History or background information on vertigo

Vestibular rehabilitation has been used in the treatment of patients with chronic vertigo as a consequence of vestibular dysfunction.


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It has been reported that patients with chronic peripheral vestibular disorders improved balance and reduced vertigo after 6 weeks of vestibular rehabilitation. Vestibular rehabilitation has also been demonstrated to be beneficial for patients who have undergone ablative vestibular surgery. Vestibular rehabilitation should be performed by a licensed occupational or physical therapist. The literature indicates that the following groups of patients are generally not good candidates for vestibular rehabilitation:.

There is moderate evidence that VR provides a resolution of symptoms in the medium-term. There is insufficient evidence to discriminate between differing forms of VR. At the time of treatment, an ear cuff is inserted into the external ear canal and a handheld air-pressure generator connected to a tabletop air-pressure therapy unit automatically delivers low-frequency, low-amplitude pressure pulses to the middle ear through the tympanostomy tube.

The Meniett uses positive pressure pulses to the middle ear via the earpiece and ventilation tube to purportedly reduce excess fluid and pressure in the inner ear. The Meniett device Medtronic Xomed, Jacksonville, FL is a local pulsated pressure treatment used for the management of patients with Meniere's disease. It is a portable pressure-pulse generator designed to restore the balance in the hydrodynamics of the inner ear.

After a standard ventilation tube is inserted into the tympanum, pressure pulses generated by the Meniett technology are transmitted into the middle ear.

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The clinical effect occurs as the pulses reach the inner ear. The typical treatment cycle is completed in 5-min sessions, performed 3 times a day. After prescription and training by a physician, patients can treat themselves with the device at home. Odkvist et al reported that 2-week Meniett treatment resulted in significant improvement concerning frequency and intensity of vertigo, dizziness, aural pressure and tinnitus as indicated on the visual analogue scales questionnaire.

Although the findings of this study appear to be promising, its sample size was small 31 in the treatment group and 25 in the control group. Furthermore, there are no long-term follow-up data regarding the effectiveness of this new technology. Barbara et al compared the use of ventilation tube VT in the middle ear with the combined use of VT and the Meniett device.

The authors concluded that a longer and more reliable long-term follow-up of this therapeutic approach VT plus Meniett is needed. The findings of these short-term, preliminary descriptive reports of treatment with the Meniett device need to be validated by prospective randomized controlled studies with larger sample size and adequate follow-up.

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However, this was a short-term clinical study. The investigators agreed that a longer term clinical study was warranted, in part because the difference between treatment and control groups diminished over time. There was a trend towards a reduction of the frequency of vertiginous attacks that was not significant. However, there were no significant differences between the active and placebo groups in perception of tinnitus, aural pressure, and hearing, before and after the treatment period. A study by Rajan et al of the long-term effects of the Meniett device is described as a cross-sectional case study.

Well-designed controlled studies are necessary because of the unpredictable natural course of the disease and because of the susceptibility of symptoms to placebo effects. With a mean follow-up of 39 months; there was some initial decrease in the frequency of vertigo episodes, but no improvement in functional level, self-perceived dizziness handicap, hearing status or tinnitus. After I year, only 2 patients preferred to continue with the therapy. The authors concluded that the Meniett device is unlikely to be helpful in the long-term treatment of severe, drug-resistant Meniere's disease.

They noted that treatment with the Meniett device is a safe and effective option for people with substantial vertigo uncontrolled by medical therapy. This study was based on an unblinded protocol. It should be noted that no objective measurement of hearing was obtained, and most patients indicated that their hearing did not improve with either short-term or long-term use of the Meniett device. In summary, available evidence contain few patients enrolled in randomized, placebo controlled studies, which are critical in differentiating treatment effect to spontaneous improvement that may reflect the natural course of the disorder, including its remissions and recurrences.

Well-designed studies i. The date of the last search was May 13, A total of 4 randomized controlled trials RCTs were identified that compared the effectiveness of the Meniett device versus a placebo device in patients with Meniere's 'disease' as defined by the AAOO criterion. Two review authors independently assessed study eligibility and risk of bias, and extracted data. The outcome data were dichotomous for all the included trials. The 4 RCTs compared patients with the Meniett device against patients with the placebo device from 4 RCT's over a follow-up period of 2 weeks to 4 months.

