Archives of Physical Medicine and Rehabilitation
journal homepage: www.archives-pmr.org
Archives of Physical Medicine and Rehabilitation 2015;-:-------
ORIGINAL ARTICLE
Computer-Assisted Training as a Complement in
Rehabilitation of Patients With Chronic Vestibular
DizzinessdA Randomized Controlled Trial
Michael Smaerup, PT, MA,a Erik Grönvall, MScEng, PhD,b Simon B. Larsen, MScEng, PhD,c
Uffe Laessoe, PT, PhD,d Jens-Jacob Henriksen, MD,e Else Marie Damsgaard, MDf
From the aDepartment of Geriatrics, Aarhus University Hospital, Aarhus C; bComputer Games and Interaction Design, IT University of
Copenhagen, Copenhagen S; cAlexandra Institute Ltd, Aarhus N; dDepartment of Health Science and Technology, Aalborg University, Aalborg;
e
Ear, Nose, and Throat Department, Aarhus University Hospital, Aarhus C; and fDepartment of Geriatrics, Aarhus University Hospital, Aarhus C,
Denmark.
Abstract
Objective: To compare a computer-assisted home exercise program with conservative home-training following printed instructions in the
rehabilitation of elderly patients with vestibular dysfunction.
Design: Single-blind, randomized, controlled trial.
Setting: Geriatric department of a university hospital.
Participants: Patients with chronic dizziness due to vestibular dysfunction (NZ63) were randomly assigned to either rehabilitation in the clinic
followed by computer-assisted home exercises (intervention group: nZ32) or rehabilitation in the clinic followed by home exercises according to
printed instructions (control group: nZ31).
Interventions: Patients in the intervention group received assisted rehabilitation by a computer program.
Main Outcome Measures: Measurements at baseline and at 8 and 16 weeks were compared. These included the One Leg Stand Test, Dynamic
Gait Index, Chair Stand Test, Motion Sensitivity Test, Short Form-12, Dizziness Handicap Inventory, and visual analog scale.
Results: Both groups improved significantly during 16 weeks of rehabilitation. However, neither t tests nor repeated-measures analysis of
variance demonstrated any significant differences between the 2 groups. The overall compliance rate to computer program exercises during 16
weeks was 57%.
Conclusions: A computer-assisted program to support the home training of elderly patients with vestibular dysfunction did not improve
rehabilitation more than did printed instructions.
Archives of Physical Medicine and Rehabilitation 2015;-:------ª 2015 by the American Congress of Rehabilitation Medicine
Dizziness is considered to be the most common complaint of
patients 75 years and older.1 Sloane and Baloh2,3 reported that
46% of 116 patients older than 70 years referred to a neurootology
clinic for dizziness presented with vestibular disorders. Also, a
study of 6785 persons included in the U.S. National Health and
Nutrition Examination surveys showed a significant increase in the
prevalence of vestibular dysfunction with age.4
Supported by the Danish Health Foundation, Ejnar and Aase Danielsen Foundation, the Association of Danish Physiotherapists, the Department of Clinical Medicine, Aarhus University, and
the Helene Elsass Center.
Clinical Trial Registration No.: NCT01344408.
Disclosures: none.
A 2012 Cochrane review demonstrated that about 30% of
people 65 years or older experience a fall, with a higher incidence
among older people living in institutions.5,6 Ninety-five percent of
all hip fractures resulting in hospitalization, disability, or death are
caused by falls.7 Vestibular dysfunction is recognized as an
intrinsic factor leading to falls,8 and vestibular rehabilitation (VR)
has been shown to reduce the risk.8-10 A Cochrane review
concluded that evidence for the efficacy of VR in patients with
vestibular dysfunction was moderate to strong.11 Another review
looked at the effects of VR in middle-aged and older adults and
found evidence for a positive effect of VR in elderly patients
with vestibular disturbances.12 Numerous studies of patients with
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http://dx.doi.org/10.1016/j.apmr.2014.10.005
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M. Smaerup et al
chronic vestibular dysfunction indicate that individualized treatment strategies are more useful than general protocols; hence, VR
planning is a specialized task.13,14 Several authors report that a
reduction in dizziness by VR can be achieved only by combining
rehabilitation at a clinic with daily home exercises.12,15 However,
compliance with home exercises can be poor among elderly
patients.16,17
The development of video games over the last decade has led
to programs designed to rehabilitate or train their players.17,18 A
generally accepted view is that video games may improve rehabilitation, but their practicality and benefits require validation. So
far, the games have been used in clinical settings, but not in home
environments where an important proportion of VR must occur to
be successful.18
The objective of the study was to compare a computer training
program with conservative home-training according to printed
instructions in the rehabilitation of elderly patients with vestibular
dysfunction.
