuver). This begins after a latency of 3-4 sec, with a range varying from 1-40 sec.
The manifestation will subside after 10-60 sec. and may abate even in precipitating position. With re-attainment of seated position, the vertigo may revive in the opposite direction, but lasts only several seconds. Although the patient case history is important in the diagnosis of Benign paroxysmal BPPV bserving a classic response during Dix and Hallpike maneuver. A classic response as defined by Dix and Hallpike9, 2has four components : Latency period of few seconds, rotatory nystagmus towards undermost ear (Rt. Ear anti clock wise, left ear clock wise), fatigue after repeated maneuver, duplication of the patient report of Vertigo. However in BPPV ENG results are normal as are the results of Posturography and other clinical tests.
MATeRIAl ANd MeThOd
The study was conducted in Department of Rehabilitation. Study group patients came directly in department of rehabilitation and were referred from the Department of ENT after thorough clinical examination and investigation like caloric testing and audiogram.
Based upon the following diagnostic basis, fifty patients were included in the study. The patients were divided into two groups: Group I – Patients treated by beta histine hydrochloride only, Group II – Patients treated by Vestibular training, with drug given only in emergency circumstances. Patients in whom provisional diagnosis of BPPV was established in our out patient department, beta histine hydrochloride (minimum doses of 8mg three times daily) were given for one month of pre treatment period for acute attack of vertigo to settle down. In pre treatment period with help of beta histine hydrochloride the severity of vertigo, dizziness, nausea or vomiting etc.
was similar in all patient before their categorization in group I or II. In group I Beta histine hydrochloride was administered as a standard anti vertiginous drug at a dose
of 8mg three times daily for one month. During the next five months, the drug was given when patient came with same complaints of dizziness or vertigo, for a period of fifteen days or till symptoms subsided. In-group II beta histine hydrochloride was given only when patient had acute attack of nausea or vomiting during the exercise programme of vestibular training. Training was stopped until acute attack settled down around fifteen days. Two types of exercises – Brandt’s Exercises10 as proposed by Brandt and Daroff. Habituation Exercises as proposed by Noore and Deewerdt11 and Three Phases of Exercises as described by Tangerman and Wheeler12 Phase I – Similar to Brandt and Daroff Protocol Phase II & III – Cawthorne
& Cooksey exercises which incorporate Eye and Head Movements and Variety of Balance Exercises were used in our study. Patients were asked to do exercises every three hours for fifteen minutes during day until patient had no episodes of vertigo for two consecutive days.
Patients were advised to do exercises fifteen minutes three times daily for remaining study period. All patients were instructed to continue their usual daily activities during the study period. In-patients in group II during Vestibular training if acute attack of nausea or vomiting set in then Vestibular training was stopped until acute attack settled down and usually the training is stopped for fifteen days. Using a scoring system VSS severity of symptoms such as vertigo, dizziness and nausea and abnormality of signs in examinations such as Mann’s test, Stepping test and Postural and Positioning test of Dix and Hallpike were evaluated. A comprehensive evaluation of dizziness and disability including the burden of chronic deficits and disability was done by multiple system assessments like Disability scale and Dizziness handicap inventory. Vertigo severity scale was developed by Harrison MS13 in 1975. The evaluation of each patient was done by change in total sum of numerical value of a score for each item during study period. A global judgment of treatment effect was defined by a severity score for all items or a sum of all scores in each patient and was classified accordingly. Data collected from all the variables were entered into a computer using a data base programme . Cross checking of the data for any inconsistensy was done before the data was put for statistically analysis which included both descriptive and inferential statistics. Statistically analysis is done by using non parametric Wilcoxon signed rank test on pre and post treatment results of both groups. Then these results of both groups were again compared statistically by using non parametric Mann Whitney test
114 Indian Journal of Public Health Research & Development, April-June 2018, Vol.9, No. 2
ReSulTS & ObSeRVATIONS
The data of fifty patients with Benign paroxysmal positional vertigo included in this study were analyzed to compare treatment effects of Vestibular training.
