Comparative Efficacy of Vestibular Rehabilitation, Noisy Galvanic Vestibular Stimulation, and Their Combination on Postural Control, Dizziness, Anxiety, and Depression in Patients with Persistent Postural-Perceptual Dizziness
-
Samer Sami Azeez
,
Mansoureh Adel Ghahraman
,
Elham Tavanai
,
Shohreh Jalaie
,
Kazem Malmir
,
Arafat Aldujaili
Abstract
Background and Aim: Persistent postural-perceptual dizziness (PPPD) is a chronic vestibular disorder characterized by persistent dizziness, non-spinning vertigo, or unsteadiness exacerbated by moving visual stimuli and upright postures. Vestibular rehabilitation therapy (VRT) has shown favorable outcomes. While noisy galvanic vestibular stimulation (nGVS) has been associated with improvements in various psychiatric and neurological conditions, its efficacy in PPPD remains unclear. This study aimed to assess the effectiveness of VRT, nGVS, and their combination on patients with PPPD in terms of postural control, dizziness, anxiety, and depression.
Method: Twenty-seven patients diagnosed with PPPD were randomly assigned to three groups receiving treatment for six weeks: 1) VRT, 2) GVS, and 3) VRT+GVS. Outcome measures included static postural control parameters, Dizziness Handicap Inventory (DHI), and Hospital Anxiety and Depression Scale (HADS) scores.
Results: All groups demonstrated significant improvements in subjective measures (DHI and HADS) following treatment. Postural control improvements were observed only in specific conditions within each group, with no overall significant differences between the groups except for mediolateral (ML) path length with eyes closed on a soft surface. Significant correlations were observed between improvements in postural control outcomes and questionnaire scores within each group.
Conclusion: VRT and GVS, both individually and in combination, were effective in subjective measurements but had minimal impact on static postural control. Adding nGVS to VRT did not provide additional benefits for PPPD patients. The correlations between postural control and psychological outcomes suggest that improvements in perceived dizziness, anxiety, and depression may be linked to postural stabilization.
Trial Registration Number: The study was registered in the Iranian Registry of Clinical Trials on 18 September 2023 (IRCT20160131026279N6).
1. Staab JP, Eckhardt-Henn A, Horii A, Jacob R, Strupp M, Brandt T, et al. Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): Consensus document of the committee for the Classification of Vestibular Disorders of the Bárány Society. J Vestib Res. 2017;27(4):191-208. [DOI:10.3233/VES-170622]
2. Popkirov S, Staab JP, Stone J. Persistent postural-perceptual dizziness (PPPD): a common, characteristic and treatable cause of chronic dizziness. Pract Neurol. 2018;18(1):5-13. [DOI:10.1136/practneurol-2017-001809]
3. Madrigal J, Herrón-Arango AF, Bedoya MJ, Cordero Chen J, Castillo-Bustamante M. Persistent Challenges: A Comprehensive Review of Persistent Postural-Perceptual Dizziness, Controversies, and Clinical Complexities. Cureus. 2024;16(5):e60911. [DOI:10.7759/cureus.60911]
4. Thompson KJ, Goetting JC, Staab JP, Shepard NT. Retrospective review and telephone follow-up to evaluate a physical therapy protocol for treating persistent postural-perceptual dizziness: A pilot study. J Vestib Res. 2015;25(2):97-103; quiz 103-4. [DOI:10.3233/VES-150551]
5. Kundakci B, Sultana A, Taylor AJ, Alshehri MA. The effectiveness of exercise-based vestibular rehabilitation in adult patients with chronic dizziness: A systematic review. F1000Res. 2018;7:276. [DOI:10.12688/f1000research.14089.1]
