Effect of Yogasanas Versus Gaze Stability and Habituation Exercises on Dizziness in Vestibular Dysfunction
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.329557
Source of Support: None, Conflict of Interest: None
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.
Keywords: Motion, reflex, vertigo
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. 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. 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. The most common cause of bilateral vestibular hypofunction is ototoxicity. 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.
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. Evidence-based vestibular rehabilitation therapy is a known problem-oriented approach to initiate compensation. 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. 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. According to a study conducted by Nagarathna et al. 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.
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.
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). Fifty participants were screened, out of which 32 participants were involved in the study.
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.
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.
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].
Exercise protocol used for gaze stability exercises for Group B [Figure 2] was as follows:
Exercise protocol used for habituation exercises for Group B was as follows:
The exercises were terminated if the patients had any of the following:
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.
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).
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].
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].
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.
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.
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. 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. 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. 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. 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. 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. 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.,
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.
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.
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
Conflicts of interest
There are no conflicts of interest.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]