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Table of Contents    
ORIGINAL ARTICLE
Year : 2021  |  Volume : 69  |  Issue : 5  |  Page : 1241-1246

Effect of Yogasanas Versus Gaze Stability and Habituation Exercises on Dizziness in Vestibular Dysfunction


1 Neurophysiotherapy Department, Dr D.Y Patil College of Physiotherapy, Dr D.Y Patil Vidyapeeth, Pune, India
2 Department of Community Physiotherapy, Dr D.Y Patil College of Physiotherapy, Dr D.Y Patil Vidyapeeth, Pune, India
3 Principal, Dr D.Y Patil College of Physiotherapy, Dr D.Y Patil Vidyapeeth, Pune, India

Date of Submission24-Oct-2020
Date of Decision28-May-2021
Date of Acceptance06-Jul-2021
Date of Web Publication30-Oct-2021

Correspondence Address:
Namrata D Rawtani
Dr D.Y Patil College of Physiotherapy, Dr D.Y Patil Vidyapeeth, Sant Tukaram Nagar, Plot No. BGP, 190, Pimpri Colony, Pimpri-Chinchwad, Maharashtra - 411 018
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.329557

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 » Abstract 

Background: Dizziness is a typical manifestation of vestibular pathologies. Clinical studies have shown that it affects 1.82% of young adults to more than 30% older adults. Habituation and compensation are some traditional rehabilitation protocols.
Objective: Yoga is also known to have a significant effect on vestibulopathy. Hence, a need arises to compare the above two maneuvers.
Materials and Methods: Participants were recruited (n = 32) after screening using the Dix–Hallpike and head impulse test. They were then divided into two groups (n = 16). The first one, Group A, received yogasanas, and the second one, Group B, received gaze stabilization and habituation exercises for 4 days a week for 3 weeks. Pre- and post intervention outcome measures were taken using the Motion Sensitivity Quotient (MSQ) score and Dizziness Handicap Inventory (DHI) scale.
Results: In reducing symptoms of dizziness, the between-group comparison shows that Group A has shown greater improvement (12.37% ±1.43%) in MSQ and Group B has shown greater improvement (16.12 ± 3.56) in DHI. Within-group comparison shows that both the interventions are effective in reducing symptoms of dizziness (P < 0.05).
Conclusion: Both yogasanas and gaze stabilization along with habituation exercises are effective in improving the symptoms in patients with peripheral vestibular dysfunction. When compared between the groups, yogasanas had a superior hand in the MSQ score, whereas gaze stabilization and habituation exercises had a superior hand in the DHI scale.


Keywords: Motion, reflex, vertigo
Key Message: Evidence-based vestibular therapy is known to initiate compensation, but yoga can also help patients regain focus, movement, and coordination.


How to cite this article:
Gazbare PS, Rawtani ND, Rathi M, Palekar TJ. Effect of Yogasanas Versus Gaze Stability and Habituation Exercises on Dizziness in Vestibular Dysfunction. Neurol India 2021;69:1241-6

How to cite this URL:
Gazbare PS, Rawtani ND, Rathi M, Palekar TJ. Effect of Yogasanas Versus Gaze Stability and Habituation Exercises on Dizziness in Vestibular Dysfunction. Neurol India [serial online] 2021 [cited 2021 Nov 30];69:1241-6. Available from: https://www.neurologyindia.com/text.asp?2021/69/5/1241/329557




