Effects of the Use of Anchor Systems in the Rehabilitation of Dynamic Balance and Gait in Individuals With Chronic Dizziness of Peripheral Vestibular Origin: A Single-Blinded, Randomized, Controlled Clinical Trial

Published:August 26, 2019DOI:



      To assess the effectiveness of the anchors in the balance rehabilitation of participants with chronic peripheral vestibulopathy who failed to respond positively to conventional rehabilitation for dynamic balance and gait.


      Assessor-blind, randomized controlled trial.


      Department of Otoneurology and Laboratory of Assessment and Rehabilitation of Equilibrium.


      Women with chronic dizziness of peripheral vestibular origin (N=42), who continued to show otoneurologic symptoms for more than 6 months after starting classic vestibular rehabilitation, with no clinical improvement observed.


      Participants were randomly assigned to receive a clinical intervention with the anchor system, a clinical intervention without the anchor system, or no intervention or anchor system. The intervention was based on multi-sensory exercises for 6 weeks, twice a week, totaling 12 sessions, in groups of up to 4 participants, with an average time of 40 minutes per session.

      Main Outcome Measures

      The primary outcome was functional balance as assessed by the short version of the Balance Evaluation Systems Test. The secondary outcomes were gait parameters of step width in meters, step length in meters, and gait speed in meters per second. The measures were assessed preintervention and postintervention, and after a 3-month follow-up period.


      The proposed intervention was beneficial for dizziness, balance, and gait for both groups studied. At the 3-month follow-up, only the group that used anchors retained the benefits related to the physical aspects of dizziness, balance, and gait.


      The present study found that the proposed intervention protocol, with or without the use of anchors, was beneficial for improving the dizziness, balance, and gait. However, retention of the benefits achieved through the exercise protocol was observed only for those using the anchor system, which promotes the use of haptic information. The use of anchors was effective, in short protocols (12wk), with maintenance of results after 3 months.


      List of abbreviations:

