Post by eliuri on Jan 2, 2015 0:29:13 GMT -5
Dr Jefferey Staab who coined the diagnostic label of CSD and set forth its diagnostic criteria has an interesting section on VBRT (Vestibular and Balance Rehabilitation Therapy) for CSD.
Three things emerge from his most recent writings on this:
1) The role of VBRT in CSD has not been studied directly but is mostly inferred from retrospective studies where VBRT was used in patients of whom the diagnosis was not known, ie non-specific dizziness.
2) The mechanism by which VBRT works here is along the lines of desensitization rather than compensation.
3) VBRT for CSD needs to be done very much slower and for a considerably longer time to realize success than the VBRT in the early acute phase in which compensation is the major goal.
Here's the relevant section in DR Staab's article on this:
=================
Vestibular and Balance
Rehabilitation Therapy
VBRT is an established intervention for
patients with a variety of vestibular disorders.
It is generally thought that VBRT
works by promoting compensation for
peripheral or central vestibular deficits.
A review of research leading to the development
of VBRT, however, suggests
that it may exert its therapeutic benefits
by an entirely different mechanism, one
that is much more applicable to patients
with CSD.13
The pivotal trials of VBRT
conducted in the early 1990s enrolled
patients with nonspecific dizziness that
had persisted well beyond the time
period during which compensation for
acute vestibular injury takes place.13
This suggests that VBRT operated primarily
as a habituation or desensitization
paradigm to reverse classically
conditioned hypersensitivity to motion
stimuli and operantly conditioned alterations
in gait and stance. In fact, some
of the early researchers used the term
habituation therapy in their early
investigations. The authors of most
large VBRT studies did not report
detailed neuro-otologic diagnoses for
their subjects. Their selection criteria
were more symptomatic in nature,
targeting deficits in function rather than
specific medical diagnoses. Nevertheless,
a review of their selection criteria
indicates that these studies certainly
included patients with CSD.13
To date, no investigations of VBRT
have been specifically designed for
patients with CSD. Therefore, the benefits
of VBRT for CSD must be extrapolated
from clinical experience and
published studies of mixed groups of
patients with chronic nonspecific dizziness.
These suggest an efficacy of 60%
to 80% for reducing the severity of
vestibular symptoms, increasing mobility,
and enhancing daily function.13
These results place VBRT on par with
serotonergic antidepressants. Vestibular
habituation may also be effective in
reducing anxiety and depressive symptoms
in patients with chronic dizziness.
13
In practice, VBRT is a primary
therapeutic option for CSD, with or
without treatment using an SSRI or
SNRI. However, successful treatment of
patients with CSD using VBRT requires
a gentler approach than typically used
for treatment of individuals with acute
vestibular deficits. Habituation exercises
must be less intense at the beginning of
therapy and must be increased more
gradually, or they will exacerbate symptoms.
If that happens, patients are likely
to stop therapy prematurely and consider
VBRT to be a failure.
Maximum benefit may require 3 to 6 months of
diligent treatment. Table 7-3 lists VBRT
treatment strategies that increase the
chances of success in CSD.
TABLE 7-3 Characteristics of a Successful Vestibular Habituation
Program for Chronic Subjective Dizziness
* Pacing
Habituation exercises for chronic subjective dizziness (CSD) begin more
gently and increase more slowly than compensation exercises for acute
vestibular deficits.
A daily exercise plan overcomes instinctive avoidance of provocative
stimuli even if it starts with just a few minutes of habituation activities
that the patient performs at home.
Scheduled breaks during exercises improve adherence and limit the
potential to exacerbate symptoms.
* Persistence
The habituation process for CSD may take more time than the
compensation process for acute vestibular deficits.
Full benefits of vestibular habituation may not be realized for 3 to 6months.
* Visual Flow and Visual Complexity
Exercises that include visual flow and complex visual stimuli address the
visual symptoms of CSD.
* Real-World Settings
Use of indoor and outdoor settings that patients typically encounter
promotes reintegration into daily activities
From:
Jefferey Staab MD: Chronic Subjective Dizziness: Continuum Lifelong Learning Neurol 2012;18(5):1118–1141
====================
Obviously, this is still a very sketchy outline of the basic approach. More specific regimens clearly need to be developed. Ideally, a vestibular therapist should be working in conjunction with a physical therapist for optimal results , given the probable role of muscle tension in many with this syndrome.