The background of each patient with BPPV Sex, age, pretreatment period and duration of onset of illness and complications did not differ significantly among two groups. The mean pretreatment period was four to five weeks in each group. Patient of BPPV on Vestibular training had marked to moderate improvement in Disability score and had marked decreased in number of acute attacks. All patients (Drug therapy and Vestibular training) included in our study showed marked change in DHI pre and post treatment. There was significant difference in dizziness handicapped inventory score between the two groups. Global improvement score also showed mild change in VSS of patients on drug therapy and moderate improvement in VSS of patients who were practicing Vestibular training. All patients
had similar VSS scores in pre treatment period. Patients who did Vestibular training had marked improvement in vertigo and nausea and some improvement in Dizziness, Mann’s and Stepping test where as most of the patients who were on drug therapy had very minimal change in VSS. In drug group patient with nausea did not show any significant improvement (p value .317) where as in Vestibular therapy group patients with nausea had marked improvement (p value .000) In statistical analysis we were able to judge that in both Vestibular therapy group and drug group. Post treatment verses pre treatment P value is highly significant. This means that the effect of drug and Mean rank of difference of post treatment verses pre treatment variables i.e. disability scale, DHI, No. of acute attacks, Manns test, Stepping test, Vertigo, Dizziness, Nausea, VSS was much more of our Vestibular training group then drug group.
This shows that our Vestibular training group responded much better to treatment then drug group.
Table 1: In Vestibular therapy group and drug group difference of post scale to pre scales are highly significant. Non parametric Wilcoxan signed ranks test is used.
Variables Z
GROUP – I Asymptomatic
Significant (2 tailed p value)
Significant/
significant Non-(p<.05 significant)
Z
gROuP-II Asymptomatic
Significant (2 tailed p value)
Significant/
significant
Non-Post−Pre Disability -4.457 .000 HS -4.456 .000 HS
Post −Pre DHI -4.375 .000 HS -4.375 .000 HS
Post−Pre Acute attacks -2.024 .043 S -4.439 .000 HS
Post −Pre Manns Test -2.646 .008 HS -4.613 .000 HS
Post−Pre Stepping Test -3.317 .001 HS -4.716 .000 HS
Post –Pre Vertigo -3.000 .003 HS -4.914 .000 HS
Post−Pre Dizziness -2.236 .025 HS -4.320 .000 HS
Post –Pre Nausea -1.000 .317 NS -3.873 .000 HS
Post−Pre VSS -3.286 .001 HS -4.234 .000 HS
Table 2: Independent samples of Vestibular therapy and drug group were compared by Mann-whitney test.
Difference of post verses pre therapy of both group were taken and were compared in both groups.
gROuP Mean Rank Z P Value Significant/Non Significant
DIF_DISABILITY 1
2 17.56
33.44 -4.089 .000 HS
DIF_DHI 1
2 18.80
32.20 -3.253 .000 HS
DIF_ACUTE ATT 1
2 14.00
37.00 -6.172 .000 HS
Indian Journal of Public Health Research & Development, April-June 2018, Vol.9, No. 2 115 Contd…
DIF_MANN TEST 1
2 16.44
34.56 -4.952 .000 HS
DIF_STEPPING 1
2 17.62
33.38 -4.518 .000 HS
DIF_VERTIGO 1
2 17.32
33.68 -4.812 .000 HS
DIF_DIZZINESS 1
2 13.60
37.40 -6.026 .000 HS
DIF_NAUSEA 1
2 18.50
32.50 -4.202 .000 HS
DIF_VSS 1
2 19.46
31.54 -3.099 .002 HS
CONCluSION
Vestibular training is effective treatment for BPPV and considerably reduces the disability. Improvement rates in both groups, Vestibular training group showed marked improvement in a Disability scale, DHI, No.
of acute attacks, vertigo severity scale where as Drug group showed only slight improvement in above scales.
Vestibular training is definitely better management programme than Drug therapy. DHI is applicable in Indian conditions especially in metropolitan cities like Delhi. Drug therapy is indicated in acute attack of vertigo. No side effect of drug is seen in our study. Beta histine hydrochloride has role in retarding the response of adaptation exercises in BPPV.
ethical Clearance: Taken from human ethical committee
Funding: None
Conflict of Interest: None Acknowledgement: Nil
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