Methods
A possible support for home rehabilitation may be the computer
training program “Move It To Improve It” (Mitii).a It has been
used to home-train patients with cerebral palsy. Its exercises are
both motivating and guiding.19 Mitii represents a “low-tech”
solution that simply requires a webcam-enabled computer. For the
present study, the program was adapted for patients with vestibular
dysfunction. The project took place in the Department of Geriatrics, The Falls Prevention Clinic, Aarhus University Hospital,
Aarhus C, and in the ENT Department, Aarhus University Hospital, Aarhus C.
Design
This randomized study of patients with VR compared home
exercises supported by the Mitii computer program with a control
group given printed instructions. An assessor blinded to the
exercise procedures examined all participants at baseline and after
8 and 16 weeks of exercises.
The study was approved by the Danish National Committee on
Health Research Ethics (project ID M-20090189) and the Danish
Data Protection Agency (project ID 1-16-02-84-09). All participants gave informed and signed consent.
Participants
All patients (65y) presented with stable peripheral, central,
and/or mixed vestibular dysfunction. Some were recruited from
the Fall Clinic, Geriatric Department, Aarhus University Hospital, Denmark, after referral by their general practitioners or
from the Emergency Department at Aarhus University Hospital.
Others replied to a newspaper advertisement asking for volunteers. A geriatrician evaluated the causes of the patients’ falls.
Those with vestibular dysfunction who agreed to participate in
the project were referred to the Ear, Nose and Throat Department at Aarhus University Hospital to verify the diagnosis of
vestibular dysfunction. Diagnostic tests comprised vestibular
evoked myogenic potentials; subjective visual video head
List of abbreviations:
Mitii Move It To Improve It
VR vestibular rehabilitation
impulses (vertical and horizontal); spontaneous nystagmus; the
bithermal caloric vestibular ocular reflex test (including visual
suppression); an oculomotor test including saccades, smooth
pursuit, and optokinetic responses; the Roll test; the Dix Hallpike, Hennebert gaze-induced nystagmus; and the Romberg
nystagmus test.
Exclusion criteria comprised unstable peripheral vestibular
dysfunction, that is, Menière disease, benign paroxysmal positional vertigo, and acute neuronitis vestibularis. Other exclusion
criteria were poor vision (6/60), contraindications to exercise
therapy, significant cardiac problems, use of medicines with potential vestibular adverse effects (benzodiazepines and sedatives),
dementia (Mini-Mental State Examination scores of <27, or a
history suggesting dementia), stroke in the previous 6 months,
other cognitive dysfunctions, and hip fracture within the last
3 months.
Sample size and randomization
Findings of a previous rehabilitation exercise trial in patients with
dizziness showed a mean improvement of 6.68.4 seconds on the
One Leg Stand Test for the intervention group compared with
0.46.9 seconds for the control group.20 On the basis of these
figures, we expected a mean improvement of approximately 6
seconds for the intervention group compared with the control
group in the present study. Hence, with a 2-tailed significance of
5%, 80% power, and an expectation of 15% dropouts, the sample
size was estimated at 29 patients per rehabilitation group.