6. Nada EH, Ibraheem OA, Hassaan MR. Vestibular Rehabilitation Therapy Outcomes in Patients With Persistent Postural-Perceptual Dizziness. Ann Otol Rhinol Laryngol. 2019;128(4):323-9. [DOI:10.1177/0003489418823017]
7. Axer H, Finn S, Wassermann A, Guntinas-Lichius O, Klingner CM, Witte OW. Multimodal treatment of persistent postural-perceptual dizziness. Brain Behav. 2020;10(12):e01864. [DOI:10.1002/brb3.1864]
8. Choi SY, Choi JH, Oh EH, Oh SJ, Choi KD. Effect of vestibular exercise and optokinetic stimulation using virtual reality in persistent postural-perceptual dizziness. Sci Rep. 2021;11(1):14437. [DOI:10.1038/s41598-021-93940-z]
9. Eldøen G, Kvalheim SE, Thesen T, Mygland Å, Ljøstad U, Bakke S, et al. Web-based vestibular rehabilitation in persistent postural-perceptual dizziness. Brain Behav. 2021;11(10):e2346. [DOI:10.1002/brb3.2346]
10. Teh CS, Abdullah NA, Kamaruddin NR, Mohd Judi KB, Fadzilah I, Zainun Z, et al. Home-based Vestibular Rehabilitation: A Feasible and Effective Therapy for Persistent Postural Perceptual Dizziness (A Pilot Study). Ann Otol Rhinol Laryngol. 2023;132(5):566-77. [DOI:10.1177/00034894221111408]
11. Ibrahim NMK, Hazza NMA, Yaseen DM, Galal EM. Effect of vestibular rehabilitation games in patients with persistent postural perceptual dizziness and its relation to anxiety and depression: prospective study. Eur Arch Otorhinolaryngol. 2024;281(6):2861-9. [DOI:10.1007/s00405-023-08369-z]
12. Wuehr M, Nusser E, Krafczyk S, Straube A, Brandt T, Jahn K, et al. Noise-Enhanced Vestibular Input Improves Dynamic Walking Stability in Healthy Subjects. Brain Stimul. 2016;9(1):109-16. [DOI:10.1016/j.brs.2015.08.017]
13. Fujimoto C, Yamamoto Y, Kamogashira T, Kinoshita M, Egami N, Uemura Y, et al. Noisy galvanic vestibular stimulation induces a sustained improvement in body balance in elderly adults. Sci Rep. 2016;6:37575. [DOI:10.1038/srep37575]
14. Wardman DL, Taylor JL, Fitzpatrick RC. Effects of galvanic vestibular stimulation on human posture and perception while standing. J Physiol. 2003;551(Pt 3):1033-42. [DOI:10.1113/jphysiol.2003.045971]
15. Scinicariello AP, Eaton K, Inglis JT, Collins JJ. Enhancing human balance control with galvanic vestibular stimulation. Biol Cybern. 2001;84(6):475-80. [DOI:10.1007/PL00007991]
16. Babaee S, Shaabani M, Vahedi M. Comparison of verticality perception and postural sway induced by double temple-mastoidal and bipolar binaural 20 Hz sinusoidal galvanic vestibular stimulation. J Vestib Res. 2022;32(5):407-21. [DOI:10.3233/VES-210112]
17. Ko LW, Chikara RK, Chen PY, Jheng YC, Wang CC, Yang YC, et al. Noisy Galvanic Vestibular Stimulation (Stochastic Resonance) Changes Electroencephalography Activities and Postural Control in Patients with Bilateral Vestibular Hypofunction. Brain Sci. 2020;10(10):740. [DOI:10.3390/brainsci10100740]
18. Schniepp R, Boerner JC, Decker J, Jahn K, Brandt T, Wuehr M. Noisy vestibular stimulation improves vestibulospinal function in patients with bilateral vestibulopathy. J Neurol. 2018;265(Suppl 1):57-62. [DOI:10.1007/s00415-018-8814-y]
19. Wuehr M, Boerner JC, Pradhan C, Decker J, Jahn K, Brandt T, et al. Stochastic resonance in the human vestibular system - Noise-induced facilitation of vestibulospinal reflexes. Brain Stimul. 2018;11(2):261-3. [DOI:10.1016/j.brs.2017.10.016]
20. Fujimoto C, Egami N, Kawahara T, Uemura Y, Yamamoto Y, Yamasoba T, et al. Noisy Galvanic Vestibular Stimulation Sustainably Improves Posture in Bilateral Vestibulopathy. Front Neurol. 2018;9:900.
