[A clinical study into the vestibular function and therapy of patients with chronic positional symptoms after acute vestibular syndrome]

Objective:To investigate the status of the vestibular function of the patients with chronic positional symptoms after peripheral acute vestibular syndrome (AVS) and the curative effect of the vestibular rehabilitation therapy (VRT). Method:Using caloric test (CT), head shaking nystagmus test (HST), cervical vestibular evoked myogenic potentials as well as ocular vestibular evoked myogenic potentials to estimate the function of semicircular canal and otolith organs. The patients with normal VEMPs are divided as Group A. Otherwise are as Group B. Both groups are treated with VRT. The curative effect is estimated by vestibular symptom index (VSI) and Berg balance scale (BBS). Result:Thirty-three of 37 patients (86.5%) had an abnormal result of CT and HST, with 23 of these patients (65.7%) had an abnormal of both test. Twenty-two patients (59.5%) were in Group A and 15 (40.5%) in Group B. Before the therapy, Group B had a higher score of the balance and dizziness symptoms of VSI (P<0.05), and Group A had a higher score of the BBS (P<0.05). After the therapy, the VSI scores of both groups dropped and scores of the BBS raised. Conclusion:Patients with chronic positional symptoms after peripheral AVS have dynamic vestibular lesions to different extents. Those with otolith organs lesions tend to have a worse function of balance. Nevertheless, patients have a better off after VRT.

"Positive to Negative" Dix-Hallpike test and Benign Paroxysmal Positional Vertigo recurrence in elderly undergoing Canalith Repositioning Maneuver and Vestibular Rehabilitation

Introduction Benign Paroxysmal Positional Vertigo is the most common cause of dizziness in elderly people. Recent studies have shown that the elderly present higher Benign Paroxysmal Positional Vertigo recurrence and that vertiginous symptomatology remission varies according to comorbidities and the therapeutic techniques applied.

Objective To assess the short-term effectiveness of Vestibular Rehabilitation in addition to Canalith Repositioning Maneuver on positive to negative Dix-Hallpike test, on recurrence and number of maneuvers to achieve a negative test in elderly patients with chronic Benign Paroxysmal Positional Vertigo.

Methods In this randomized controlled trial, 7 older adults (median age: 69 years, range 65–78) underwent Canalith Repositioning Maneuver and Vestibular Rehabilitation for thirteen weeks. Seven older adults (median age: 73 years, range 65–76) in the control group received only Canalith Repositioning Maneuver. The participants were assessed at baseline (T0), one (T1), five (T5), nine (T9), and thirteen weeks (T13). We assessed the differences between the groups by Mann-Whitney and Fisher exact tests, and used the Friedman and Wilcoxon tests to determine the intragroup differences.

Results No significant differences were found between groups for the positive to negative Dix-Hallpike test, recurrence, and number of maneuvers to achieve a negative test. The number of maneuvers to achieve negative Dix-Hallpike test was lower in intragroup comparisons in the experimental group.

Conclusion The findings suggest that additional Vestibular Rehabilitation did not influence the positive to negative Dix-Hallpike test, recurrence, or number of maneuvers to achieve a negative test in elderly patients with chronic Benign Paroxysmal Positional Vertigo.

Vertigo and hearing loss

Symptoms referable to disorders affecting the inner ear and vestibulocochlear nerve (eighth cranial nerve) include dizziness, vertigo, tinnitus, and hearing loss, in various combinations. Similar symptoms may occur with involvement of the central nervous system, principally the brainstem and cerebellum, to which the vestibular and auditory systems are connected. Imaging choices should be tailored to patient symptoms and the clinical context. Computed tomography (CT) should be used primarily to assess bony structures. Magnetic resonance imaging (MRI) should be used primarily to assess soft-tissue structures. Vascular imaging by angiography or venography should be obtained when vascular lesions are suspected. No imaging should be obtained in patients with typical presentations of common peripheral vestibular or auditory disorders. In current clinical practice, neuroimaging is often overused, especially CT in the assessment of acute dizziness and vertigo in the emergency department. Despite low sensitivity for ischemic strokes, CT is often used to rule out neurologic causes. When ischemic stroke is the principal concern in acute vestibular presentations, imaging should almost always be by MRI with diffusion-weighted images, rather than CT. In this chapter, we describe recommended strategies for audiovestibular imaging based on patient symptoms and signs.

Vertiginous Symptoms and Objective Measures of Postural Balance in Elderly People with Benign Paroxysmal Positional Vertigo Submitted to the Epley Maneuver

Introduction Benign Paroxysmal Positional Vertigo (BPPV) is one of the most common and treatable causes of peripheral vestibular vertigo in adults. Its incidence increases with age, eventually leading to disability and a decreased quality of life. Objective The research aims to assess short-term effects of Otolith Repositioning Maneuver (ORM) on dizziness symptoms, quality of life, and postural balance in elderly people with Benign Paroxysmal Positional Vertigo. Methods A quasi-experimental study, which evaluated 14 elderly people that underwent the Otolith Repositioning Maneuver and reevaluation after one week. The authors performed statistical analysis by descriptive analysis of central tendency and dispersion; for pre- and post-treatment conditions, the authors used the Wilcoxon test. Results All aspects of the Dizziness Handicap Inventory (physical, functional, emotional, and total scores) as well as the Visual Analogue Scale (VAS) decreased after therapy (p < 0.05 and p = 0.001, respectively). However, more than half of the elderly participants did not achieve negative Dix-Hallpike. Regarding static and dynamic balance, there were significant differences in some parameters of the modified Clinical Test of Sensory Interaction and Balance, Limits of Stability and gait assessment measured by the Dizziness Gait Index (p < 0.05). Conclusion Results reveal clinical and functional benefits in elderly people with Benign Paroxysmal Positional Vertigo submitted to Otolith Repositioning Maneuver. However, most of the participants did not overcome Benign Paroxysmal Positional Vertigo and not all aspects of postural balance improved. Therefore, a longer follow-up period and a multidisciplinary team are required to establish comprehensive care for elderly patients with dizziness complaints.