Randomization after screening and before baseline assessments was provided by a central computer program with permuted
block sizes and stratification according to peripheral, central, or
mixed vestibular dysfunction. Accordingly, the computer program
randomized patients to various blocks of 3, 6, or 9 patients and
assigned a total of 32 patients to the intervention group and 31 to
the control group (fig 1).
Intervention
Patients in the intervention and control groups received identical
rehabilitation training at the hospital twice a week for 16 weeks.
For both groups, rehabilitation at hospital was combined with
home exercises. The intervention group was provided with a
specifically adapted computer-based Mitii program, whereas the
control group was given a printed home-training program. Rehabilitation aimed at (1) endurance training, (2) vestibular ocular
reflex and cervical ocular reflex training for gaze stability, (3)
resetting the vestibular ocular reflex gain, (4) enhancing smoothpursuit eye movements, and (5) using somatosensory and
vestibular inputs for postural control.
The Mitii training program was set up in the participants’
homes using an Internet-connected computer and a web camera
connected to a cloud-based interactive training system using the
Adobe Flash technology.b The system was developed by a
collaboration between the Helene Elsass Centre, the Headfitted
Software Development Company, and the University of Copenhagen.21-24
Participants logged into the Mitii website and accessed their
individualized training program. The specific content and progression of the program were based on monthly evaluations of
each patient’s performance. The level of difficulty was adjusted by
increasing the task challenges (speed, number of repetitions,
placing of target and pick-up area on the screen, size of objects,
time to react, etc). A sequence of individual tasks and games was
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Computer-assisted training in rehabilitation
Fig 1
3
Participants at each stage of the trial. Abbreviation: BPPV, benign paroxysmal positional vertigo. *Diagnosed after inclusion.
arranged for a daily exercise program of 20 to 30 minutes
(table 1). All exercises required patients to stand. Before each
exercise, a short video showed the patient what to do. The program comprised drag-and-drop and follow-the-leader exercises.
For drag-and-drop exercises, patients wore a headband with a
green marker at the front. The computer webcam registered the
position of the green marker and transferred this information to
the screen cursor control (fig 2) for the cursor to be controlled by
head movements. A virtual object on the screen was manipulated
by grabbing and dragging it to a different location, or onto another
virtual object. The exercises instigated head movements and
challenged the vestibulo-ocular reflex (see table 1). Other
exercises challenged the patients’ postural balance. A follow-theleader exercise uploaded a video sequence of a therapist’s
movements that the patient was expected to follow visually. These
exercises challenged the patient’s vestibulo-ocular reflex. After
completing each exercise, a message, for example, “well done,”
appeared on the screen. No other feedback was given concerning
the manner or quality of performance. The duration of performance was registered and displayed for the hospital project
physiotherapist who contacted participants if the program was not
used for 7 days.
The project physiotherapist (M.S.) gave intervention group
patients oral and written instructions concerning Mitii home
exercises. During the study period, the patients were contacted
once a month by the physiotherapist to adjust the duration,
speed, and difficulty of the exercises according to their progress.
The physiotherapist and the patients also evaluated the compliance with Mitii. Home-training instructions for the control group
were provided by hospital physiotherapists. Home exercises for
the control group also addressed vestibulo-ocular reflex and
balance training, as described and illustrated in their leaflet. No
exercise follow-up was provided for the control group. Both
groups were told to perform their exercises for 20 to 30 minutes
at least once daily.