Vestibular pathology is typically manifested by vertigo, which is an illusionary sense of rotatory motion. Patients with vestibular disorders exhibit symptoms of dizziness, imbalance, and anxiety that severely affect their physical and psychosocial domains.[1] Anatomically, this system is divided into three components, the efferent system, which gives information to the vestibular nuclear apparatus, and the cerebellum about the spatial position of the head, its velocity, and angular acceleration. The central nervous system analyzes signals from these inputs and assumes the position of the head and trunk. This impulse further travels to the muscles of the eye and the spinal reflex centers to supply three important spinal reflexes, which are the vestibulo-occular, vestibulocollic, and vestibulospinal responses. The vestibulo-occular reflex (VOR) produces clear and stable vision when the head is moving. The vestibulocollic regulates the superficial and deep muscles of the head and neck to maintain a neutral position of the cervical spine. The vestibulospinal reflex (VSR) maintains balance strategies and produces compensatory trunk movements to prevent falls.[1] The peripheral vestibular system contains five sensory structures: three of which are the semicircular canals and the other two are otolith organs (they are called the utricle and the saccule). The semicircular canals enlarge at one end to form the ampulla that contains highly specialized sensory hair cells to detect fluid movements.[2] The most common cause of bilateral vestibular hypofunction is ototoxicity.[3] Unilateral vestibular hypofunction is caused by decreased receptor input due to trauma or vascular events. Some other common conditions that cause vertigo include vestibular neuritis, Meniere's syndrome, vestibular migraine and vertebrobasilar artery insufficiency, and benign paroxysmal positional vertigo, which occurs as a result of dislodgement of otoconia from utricle (usually caused by cupulolithiasis and canalithiasis), which enters into the endolymph, thereby disturbing the normal endolymph dynamics.[4]

Those who suffer from vestibular symptoms are unable to do a wide spectrum of activities. This impairs their quality of living and the efficiency of daily activities. The severity of this condition is known to affect 11.53% of adults with the problem of chronic dizziness and 33.4% of adults with impaired balance. Along with episodes of dizzy spell, it also causes postural imbalances and a feeling of rotation, which takes several minutes to turn normal. Instability of gaze, abnormality in the perception of movement, and the altered orientation of spatial position are some of the impairments seen in vestibular dysfunction. Macdowell et al. concluded in a study that integrating yoga poses and breathing in vestibular rehabilitation could benefit both psychological and physical symptoms of vestibular disorders.[14] Evidence-based vestibular rehabilitation therapy is a known problem-oriented approach to initiate compensation.[5] It is based on adaptation, habituation, substitution, and compensation. Adaptation exercises are designed to allow the vestibular system to modify the magnitude of VOR to any particular given stimulus (e.g. head or trunk movement). On the other hand, the habituation exercise mainly uses the VSR and constant repeated exposure to the provocative stimulus that will lead to an adaptation of the motion causing symptoms and thereby reducing disability.[6] Yoga postures have been known to have a significant effect on vestibular symptoms. Holding back some controversial theories about maintaining yoga poses in acute vestibular cases, they still activate the nervous system and balance centers in the inner ear. According to the concept of yoga, the origin of a disease can affect the other layer of existence. If an imbalance starts at the mind level (anxiety, stress), it plays a role in affecting the physical level (endurance, weakness, dizziness), and when unattended may affect other pathways. Yoga has a direct effect on the sympathetic nervous system and improves blood flow to the head and neck region. Yoga can help vestibular patients regain focus, movement, and coordination.[7] According to a study conducted by Nagarathna et al.[15] yoga pose (asanas), breathing (pranayama), and meditation (dhyana) produce positive results in the psychological symptoms of anxiety and imbalance due to vestibular pathology, when used in conjunction with vestibular rehabilitation. There is a scarcity of research about the influence of yoga alone in peripheral vestibular disorders; hence, its effect in this field is an explorable research question. This study, therefore, attempted to investigate the influence of yogasanas versus conventional physical therapy treatment on dizziness in vestibulopathy.[8]


 » Materials and Methods Top


Study design and study setting

An experimental study was conducted in Dr. D Y Patil Neurology outpatient department and ENT/Vertigo clinics in Pune, after ethical clearance from the institutional ethical committee. Participants were recruited for the same, and intervention was carried out from September 2019 to January 2020. The method used for sampling was convenient sampling. The purpose of this study was explained to the participants, and written informed consent was obtained from all of them. Approval was taken from ethics committee, Date of approval – 22nd April 2019.