However, this reduction was not significantly different between the 2 groups in any study or on meta-analysis [mean difference in vertigo free days between Meniett and placebo device of 0. There was also no substantive data to support a greater reduction in the severity of the vertigo or any other outcome with the Meniett device compared with the placebo device.

In a Cochrane review, van Sonsbeek and colleagues evaluated the effects of positive pressure therapy e. The date of the search was June 6, ; RCTs comparing positive pressure therapy using the Meniett or a similar device with placebo in patients with Meniere's disease were selected for analysis. The primary outcome was control of vertigo; secondary outcomes were loss or gain of hearing, severity of tinnitus, perception of aural fullness, functional level, complications or adverse effects, and sick days.

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Two authors independently selected studies, assessed risk of bias and extracted data. They contacted authors for additional data.


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Where possible, these researchers pooled study results using a fixed-effect, mean difference MD meta-analysis and tested for statistical heterogeneity using both the Chi 2 test and I 2 statistic. This was only possible for the secondary outcomes loss or gain of hearing and sick days. These investigators included 5 randomized clinical trials with participants. All trials were prospective, double-blind, placebo-controlled RCTs on the effects of positive pressure therapy on vertigo complaints in Meniere's disease.

Overall, the risk of bias varied: 3 out of 5 studies were at low risk, 1 was at unclear risk and 1 was at high risk of bias.

www.cantinesanpancrazio.it/components/deqicetim/353-spiare-whatsapp.php For the primary outcome, control of vertigo, it was not possible to pool data due to heterogeneity in the measurement of the outcome measures. In most studies, no significant difference was found between the positive pressure therapy group and the placebo group in vertigo scores or vertigo days.

Only 1 study, at low risk of bias, showed a significant difference in 1 measure of vertigo control in favor of positive pressure therapy. In this study, the mean visual analog scale VAS score for vertigo after 8 weeks of treatment was For the secondary outcomes, these investigators carried out 2 pooled analyses. They found statistically significant results for loss or gain of hearing. Hearing was 7. The severity of tinnitus and perception of aural fullness were either not measured or inadequate data were provided in the included studies.

For the secondary outcome functional level , it was not possible to perform a pooled analysis. One included study showed less functional impairment in the positive pressure group than the placebo group AAO-HNS criteria, 1- to 6-point scale: MD In addition to the pre-defined secondary outcome measures, these researchers included sick days as an additional outcome measure, as 2 studies used this outcome measure and it is a complementary measurement of impairment due to Meniere's disease.

They did not find a statistically significant difference in sick days.

Understanding the Causes of Vertigo

No complications or adverse effects were noted by any study. The authors concluded that there is no evidence, from 5 included studies, to show that positive pressure therapy is effective for the symptoms of Meniere's disease. There is some moderate quality evidence, from 2 studies, that hearing levels are worse in patients who use this therapy.

The positive pressure therapy device itself is minimally invasive. However, in order to use it, a tympanostomy tube grommet needs to be inserted, with the associated risks. These include the risks of anesthesia, the general risks of any surgery and the specific risks of otorrhea and tympano-sclerosis associated with the insertion of a tympanostomy tube. There were no statistical differences or correlations in control group.

The authors stated that this study had several drawbacks.


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First, the number of patients in this study was relatively small. Second, these researchers did not evaluate some vascular risk factors, including tobacco smoking, diabetes, hypertension, and so on. Third, it was not a randomized control study, which might have resulted in clinical bias. These investigators pointed out that, image changes, pathological results, and a long term follow-up is needed to support the conclusions of this study, and to overcome inherent defects of cross-sectional study. The authors concluded that these findings suggested that ischemia of the inner ear might be one of the causes of BPPV and that DPL I may be used to assess the ischemic degree in subjects over 20 years of age.

Any type of sensorineural hearing loss will disrupt the pattern of sound passing from the cochlea to the brainstem; abnormal results are therefore non-specific. Review History. Clinical Policy Bulletin Notes.

Uncertain disorders related to visual vertigo

Links to various non-Aetna sites are provided for your convenience only. Aetna Inc. Chronic Vertigo. Print Share. Vestibular Rehabilitation Aetna considers vestibular rehabilitation for chronic vertigo medically necessary when all of the following criteria are met: Symptoms e.