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Outcome measures
The One Leg Stand Test20,25 for postural control measured the
time (maximum, 30s) taken by the patients to move their feet from
the start position. Both right and left leg stands were tested, and
the best leg value was used in the analysis. The Dynamic Gait
Index26 assessed dynamic postural stability as functional gait
according to 8 tasks with varying demands, for example, walking
at different speeds, walking with head turns, ambulation over and
around obstacles, making a quick turn while walking, and
ascending and descending stairs. Each item was rated on a 4-level
ordinal scale, with a maximum score of 24. The Dizziness
Handicap Inventory27 measured the effect of dizziness on quality
of life. The Short Form-12 questionnaire28 assessed the quality of
life. Responses to this questionnaire were summarized by independent Physical and Mental Composite scores. The Motion
Sensitivity Test29 assessed the dizziness prompted by a series of
16 quick changes of head or body positions. The visual analog
scale20 rated vertigo and unsteadiness on a 0 to 100mm scale,
ranging from “no symptoms” to “worst possible.” The Chair Stand
Test29,30 measured balance and strength of the lower extremities
by recording the number of times (within 30s) a patient could rise
from a chair. Baseline characteristics were also recorded: age, sex,
duration of dizziness, and type of vestibular dysfunction (central,
mixed, or peripheral). The number of hospital training sessions
during the study period was registered manually. The number and
duration of the Mitii sessions were recorded by the server.
Statistical analysis
Data were analyzed on intention-to-treat and per-protocol bases
using STATA statistical software (version 12).c Two participants in
the intervention group declined to participate but were assessed
at baseline and at 8 and 16 weeks and were included in the
intention-to-treat analysis. Groups were compared at baseline
4
M. Smaerup et al
Table 1
Tasks and domains trained in the Mitii program and description of the corresponding actions*
Task
Task Description
Action
Domains Trained
Flight simulator
Ability to balance against series
of lateral displacements
Balance and postural
control
Follow the leader
Follow a sequence of movements
Shift weight from side to side with
knee in w20 flexion and stabilize
eyes on moving object
Side-to-side head movement of w60
at a speed of 90 /s, 1.5Hz
Move game
Rotate head or flex/extend neck
while focusing on a target
Side-to-side head movement of w60
at a speed of 90 /s, 1.5Hz
Follow game
Ability to balance and activate
larger muscle groups in lower
extremities
Shift weight from side to side with
knee in w20 flexion and stabilize
eyes on moving object
Don’t move game
Rotate head when fairy turns
into green color
Side-to-side head movement of w60
at a speed of 90 /s, 1.5hz
Get up/get down
Ability to balance and activate
larger muscle groups in lower
extremities
Shift weight from side to side w20
knee flexion and get up and down
from 90 knee flexion to full extension
Vestibular ocular reflex
and cervical ocular
reflex for gaze stability
Vestibular ocular reflex
and cervical ocular
reflex for gaze stability
Saccadic eye movements
for gaze stability
Lower limb strength
Balance
Vestibular ocular reflex
and cervical ocular
reflex for gaze stability
Lower limb strength
Balance and postural
control
* The physiotherapist at the hospital is allowed to change the speed and the complexity of each task.
using independent t tests. Repeated analysis of variance tests were
used to analyze examinations at baseline and at 8 and 16 weeks.
No significant differences were found between the 2 groups. The
groups were also compared by paired and independent t tests (with
confidence intervals). Exercise compliance in the intervention
group was calculated by dividing the actual number of training
sessions by the recommended number, that is, 16 weeks of once
daily exercise training, which is 112 recommended sessions per
patient. The Wilcoxon signed-rank test was used to analyze the
change in compliance from baseline to 16 weeks of rehabilitation.
Results
The intervention and control groups did not differ significantly
(>.05) on any variable at baseline (table 2). The mean duration of
dizziness was >6 years. Central vestibular dysfunction was the
most common diagnosis. The mean number of hospital sessions
was 23 for the Mitii group and 24 for the control group contra 32
sessions recommended for both groups.
Within-group rehabilitation effects were significant and
showed improvement for both groups with respect to the Dynamic
Gait Index and the Chair Stand Test. Also, the intervention group
improved significantly with the Dizziness Handicap Inventory and
Motion Sensitivity tests, but not significantly more than did the
control group (table 3). Repeated analysis of variance tests at
baseline and at 8 and 16 weeks did not show significant differences between the 2 groups. Also, analysis per-protocol did not
show any significant difference between the intervention and
control groups. During 112 possible days of home training, patients in the intervention group used the Mitii system once daily
on 57% of the days (median, 51 sessions; 25th percentileZ19
sessions; 75th percentileZ65 sessions). The total duration of
training sessions was not associated with outcome when tested
using the Spearman rank correlation test (fig 3). Compliance with
training peaked between 1 and 2 months of training (fig 4).