Sample size

Data were analyzed using WINPEPI software for Windows Version 4: 2001. Standard deviation (SD) of a previously conducted study was considered as a reference for sample size calculation (pretreatment SD = 19.3; posttreatment SD = 7.3).[9] Fifty participants were screened, out of which 32 participants were involved in the study.

Inclusion criteria

Patients were included based on the following criteria: age between 35 and 55 years, male or female, those who exhibited vestibular symptoms and diagnosed with peripheral vestibular dysfunction by the physician, clinically diagnosed by a therapist as positive in any one or both the screening tests, namely head impulse test and Dix–Hallpike maneuver.

Exclusion criteria

Patients were excluded based on the following criteria: those with cervical degeneration, radiculopathy and acute neck pain, or any acute lower back pain; those having a history of neurological disease such as stroke, multiple sclerosis, Parkinson's, tumors, or major central nervous system lesions; those with any severe psychiatric disorder such as schizophrenia or bipolar disorder; and those who are not willing to participate.


 » Materials and Methods Top


The two screening tests used were Dix–Hallpike test and head impulse test. The participant was expected to be positive in any one or both the tests. They were then divided randomly and allocated into two groups by the chit method. Each group consisted of 16 participants The pre-intervention outcome measures were taken using Motion sensitivity quotient (MSQ) and Dizziness Handicap Inventory (DHI) scale. The baseline data of each individual was checked for normality distribution using Shapiro–Wilk test. Group A received yogasanas 4 days per week for 3 weeks with each session being for 20 minutes. All the asanas were repeated for five cycles and were held for 60 seconds. Group B received gaze stabilization and habituation exercises 4 days per week for 3 weeks with each session being of 15- to 20-minute duration. The exercises initially started with a slow and comfortable pace, and speed was increased as habituation increased (symptoms reduced). At the end of 3 weeks, postintervention outcome measures were taken using the MSQ and DHI scale.

Yogasanas given to Group A were Upavistha Konasana (wide-angle seated forward bend), Vakrasana (twisted yoga pose), Setubandhasana (bridge pose), Balasana (child's pose), Bhujangasana (cobra pose), and Bhramari Pranayama (humming bee sound) [Figure 1].
Figure 1: Group A: Yoga: Upavistha Konasana

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Exercise protocol used for gaze stability exercises for Group B [Figure 2] was as follows:[9]
Figure 2: Group B: Gaze Stabilization Exercises

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Exercise protocol used for habituation exercises for Group B was as follows:[9]



Termination criteria

The exercises were terminated if the patients had any of the following:

  1. Chest pain or discomfort
  2. Exacerbation of vestibular symptoms
  3. DOMS (delayed onset of muscle soreness)


Safety precautions were taken for all the participants to take adequate rest between the exercises and to prevent any kind of discomfort to the participants.

Statistical analysis

The collected data were compiled using Microsoft Excel. Baseline data of both the groups were checked for normality. According to Shapiro–Wilk test, the baseline data had a normal distribution (P > 0.05, P = 0.8). A P value less than 0.05 was considered significant. The paired t test was used to analyze the within-group difference (pre and post), whereas the independent t test was used to analyze the between-group difference (Groups A and B).


 » Results Top


Participants of age-group between 35 and 55 years were involved in the study, among which both males (n = 29) and females (n = 3) were present. The total number of participants was 32. The mean age in Group A was 46.87 years. The mean age in Group B was 43.81 years. Within-group comparison showed that both the interventions are effective in reducing symptoms of dizziness in vestibular patients (P < 0.05). Analysis shows that when comparing the mean differences of MSQ score between Groups A and B, pre and post 3 weeks Group A (yogasanas) showed greater improvement (12.37% ± 1.432%) than Group B (15.87% ± 1.856%) in reduction of the symptom of dizziness in vestibular dysfunction [Table 1].
Table 1: Pre and post data comparison of motion sensitivity quotient (MSQ) score within Groups A and B