~eliuri
Three things emerge from his most recent writings on this:
1) The role of VBRT in CSD has not been studied directly but is mostly inferred from retrospective studies where VBRT was used in patients of whom the diagnosis was not known, ie non-specific dizziness.
2) The mechanism by which VBRT works here is along the lines of desensitization rather than compensation.
3) VBRT for CSD needs to be done very much slower and for a considerably longer time to realize success than the VBRT in the early acute phase in which compensation is the major goal.
Here's the relevant section in DR Staab's article on this:
=================
Vestibular and Balance
Rehabilitation Therapy
VBRT is an established intervention for
patients with a variety of vestibular disorders.
It is generally thought that VBRT
works by promoting compensation for
peripheral or central vestibular deficits.
A review of research leading to the development
of VBRT, however, suggests
that it may exert its therapeutic benefits
by an entirely different mechanism, one
that is much more applicable to patients
with CSD.13
The pivotal trials of VBRT
conducted in the early 1990s enrolled
patients with nonspecific dizziness that
had persisted well beyond the time
period during which compensation for
acute vestibular injury takes place.13
This suggests that VBRT operated primarily
as a habituation or desensitization
paradigm to reverse classically
conditioned hypersensitivity to motion
stimuli and operantly conditioned alterations
in gait and stance. In fact, some
of the early researchers used the term
habituation therapy in their early
investigations. The authors of most
large VBRT studies did not report
detailed neuro-otologic diagnoses for
their subjects. Their selection criteria
were more symptomatic in nature,
targeting deficits in function rather than
specific medical diagnoses. Nevertheless,
a review of their selection criteria
indicates that these studies certainly
included patients with CSD.13
To date, no investigations of VBRT
have been specifically designed for
patients with CSD. Therefore, the benefits
of VBRT for CSD must be extrapolated
from clinical experience and
published studies of mixed groups of
patients with chronic nonspecific dizziness.
These suggest an efficacy of 60%
to 80% for reducing the severity of
vestibular symptoms, increasing mobility,
and enhancing daily function.13
These results place VBRT on par with
serotonergic antidepressants. Vestibular
habituation may also be effective in
reducing anxiety and depressive symptoms
in patients with chronic dizziness.
13
In practice, VBRT is a primary
therapeutic option for CSD, with or
without treatment using an SSRI or
SNRI. However, successful treatment of
patients with CSD using VBRT requires
a gentler approach than typically used
for treatment of individuals with acute
vestibular deficits. Habituation exercises
must be less intense at the beginning of
therapy and must be increased more
gradually, or they will exacerbate symptoms.
If that happens, patients are likely
to stop therapy prematurely and consider
VBRT to be a failure.
Maximum benefit may require 3 to 6 months of
diligent treatment. Table 7-3 lists VBRT
treatment strategies that increase the
chances of success in CSD.
TABLE 7-3 Characteristics of a Successful Vestibular Habituation
Program for Chronic Subjective Dizziness
* Pacing
Habituation exercises for chronic subjective dizziness (CSD) begin more
gently and increase more slowly than compensation exercises for acute
vestibular deficits.
A daily exercise plan overcomes instinctive avoidance of provocative
stimuli even if it starts with just a few minutes of habituation activities
that the patient performs at home.
Scheduled breaks during exercises improve adherence and limit the
potential to exacerbate symptoms.
* Persistence
The habituation process for CSD may take more time than the
compensation process for acute vestibular deficits.
Full benefits of vestibular habituation may not be realized for 3 to 6months.
* Visual Flow and Visual Complexity
Exercises that include visual flow and complex visual stimuli address the
visual symptoms of CSD.
* Real-World Settings
Use of indoor and outdoor settings that patients typically encounter
promotes reintegration into daily activities
From:
Jefferey Staab MD: Chronic Subjective Dizziness: Continuum Lifelong Learning Neurol 2012;18(5):1118–1141
====================
Obviously, this is still a very sketchy outline of the basic approach. More specific regimens clearly need to be developed. Ideally, a vestibular therapist should be working in conjunction with a physical therapist for optimal results , given the probable role of muscle tension in many with this syndrome.
~eliuri