      CNS (central nervous system), DHI (Dizziness Handicap Inventory), G1 (intervention group with anchors), G2 (intervention group without anchors), G3 (control group with vestibulopathy), Mini-BESTest (short version of the Balance Evaluation Systems Test), MoCA (Montreal Cognitive Assessment), VR (vestibular rehabilitation)
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        • Tinetti M.E.
        • Williams C.S.
        • Gill T.M.
        Health, functional, and psychological outcomes among older persons with chronic dizziness.
        J Am Geriatr Soc. 2000; 48: 417-421
        • Caldas M.A.
        • Ganança C.F.
        • Ganança F.F.
        • Ganança M.M.
        • Caovilla H.H.
        Vertigem posicional paroxística benigna: caracterização clínica.
        Braz J Otorhinolaryngol. 2009; 75: 502-506
        • Gazzola J.M.
        • Ganança F.F.
        • Aratani M.C.
        • Perracini M.R.
        • Ganança M.M.
        Clinical evaluation of elderly people with chronic vestibular disorder.
        Braz J Otorhinolaryngol. 2006; 72: 515-522
        • Herdman S.J.
        Vestibular rehabilitation.
        3rd ed. FA Davis Company, Philadelphia2007
        • Hall C.D.
        • Herdman S.J.
        • Whitney S.L.
        • et al.
        Vestibular rehabilitation for peripheral vestibular hypofunction: an evidence-based clinical practice guideline: from the American Physical Therapy Association neurology section.
        J Neurol Phys Ther. 2016; 40: 124-155
        • Mauerberg-deCastro E.
        Developing an "anchor" system to enhance postural control.
        Motor Control. 2004; 8: 339-358
        • Maurer C.
        • Mergner T.
        • Bolha B.
        • Hlavacka F.
        Vestibular, visual, and somatosensory contributions to human control of upright stance.
        Neurosci Lett. 2000; 281: 99-102
        • Mauerberg-deCastro E.
        • Lucena C.S.
        • Cuba B.W.
        • Boni R.C.
        • Campbell D.F.
        • Moraes R.
        Haptic stabilization of posture in adults with intellectual disabilities using a nonrigid tool.
        Adapt Phys Activ Q. 2010; 27: 208-225
        • Mauerberg-deCastro E.
        • Moraes R.
        • Campbell D.F.
        Short-term effects of the use of non-rigid tools for postural control by adults with intellectual disabilities.
        Motor Control. 2012; 16: 131-143
        • Freitas Mde B.
        • Mauerberg-deCastro E.
        • Moraes R.
        Intermittent use of an "anchor system" improves postural control in healthy older adults.
        Gait Posture. 2013; 38: 433-437
        • Costa A.A.
        • Manciopi P.A.
        • Mauerberg-deCastro E.
        • Moraes R.
        Haptic information provided by the "anchor system" reduces trunk sway acceleration in the frontal plane during tandem walking in older adults.
        Neurosci Lett. 2015; 609: 1-6
        • Costa A.A.D.S.
        • Santos L.O.D.
        • Mauerberg-deCastro E.
        • Moraes R.
        Task difficulty has no effect on haptic anchoring during tandem walking in young and older adults.
        Neurosci Lett. 2017; 666: 133-138
        • Hedayat I.
        • Moraes R.
        • Lanovaz J.L.
        • Oates A.R.
        Different haptic tools reduce trunk velocity in the frontal plane during walking, but haptic anchors have advantages over lightly touching a railing.
        Exp Brain Res. 2017; 235: 1731-1739
        • Mauerberg-deCastro E.
        • Moraes R.
        • Tavares C.P.
        • Figueiredo G.A.
        • Pacheco S.C.
        • Costa T.D.
        Haptic anchoring and human postural control.
        Psychol Neurosci. 2014; 7: 301-318
        • Bisdorff A.
        • Brevern M.V.
        • Lempert T.
        • Newman-Toker D.E.
        Classification of vestibular symptoms: towards an international classification of vestibular disorders.
        J Vestib Res. 2009; 19: 1-13
        • Simões M.R.
        • Freitas S.
        • Santana I.
        • et al.
        Montreal cognitive assessment (MoCA): Normative study for the Portuguese population..
        J Clin Exp Neuropsychol. 2011; 33: 989-996
        • Castro A.S.O.
        • Gazzola J.M.
        • Natour J.
        • Ganança F.F.
        Brazilian version of Dizziness Handicap Inventory] [Portugues].
        Pró-Fono Revista de Atualização Científica. 2007; 19: 97-104
        • Maia A.C.
        • Rodrigues-de-Paula F.
        • Magalhães L.C.
        • Teixeira R.L.
        Cross-cultural adaptation and analysis of the psychometric properties of the Balance Evaluation Systems Test and MiniBESTest in the elderly and individuals with Parkinson's disease: application of the Rasch model.
        Braz J Phys Ther. 2013; 17: 195-217
        • Rossi-Izquierdo M.
        • Santos-Pérez S.
        • Rubio-Rodríguez J.P.
        • et al.
        What is the optimal number of treatment sessions of vestibular rehabilitation?.
        Eur Arch Otorhinolaryngol. 2014; 271: 275-280
        • Almeida S.I.
        • Marques A.
        • Santos J.
        Normative values of the Balance Evaluation System Test (BESTest), Mini-BESTest, Brief-BESTest, Timed Up and Go Test, and Usual Gait Speed in healthy older Portuguese people.
        Rev Port Med Geral Fam. 2017; 35: 106-116
        • Coelho A.R.
        • Abreu D.C.
        Effects of anchor system during balance rehabilitation in subjects with chronic dizziness of peripheral vestibular origin: a controlled, randomized, single-blind clinical trial.
        MOJ Gerontol Ger. 2018; 3: 414-420
        • Hattie J.
        Visible learning.
        2nd ed. Routledge, London2009
        • Caixeta G.C.
        • Doná F.
        • Gazzola J.M.
        Cognitive processing and body balance in elderly subjects with vestibular dysfunction.
        Braz J Otorhinolaryngol. 2012; 78: 87-95
        • Magnani P.E.
        • Genovez M.B.
        • Porto J.M.
        • et al.
        Use of the BESTest and the Mini-BESTest for fall risk prediction in community-dwelling older adults between 60 and 102 years of age.
        J Geriatr Phys Ther. 2019 May 6; ([Epub ahead of print])
        • Wuehr M.
        • Nusser E.
        • Decker J.
        • et al.
        Noisy vestibular stimulation improves dynamic walking stability in bilateral vestibulopathy.
        Neurology. 2016; 86: 2196-2202
        • Meldrum D.
        • Herdman S.
        • Moloney R.
        • et al.
        Effectiveness of conventional versus virtual reality based vestibular rehabilitation in the treatment of dizziness, gait, balance impairment in adults with unilateral peripheral vestibular loss: a randomised controlled trial.
        BMC Ear Nose Throat Disord. 2012; 12: 3-8
        • Kim S.C.
        • Kim J.Y.
        • Lee H.N.
        • et al.
        A quantitative analysis of gait patterns in vestibular neuritis patients using gyroscope sensor and a continuous walking protocol.
        J Neuroeng Rehabil. 2014; 11: 58-64
        • Schniepp R.
        • Schlick C.
        • Schenkel F.
        • et al.
        Clinical and neurophysiological risk factors for falls in patients with bilateral vestibulopathy.
        J Neurol. 2017; 264: 277-283
        • Wuehr M.
        • Schniepp R.
        • Schlick C.
        • et al.
        Sensory loss and walking speed related factors for gait alterations in patients with peripheral neuropathy.
        Gait Posture. 2014; 39: 852-858
        • Jahn K.
        • Deutschländer A.
        • Stephan T.
        • et al.
        Supraspinal locomotor control in quadrupeds and humans.
        Prog Brain Res. 2008; 171: 353-362
        • Bent L.R.
        • Inglis J.T.
        • McFadyen B.J.
        When is vestibular information important during walking?.
        J Neurophysiol. 2004; 92: 1269-1275
        • Mergner T.
        • Rosemeier T.
        Interaction of vestibular, somatosensory and visual signals for postural control and motion perception under terrestrial and microgravity conditions—a conceptual model.
        Brain Res Rev. 1998; 28: 118-135