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On the other hand, analysis shows that when comparing the mean differences of DHI (analyzes functional, emotional, and physical components) between Groups A and B, pre and post 3 weeks, Group B (gaze stabilization and habituation exercises) showed greater improvement (16.12 ± 3.565) than Group A (21.62 ± 2.213) in reducing the symptoms of dizziness in vestibular dysfunction [Table 2].
Table 2: Pre and post data comparison of Dizziness Handicap Inventory (DHI) scale within Groups A and B

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 » Discussion Top


The purpose of this study was to compare the effects of yogasanas and gaze stabilization and habituation exercises on the symptom of dizziness in vestibular dysfunction. Thirty-two participants were recruited for this study who received either yogasanas or gaze stability and habituation exercises for 12 sessions in 3 weeks.



The results of this study summarize that both yogasanas and gaze stability and habituation exercises are effective in reducing dizziness in peripheral vestibular dysfunction (P < 0.05). Comparison between the groups showed that yogasanas had a superior hand in the MSQ (12.37%) than the gaze stability along with habituation exercises (15.87%) [Table 3]. In case of the DHI, gaze stabilization along with habituation exercises has a superior hand in improving the score (16.12%) than yogasanas (21.62%) [Table 4]. The improvement received in yogasanas might be due to the positioning during the holding of the asanas. Yoga is said to dislodge the accumulated calcium crystals in the endolymph. Holding the yoga postures at different angles might alter the position of the semicircular canals and hence improve the symptoms.[8]
Table 3: Pre and Post data comparison (mean difference) for motion sensitivity quotient (MSQ) between Groups A and B

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Table 4: Pre and Post data comparison (mean difference) for Dizziness Handicap Inventory (DHI) between Groups A and B

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The improvement received in gaze stabilization exercises might be due to the use of the vestibular ocular reflex that habituates the person in being adapted to the provoking positions thereby reducing vestibular symptoms.[3]

The VOR maintains the visual focus when the head is moving in different directions at a different speed than the body. The VSR helps maintain the alignment of head position in relation to the body. More of these reflexes are required in functional activities. Activities of daily living can be quantified by the DHI in terms of physical, emotional, and functional components.[10] These reflexes were more incorporated in case of gaze stability and habituation exercises as the patient was asked to concentrate on stable and moving targets. Hence, the DHI may have shown a greater improvement for Group B. In case of yogasanas, positional changes are more focused on. The position of the semicircular canals and endolymph is altered with every asana held.[9] This may have accustomed the participant during transfers and sudden changes of position that are measured more accurately by MSQ. Hence, the MSQ may have shown greater improvements for Group A (yogasanas). Usually, in normal individuals, impulses from the labyrinthine apparatus give accurate information about head movement and its angular position. In case of abnormality, it is interpreted as a continuous movement of head by the brain. Thereby, the patient experiences spinning motion when actually there is no movement at all.[11] In a study conducted by Norre et al. the input from a disturbed vestibular apparatus, presents a sensory input that is different from the normal vestibular signals.[12] There exists a sensory conflict when the impulses of this abnormal signal clash with the normal signals provided by the visual and sensory systems. This is perceived to produce the symptoms of motion misconception.[9] In such patients, the goals of rehabilitation are to decrease dizziness and oscillopsia and improve the patient's optimum functionality. It focuses on withdrawal from social isolation.[13] Similarly, this study shows that both yoga and gaze stabilization along with habituation exercises can be used widely as vestibular rehabilitation for patients complaining of dizziness with vestibulopathy.[14],[15]

Conducted with a smaller sample size, the results of this study cannot be collectively generalized. Hence, there is a future scope to conduct a similar study over a larger sample population with various factors affecting the condition. Further studies can also be conducted in comorbid conditions where vestibular pathology is more prevalent.


 » Conclusion Top


This study shows that gaze stabilization along with habituation exercises and yogasanas are both effective in improving the symptom of dizziness in patients with peripheral vestibular dysfunction. When compared between the groups, yogasanas had a superior hand in the MSQ score, whereas gaze stabilization and habituation exercises had a superior hand in the DHI.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgments

The authors would like to acknowledge the extensive help received from the scholars whose articles are cited and mentioned as references of this manuscript. The authors are also grateful to the editors and publishers of all the journals, articles, and books, with which literature for this manuscript has been reviewed and discussed. We extend our earnest gratitude toward the participants of this study, without whom this study would not have been possible.

