April 23, 2019 at 6:05 pm #73901
Why did you choose this article or document?
I chose it because I had the honor of being asked to be involved in the development and writing of it, so know it quite intimately. I also chose it because I am concerned about the variability of what a person might receive when seeing a Physiotherapist for vestibular rehabilitation. Substandard care could be ineffective or even harmful, so the more people attempting to work with this population who are aware of these practice guidelines the better.
What is the question being asked, or other purposes of the study?
The guidelines mined a large pool of research to describe the evidence as to whether or not vestibular rehabilitation exercises are effective in enhancing the recovery of function in those with unilateral and bilateral peripheral vestibular hypofunction.
It was also hoped that the guidelines would:
o reduce variability in rehabilitation techniques such that exercise approaches are in line with best practice suggested by current evidence,
o help develop collaborative health provider relationships to enhance timely, appropriate referrals for vestibular rehabilitation, and
o get peoples’ wheels turning re: gaps in the research that they might explore in order to further improve management of this population.
If it was a review or meta-analysis:
This is directly from the review: “The study types included were meta-analyses, systematic reviews, randomized controlled trials, cohort studies, case control studies, and case series/studies. Inclusion criteria for articles included human subjects, published in English, and published after 1985. Exclusion criteria included superior canal dehiscence, blindness, primary diagnosis of benign paroxysmal positional vertigo, migraine, central vestibular disorder, or central nervous system pathology (Parkinson disease, multiple sclerosis, stroke, cerebellar ataxia).”
Were they able to include lots of studies? Why or why not? Can you comment on the quality of the studies included?
From the initial 1540 articles identified in 2013/14, duplicates and those clearly irrelevant were removed. The workgroup responsible for this project (Drs. Courtney Hall, Susan Herdman and Sue Whitney) along with trained volunteers from the APTA Neuro Section Vestibular SIG, clinically appraised the remaining articles for relevance. Each article was scored by 2 reviewers and in the case of discrepancy that could not be agreed upon, it was resolved by the workgroup. 195 articles remained, which were divided among the Advisory Board, of which I was a part, and appraised by 2 members for inclusion with a 3rd weighing in if disagreement, resulting in 121 identified as relevant. A further 14 were added in 2015 through a similar process. All articles were graded to determine Level I through V evidence, ranging from high-quality diagnostic studies, prospective studies or randomized controlled trials down to expert opinion.
Can you comment on the validity of the study?
Being a large meta-analysis using internationally accepted methods of clinical appraisal, validity is very good. We were able to use solely Level I evidence for 4 of the 10 Action Statements and at least some Level I evidence in 4 others.
How do the results relate to current practice or influence future practice?
With no standardization around what the public receives under the umbrella of Vestibular Rehabilitation, and no requirement for demonstrated competency by a regulatory body for those teaching or practising in the field, it is a bit of ‘the wild west’ out there! My hope is that therapists offering this type of rehabilitation will read more than just the summary of the action statements to understand the research behind the recommendations so that they can better identify appropriate candidates and make sure the exercise interventions they are choosing are in line with best practice. In particular, I hope that people will stop teaching smooth pursuit and saccade exercises (without incorporating head movement) for the purposes of gaze stabilization as there is strong evidence that this is not useful. Finally, I hope that those interested in researching this fascinating field will pursue areas where gaps remain (as described in the Research Recommendations) in order to help guide us all in further tailoring and dosing our exercise approaches for best outcomes.