21. Iwasaki S, Yamamoto Y, Togo F, Kinoshita M, Yoshifuji Y, Fujimoto C, et al. Noisy vestibular stimulation improves body balance in bilateral vestibulopathy. Neurology. 2014;82(11):969-75. [DOI:10.1212/WNL.0000000000000215]
22. Iwasaki S, Fujimoto C, Egami N, Kinoshita M, Togo F, Yamamoto Y, et al. Noisy vestibular stimulation increases gait speed in normals and in bilateral vestibulopathy. Brain Stimul. 2018;11(4):709-15. [DOI:10.1016/j.brs.2018.03.005]
23. Wuehr M, Nusser E, Decker J, Krafczyk S, Straube A, Brandt T, et al. Noisy vestibular stimulation improves dynamic walking stability in bilateral vestibulopathy. Neurology. 2016;86(23):2196-202. [DOI:10.1212/WNL.0000000000002748]
24. Khavarghazalani B, Adel Ghahraman M, Hoseinabadi R, Jalaie S, Kouhi A, Yazdani N. Combining Vestibular Rehabilitation and Noisy Galvanic Vestibular Stimulation for Treatment of Unilateral Vestibulopathy: A Randomized Controlled Trial. Aud Vestib Res. 2023;32(4):272-83. [DOI:10.18502/avr.v32i4.13591]
25. Woll J, Sprenger A, Helmchen C. Postural control during galvanic vestibular stimulation in patients with persistent perceptual-postural dizziness. J Neurol. 2019;266(5):1236-49. [DOI:10.1007/s00415-019-09255-7]
26. McLaren R, Smith PF, Taylor RL, Niazi IK, Taylor D. Scoping out noisy galvanic vestibular stimulation: a review of the parameters used to improve postural control. Front Neurosci. 2023;17:1156796. [DOI:10.3389/fnins.2023.1156796]
27. Alsanosi AA. Adaptation of the dizziness handicap inventory for use in the Arab population. Neurosciences (Riyadh). 2012;17(2):139-44.
28. Terkawi AS, Tsang S, AlKahtani GJ, Al-Mousa SH, Al Musaed S, AlZoraigi US, et al. Development and validation of Arabic version of the Hospital Anxiety and Depression Scale. Saudi J Anaesth. 2017;11(Suppl 1):S11-8. [DOI:10.4103/sja.SJA_43_17]
29. Kiliç G, Çelikyurt C, Algun ZC. The Effect of Vestibular Rehabilitation on Balance and Quality of Life in Patients with Bilateral Vestibular Hypofunction. Indian J Otolaryngol Head Neck Surg. 2023;75(3):2091-9. [DOI:10.1007/s12070-023-03788-0]
30. Ricci NA, Aratani MC, Doná F, Macedo C, Caovilla HH, Ganança FF. A systematic review about the effects of the vestibular rehabilitation in middle-age and older adults. Rev Bras Fisioter. 2010;14(5):361-71.