The authors are also grateful to the places of the study setting and all the doctors and medical staff who referred the patients for allowing smooth conduct and completion of this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Brandt T, Dieterich M, Strupp M. Vertigo and Dizziness. London: Springer-Verlag London Limited; 2005.  Back to cited text no. 1
    
2.
Kim SK, Lee KJ, Hahm JR, Lee SM, Jung TS, Jung JH, et al. Clinical significance of the presence of autonomic and vestibular dysfunction in diabetic patients with peripheral neuropathy. Diabetes Metab J 2012;36:64-9.  Back to cited text no. 2
    
3.
Myers SF, Ross MD. Morphological evidence of vestibular pathology in long-term experimental diabetes mellitus: II. Connective tissue and neuroepithelial pathology. Acta Otolaryngol 1987;104:40-9.  Back to cited text no. 3
    
4.
D'Silva LJ, Lin J, Staecker H, Whitney SL, Kluding PM. Impact of diabetic complications on balance and falls: Contribution of the vestibular system. Phys Ther 2016;96:400-9.  Back to cited text no. 4
    
5.
Ward BK, Wenzel A, Kalyani RR, Agrawal Y, Feng AL, Polydefkis M, et al. Characterization of vestibulopathy in individuals with type 2 diabetes mellitus. Otolaryngol Head Neck Surg 2015;153:112-8.  Back to cited text no. 5
    
6.
Friscia LA, Morgan MT, Sparto PJ, Furman JM, Whitney SL. Responsiveness of self-report measures in individuals with vertigo, dizziness and unsteadiness. Otol Neurotol 2014;35:884-8.  Back to cited text no. 6
    
7.
Ward BK, Agrawal Y, Hoffman HJ, Carey JP, Della Santina CC. Prevalence and impact of bilateral vestibular hypofunction: Results from the 2008 US National health interview survey. JAMA Otolaryngol Head Neck Surg 2013;139:803-10.  Back to cited text no. 7
    
8.
Whitney SL, Marchetti GF, Morris LO. Usefulness of the dizziness handicap inventory in the screening for benign paroxysmal positional vertigo. Otol Neurotol 2005;26:1027-33.  Back to cited text no. 8
    
9.
Clendaniel RA. The effects of habituation and gaze stability exercises in the treatment of unilateral vestibular hypofunction: A preliminary results. J Neurol Phys Ther 2010;34:111-6.  Back to cited text no. 9
    
10.
Nicholson M, King J, Smith PF, Darlington CL. Vestibulo-ocular, optokinetic and postural function in diabetes mellitus. Neuroreport 2002;13:153-7.  Back to cited text no. 10
    
11.
Bhardwaj V, Vats M. Effectiveness of gaze stability exercise on balance in healthy elderly population. Int J Physiother Res 2014;2:642-7.  Back to cited text no. 11
    
12.
Norre ME, Beckers A. Vestibular habituation training: exercise treatment for vertigo based upon the habituation effect. Otolaryngology—Head and Neck Surgery 1989;101:14-9.  Back to cited text no. 12
    
13.
Khanna T, Singh S. Effect of gaze stability exercises on balance in elderly. J Dental Med Sci 2014;13:41-8.  Back to cited text no. 13
    
14.
MacDowell SG, Wellons R, Bissell A, Knecht L, Naquin C, Karpinski A. The impact of symptoms of anxiety and depression on subjective and objective outcome measures in individuals with vestibular disorders. J Vestib Res 2017;27:295-303.  Back to cited text no. 14
    
15.
Nagarathna R, Nagendra H. Integrated approach of yoga therapy for positive health, 2nd ed. Bangalore: Swami Vivekananda Yoga Prakashana, 2004, p. 21, p. 27.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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