Thereafter, compliance decreased and flattened for the rest of the
study period.
Discussion
Overall effect of training on vestibular dysfunction
The Dynamic Gait Index and the Chair Stand tests showed significant improvements for both groups. Thus, our results confirm
the conclusions of other studies, that VR has an effect on patients
with vestibular dysfunction.11
Effect of home training with a computer compared
with written instructions
Fig 2
Participant using Mitii.
The computer training group did not improve significantly more
than did the written instructions group. No significant betweengroup differences were observed with regard to any of the
studied parameters. The intervention with Mitii showed a
compliance rate of 57%. Other studies using more traditional
home-training programs with instructions by physiotherapists
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Computer-assisted training in rehabilitation
Table 2
5
We contacted patients only once a month and pointed out the
data generated by the Mitii system to show their number of
training sessions and total exercise times. Lange et al32 claimed
that given the current level of technology, home exercise programs
should be able to generate feedback to patients on both progress
and compliance. The importance of feedback from physiotherapists could explain why studies using programs such as Nintendo
Wii were effective with clinic patients aged approximately 40
years.33 Such results may not be transferable to older patients who
collaborate less than do younger patients.34
The study showed that computer-assisted training and
printed instructions were equally effective, and it appears that
there is an overall need for improvement in home training of
vestibular lesions. An earlier study of older patients stressed the
importance of encouragement by an instructor,35 and another
study concluded that therapists’ explanations and individually
targeted exercises bear importantly on outcome.31 The program
should also present patients with immediate feedback to motivate them to continue with their exercises.36 An alternative
solution, demanding fewer resources, would be more frequent
contact with the therapist to discuss rehabilitation goals plus,
perhaps, more frequent exercise sessions. Exercise games and
online contact with a physiotherapist should also be
advantageous.
Evidence suggests that rehabilitation is made more enjoyable
and motivating when patients focus on a game (eg, Mitii) rather
than on their impairment. Patients with vestibular dysfunction may
then be more likely to continue with their exercises despite the
many repetitions necessary to modulate neural function.32 Unfortunately, the current version of Mitii may not be the solution to
this problem.
Participant characteristics*
Characteristic
Women
Age (y)
Duration of dizziness (mo)
Rehabilitation sessions at the
hospital
Types of vestibular dysfunction
Peripheral
Mixed
Central
Baseline score for outcome
measures
Dynamic Gait Index (points)
Dizziness Handicap Inventory
(points)
Motion Sensitivity Test
(points)
Visual analog scale (mm)
Chair Stand Test (rep)
One Leg Stand Test (s)
Short Form-12 Physical
Composite Score (points)
Short Form-12 Mental
Composite Score (points)
Mitii Group
(nZ30)
Control Group
(nZ30)
18 (58)
76.657.56
58.0351.31
23.458.73
20 (65)
78.686.56
71.3551.08
24.238.09
2 (6)
4 (13)
25 (81)
2 (6)
6 (20)
23 (74)
16.354.02
41.6117.96
14.873.65
42.2618.81
25.4817.42
25.7423.14
37.8122.15
11.742.98
10.0610.06
38.8612.63
36.6522.20
10.712.82
8.278.97
35.1311.65
51.669.27
52.2512.76
NOTE. Values represent mean SD or n (%).
* Wilcoxon signed-rank test, Student t test, and c2 test were used.
yielded compliance rates of 30% to 57%.31 All studies found
that compliance was highest at the start and decreases thereafter.31 We found the highest compliance in the first study
period, but no significant difference in compliance from months
1 to 4. Hence, computer-based exercises at home cannot be
claimed to produce better compliance than traditional hometraining exercises.