31. Wuehr M, Decker J, Schniepp R. Noisy galvanic vestibular stimulation: an emerging treatment option for bilateral vestibulopathy. J Neurol. 2017;264(Suppl 1):81-6. [DOI:10.1007/s00415-017-8481-4]
32. Yardley L, Beech S, Weinman J. Influence of beliefs about the consequences of dizziness on handicap in people with dizziness, and the effect of therapy on beliefs. J Psychosom Res. 2001;50(1):1-6. [DOI:10.1016/s0022-3999(00)00202-6]
33. Eder J, Kellerer S, Amberger T, Keywan A, Dlugaiczyk J, Wuehr M, et al. Combining vestibular rehabilitation with noisy galvanic vestibular stimulation for treatment of bilateral vestibulopathy. J Neurol. 2022;269(11):5731-7. [DOI:10.1007/s00415-022-11033-x]
34. Engel GL. The need for a new medical model: a challenge for biomedicine. Psychodyn Psychiatry. 2012;40(3):377-96. [DOI:10.1521/pdps.2012.40.3.377]
35. Staab JP, Ruckenstein MJ, Solomon D, Shepard NT. Serotonin reuptake inhibitors for dizziness with psychiatric symptoms. Arch Otolaryngol Head Neck Surg. 2002;128(5):554-60. [DOI:10.1001/archotol.128.5.554]
36. Bryant MS, Rintala DH, Hou JG, Protas EJ. Influence of fear of falling on gait and balance in Parkinson's disease. Disabil Rehabil. 2014;36(9):744-8. [DOI:10.3109/09638288.2013.814722]
37. DiMatteo MR. Variations in patients' adherence to medical recommendations: a quantitative review of 50 years of research. Med Care. 2004;42(3):200-9. [DOI:10.1097/01.mlr.0000114908.90348.f9]
2. Popkirov S, Staab JP, Stone J. Persistent postural-perceptual dizziness (PPPD): a common, characteristic and treatable cause of chronic dizziness. Pract Neurol. 2018;18(1):5-13. [DOI:10.1136/practneurol-2017-001809]
3. Madrigal J, Herrón-Arango AF, Bedoya MJ, Cordero Chen J, Castillo-Bustamante M. Persistent Challenges: A Comprehensive Review of Persistent Postural-Perceptual Dizziness, Controversies, and Clinical Complexities. Cureus. 2024;16(5):e60911. [DOI:10.7759/cureus.60911]
4. Thompson KJ, Goetting JC, Staab JP, Shepard NT. Retrospective review and telephone follow-up to evaluate a physical therapy protocol for treating persistent postural-perceptual dizziness: A pilot study. J Vestib Res. 2015;25(2):97-103; quiz 103-4. [DOI:10.3233/VES-150551]
5. Kundakci B, Sultana A, Taylor AJ, Alshehri MA. The effectiveness of exercise-based vestibular rehabilitation in adult patients with chronic dizziness: A systematic review. F1000Res. 2018;7:276. [DOI:10.12688/f1000research.14089.1]
6. Nada EH, Ibraheem OA, Hassaan MR. Vestibular Rehabilitation Therapy Outcomes in Patients With Persistent Postural-Perceptual Dizziness. Ann Otol Rhinol Laryngol. 2019;128(4):323-9. [DOI:10.1177/0003489418823017]
7. Axer H, Finn S, Wassermann A, Guntinas-Lichius O, Klingner CM, Witte OW. Multimodal treatment of persistent postural-perceptual dizziness. Brain Behav. 2020;10(12):e01864. [DOI:10.1002/brb3.1864]
8. Choi SY, Choi JH, Oh EH, Oh SJ, Choi KD. Effect of vestibular exercise and optokinetic stimulation using virtual reality in persistent postural-perceptual dizziness. Sci Rep. 2021;11(1):14437. [DOI:10.1038/s41598-021-93940-z]
9. Eldøen G, Kvalheim SE, Thesen T, Mygland Å, Ljøstad U, Bakke S, et al. Web-based vestibular rehabilitation in persistent postural-perceptual dizziness. Brain Behav. 2021;11(10):e2346. [DOI:10.1002/brb3.2346]
10. Teh CS, Abdullah NA, Kamaruddin NR, Mohd Judi KB, Fadzilah I, Zainun Z, et al. Home-based Vestibular Rehabilitation: A Feasible and Effective Therapy for Persistent Postural Perceptual Dizziness (A Pilot Study). Ann Otol Rhinol Laryngol. 2023;132(5):566-77. [DOI:10.1177/00034894221111408]
11. Ibrahim NMK, Hazza NMA, Yaseen DM, Galal EM. Effect of vestibular rehabilitation games in patients with persistent postural perceptual dizziness and its relation to anxiety and depression: prospective study. Eur Arch Otorhinolaryngol. 2024;281(6):2861-9. [DOI:10.1007/s00405-023-08369-z]
12. Wuehr M, Nusser E, Krafczyk S, Straube A, Brandt T, Jahn K, et al. Noise-Enhanced Vestibular Input Improves Dynamic Walking Stability in Healthy Subjects. Brain Stimul. 2016;9(1):109-16. [DOI:10.1016/j.brs.2015.08.017]
13. Fujimoto C, Yamamoto Y, Kamogashira T, Kinoshita M, Egami N, Uemura Y, et al. Noisy galvanic vestibular stimulation induces a sustained improvement in body balance in elderly adults. Sci Rep. 2016;6:37575. [DOI:10.1038/srep37575]
14. Wardman DL, Taylor JL, Fitzpatrick RC. Effects of galvanic vestibular stimulation on human posture and perception while standing. J Physiol. 2003;551(Pt 3):1033-42. [DOI:10.1113/jphysiol.2003.045971]
15. Scinicariello AP, Eaton K, Inglis JT, Collins JJ. Enhancing human balance control with galvanic vestibular stimulation. Biol Cybern. 2001;84(6):475-80. [DOI:10.1007/PL00007991]
16. Babaee S, Shaabani M, Vahedi M. Comparison of verticality perception and postural sway induced by double temple-mastoidal and bipolar binaural 20 Hz sinusoidal galvanic vestibular stimulation. J Vestib Res. 2022;32(5):407-21. [DOI:10.3233/VES-210112]
17. Ko LW, Chikara RK, Chen PY, Jheng YC, Wang CC, Yang YC, et al. Noisy Galvanic Vestibular Stimulation (Stochastic Resonance) Changes Electroencephalography Activities and Postural Control in Patients with Bilateral Vestibular Hypofunction. Brain Sci. 2020;10(10):740. [DOI:10.3390/brainsci10100740]
18. Schniepp R, Boerner JC, Decker J, Jahn K, Brandt T, Wuehr M. Noisy vestibular stimulation improves vestibulospinal function in patients with bilateral vestibulopathy. J Neurol. 2018;265(Suppl 1):57-62. [DOI:10.1007/s00415-018-8814-y]
19. Wuehr M, Boerner JC, Pradhan C, Decker J, Jahn K, Brandt T, et al. Stochastic resonance in the human vestibular system - Noise-induced facilitation of vestibulospinal reflexes. Brain Stimul. 2018;11(2):261-3. [DOI:10.1016/j.brs.2017.10.016]
20. Fujimoto C, Egami N, Kawahara T, Uemura Y, Yamamoto Y, Yamasoba T, et al. Noisy Galvanic Vestibular Stimulation Sustainably Improves Posture in Bilateral Vestibulopathy. Front Neurol. 2018;9:900.
21. Iwasaki S, Yamamoto Y, Togo F, Kinoshita M, Yoshifuji Y, Fujimoto C, et al. Noisy vestibular stimulation improves body balance in bilateral vestibulopathy. Neurology. 2014;82(11):969-75. [DOI:10.1212/WNL.0000000000000215]
22. Iwasaki S, Fujimoto C, Egami N, Kinoshita M, Togo F, Yamamoto Y, et al. Noisy vestibular stimulation increases gait speed in normals and in bilateral vestibulopathy. Brain Stimul. 2018;11(4):709-15. [DOI:10.1016/j.brs.2018.03.005]
23. Wuehr M, Nusser E, Decker J, Krafczyk S, Straube A, Brandt T, et al. Noisy vestibular stimulation improves dynamic walking stability in bilateral vestibulopathy. Neurology. 2016;86(23):2196-202. [DOI:10.1212/WNL.0000000000002748]
24. Khavarghazalani B, Adel Ghahraman M, Hoseinabadi R, Jalaie S, Kouhi A, Yazdani N. Combining Vestibular Rehabilitation and Noisy Galvanic Vestibular Stimulation for Treatment of Unilateral Vestibulopathy: A Randomized Controlled Trial. Aud Vestib Res. 2023;32(4):272-83. [DOI:10.18502/avr.v32i4.13591]
25. Woll J, Sprenger A, Helmchen C. Postural control during galvanic vestibular stimulation in patients with persistent perceptual-postural dizziness. J Neurol. 2019;266(5):1236-49. [DOI:10.1007/s00415-019-09255-7]
26. McLaren R, Smith PF, Taylor RL, Niazi IK, Taylor D. Scoping out noisy galvanic vestibular stimulation: a review of the parameters used to improve postural control. Front Neurosci. 2023;17:1156796. [DOI:10.3389/fnins.2023.1156796]
27. Alsanosi AA. Adaptation of the dizziness handicap inventory for use in the Arab population. Neurosciences (Riyadh). 2012;17(2):139-44.