Table 3
Study limitations
Patients were recruited via general practitioners, from the Emergency Department at Aarhus University Hospital, or by newspaper
advertisements. Hence, they may have had different motives for
participating in the study. Patients responding to the advertisement
may have been more fit than those referred by general practitioners
who may have been less compliant. We did not measure the control
Mean changes in outcome measures at baseline and at 16-wk follow-up*
Mitii Group
y
Outcome Measures
One Leg Stand test (s)
Dynamic Gait Index
(points)
Dizziness Handicap
Inventory (points)
Motion Sensitivity
Test (points)
Visual analog scale (mm)
Chair Stand Test (rep)
Short Form-12 Physical
Functioning (points)
Short Form-12 Mental
Functioning (points)
Mean Change (CI)
2.09 (0.15 to 4.32)
1.37 (0.18 to 2.55)
Control Group
P
Mean Change (CI)
.066
.025
Difference Between Groups
P
Difference in Mean Change (CI)
P
2.63 (0.17 to 5.44)
1.53 (0.44 to 2.63)
.065
.007
0.55 (4.06 to 2.96)
0.17 (1.74 to 1.41)
.755
.833
9.93 (15.27 to 4.60)
<.001
5.20 (10.70 to 0.30)
.063
4.73 (12.23 to 2.77)
.212
10.50 (16.70 to 4.30)
.002
7.17 (15.76 to 1.43)
.099
3.33 (13.71 to 7.04)
.523
5.93 (14.55 to 2.69)
1.33 (0.31 to 2.36)
2.70 (0.88 to 6.28)
.170
.013
.134
6.30 (14.21 to 1.61)
1.33 (0.48 to 2.19)
3.18 (0.63 to 7.00)
.114
.004
.098
0.37 (11.08 to 11.82)
0.00 (1.31 to 1.31)
0.48 (5.60 to 4.64)
.949
1.000
.851
3.33 (0.72 to 7.38)
.103
1.09 (2.66 to 4.84)
.557
2.24 (3.16 to 7.64)
.410
* For all measures except for Motion Sensitivity Test, Dizziness Handicap Inventory, and Visual Analog Scale higher values indicate better functioning.
y
Analysis are based on data from nZ30 in the Mitii group and n=30 in the control group.
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6
M. Smaerup et al
Fig 3 The association between exercise time and outcome in the intervention group. For all measures except Motion Sensitivity Test, Dizziness
Handicap Inventory, and visual analog scale, higher values indicate better functioning.
group compliance with printed instructions. Because no significant
difference was detected between the intervention and the control
groups, in contrast to significant within-group improvements, for
certain outcome measures, we cannot exclude that it may have
been VR at the clinic that produced the observed effects.
A limitation to the validity of this study was its lack of
“blinding” to treatments (participants and the therapists administering rehabilitation could not be blinded). An attempt was made
to blind assessors measuring outcomes, but the fact that the
measurements took place during 1-hour sessions introduced the
risk of revealing the patients’ treatment groups.
A further limitation is the Mitii system itself because it could
not evaluate the quality of performance or indicate how the
exercises were performed. Also, the system was unable to identify
who performed the recorded exercises.
Conclusions
A computer-assisted program to support home training of elderly
patients with vestibular dysfunction did not improve their VR
more than did printed instructions given to a control group.
Suppliers
a. Mitii Development A/S.
b. Adobe Systems.
c. Stata, version 12; StataCorp.
Keywords
Patient compliance; Rehabilitation; Therapy, computer-assisted;
Vestibular diseases
Corresponding author
Michael Smaerup, PT, MA, Department of Geriatrics, Research
Division G, Aarhus University Hospital, P.P. Oerums Gade 11, Bldg
7, Aarhus C, Denmark. E-mail address: [email protected].
Acknowledgments
Fig 4 Compliance in the rehabilitation period in the intervention
group. Abbreviation: CI, confidence interval.
We thank the health care workers of the Department of Geriatrics,
Aarhus University Hospital for their engagement in the rehabilitation of the patients included in this project.
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Computer-assisted training in rehabilitation
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