28. Terkawi AS, Tsang S, AlKahtani GJ, Al-Mousa SH, Al Musaed S, AlZoraigi US, et al. Development and validation of Arabic version of the Hospital Anxiety and Depression Scale. Saudi J Anaesth. 2017;11(Suppl 1):S11-8. [DOI:10.4103/sja.SJA_43_17]
29. Kiliç G, Çelikyurt C, Algun ZC. The Effect of Vestibular Rehabilitation on Balance and Quality of Life in Patients with Bilateral Vestibular Hypofunction. Indian J Otolaryngol Head Neck Surg. 2023;75(3):2091-9. [DOI:10.1007/s12070-023-03788-0]
30. Ricci NA, Aratani MC, Doná F, Macedo C, Caovilla HH, Ganança FF. A systematic review about the effects of the vestibular rehabilitation in middle-age and older adults. Rev Bras Fisioter. 2010;14(5):361-71.
31. Wuehr M, Decker J, Schniepp R. Noisy galvanic vestibular stimulation: an emerging treatment option for bilateral vestibulopathy. J Neurol. 2017;264(Suppl 1):81-6. [DOI:10.1007/s00415-017-8481-4]
32. Yardley L, Beech S, Weinman J. Influence of beliefs about the consequences of dizziness on handicap in people with dizziness, and the effect of therapy on beliefs. J Psychosom Res. 2001;50(1):1-6. [DOI:10.1016/s0022-3999(00)00202-6]
33. Eder J, Kellerer S, Amberger T, Keywan A, Dlugaiczyk J, Wuehr M, et al. Combining vestibular rehabilitation with noisy galvanic vestibular stimulation for treatment of bilateral vestibulopathy. J Neurol. 2022;269(11):5731-7. [DOI:10.1007/s00415-022-11033-x]
34. Engel GL. The need for a new medical model: a challenge for biomedicine. Psychodyn Psychiatry. 2012;40(3):377-96. [DOI:10.1521/pdps.2012.40.3.377]
35. Staab JP, Ruckenstein MJ, Solomon D, Shepard NT. Serotonin reuptake inhibitors for dizziness with psychiatric symptoms. Arch Otolaryngol Head Neck Surg. 2002;128(5):554-60. [DOI:10.1001/archotol.128.5.554]
36. Bryant MS, Rintala DH, Hou JG, Protas EJ. Influence of fear of falling on gait and balance in Parkinson's disease. Disabil Rehabil. 2014;36(9):744-8. [DOI:10.3109/09638288.2013.814722]
37. DiMatteo MR. Variations in patients' adherence to medical recommendations: a quantitative review of 50 years of research. Med Care. 2004;42(3):200-9. [DOI:10.1097/01.mlr.0000114908.90348.f9]
| Files | ||
| Issue | Articles in Press | |
| Section | Research Article(s) | |
| Keywords | ||
| Persistent postural-perceptual dizziness vestibular rehabilitation noisy galvanic vestibular stimulation Dizziness Handicap Inventory Hospital Anxiety and Depression Scale | ||
| Rights and permissions | |
|
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |
How to Cite
1.
Azeez SS, Adel Ghahraman M, Tavanai E, Jalaie S, Malmir K, Aldujaili A. Comparative Efficacy of Vestibular Rehabilitation, Noisy Galvanic Vestibular Stimulation, and Their Combination on Postural Control, Dizziness, Anxiety, and Depression in Patients with Persistent Postural-Perceptual Dizziness. Aud Vestib Res. 2025;.