Characteristics of vertigo and the affected vestibular nerve systems in idiopathic bilateral vestibulopathy

CONCLUSION

Vertigo attacks in IBV patients involving both the superior and inferior vestibular nerve systems were significantly more severe than vertigo attacks in patients with selective involvement of the inferior vestibular nerve system alone.

OBJECTIVE

To investigate the relationship between the frequency and duration of vertigo and the affected vestibular nerve system in idiopathic bilateral vestibulopathy (IBV).

METHODS

This study categorized 44 IBV patients into the following three sub-groups according to the affected vestibular nerve system: superior, inferior, and mixed type. These patients were also categorized into the following three sub-groups according to their clinical time course: progressive type showing no episodes of vertigo, sequential type showing recurrent vertigo attacks and single-attack type showing a single episode of vertigo.

RESULTS

Ten, 11 and 23 patients were classified as the superior, the inferior, and the mixed type, respectively. Seventeen, 23, and four patients were classified as the progressive, the sequential, and the single-attack type, respectively. For the patients having one or more vertigo attacks, the duration of the vertigo attack was longer than 24 h in 69% of the mixed type, and the duration of vertigo in the mixed type was significantly longer than that in the inferior type (p < 0.05).

Head Position Comparison between Students with Normal Hearing and Students with Sensorineural Hearing Loss

Introduction Head sense position is coordinated by sensory activity of the vestibular system, located in the inner ear. Children with sensorineural hearing loss may show changes in the vestibular system as a result of injury to the inner ear, which can alter the sense of head position in this population.

Aim Analyze the head alignment in students with normal hearing and students with sensorineural hearing loss and compare the data between groups.

Methods This prospective cross-sectional study examined the head alignment of 96 students, 48 with normal hearing and 48 with sensorineural hearing loss, aged between 7 and 18 years. The analysis of head alignment occurred through postural assessment performed according to the criteria proposed by Kendall et al. For data analysis we used the chi-square test or Fisher exact test.

Results The students with hearing loss had a higher occurrence of changes in the alignment of the head than normally hearing students (p < 0.001). Forward head posture was the type of postural change observed most, occurring in greater proportion in children with hearing loss (p < 0.001), followed by the side slope head posture (p < 0.001).

Conclusion Children with sensorineural hearing loss showed more changes in the head posture compared with children with normal hearing.

Rapid adaptation of multisensory integration in vestibular pathways

Sensing gravity is vital for our perception of spatial orientation, the control of upright posture, and generation of our everyday activities. When an astronaut transitions to microgravity or returns to earth, the vestibular input arising from self-motion will not match the brain's expectation. Our recent neurophysiological studies have provided insight into how the nervous system rapidly reorganizes when vestibular input becomes unreliable by both (1) updating its internal model of the sensory consequences of motion and (2) up-weighting more reliable extra-vestibular information. These neural strategies, in turn, are linked to improvements in sensorimotor performance (e.g., gaze and postural stability, locomotion, orienting) and perception characterized by similar time courses. We suggest that furthering our understanding of the neural mechanisms that underlie sensorimotor adaptation will have important implications for optimizing training programs for astronauts before and after space exploration missions and for the design of goal-oriented rehabilitation for patients.

The Video Head Impulse Test in a Case of Suspected Bilateral Loss of Vestibular Function

Introduction A patient who had no symptoms suggestive of bilateral loss of vestibular function presented no responses in rotational and caloric tests.

Objectives To demonstrate the importance of the video head impulse test in neuro-otologic diagnosis.

Resumed Report This patient had a neuro-otologic evaluation and presented no responses in torsion swing tests, caloric tests, and rotational tests in a Bárány chair. The video head impulse test elicited responses in four of the six semicircular canals.

Conclusion Absent responses in caloric and rotatory tests alone are not sufficient to diagnose bilateral loss of vestibular function.

Effects of physiotherapy on balance and unilateral vestibular hypofunction in vertiginous elderly

BACKGROUND

We aimed to analyze the effect of a physical therapy protocol on unilateral vestibular hypofunction and overall balance in elderly with vertigo.

METHODS

The study included nine subjects, four male subjects (68.5 ± 11.09 years old) and five females (72.4 ± 7.09 years old). It was used the performance-oriented Mobility Assessment (POMA), to evaluate the balance and the Unterberger - Fukuda test for analysis of unilateral vestibular dysfunction through rotations and displacements of the body. We developed and applied a structured physical therapy protocol, consisting of group exercises.

RESULTS

It was observed that after the protocol, all participants improved balance (33.9 ± 5.1 vs. 47.3 ± 7.6, p < 0.0001) and displacement (111.1 ± 38.0 vs. 53.3 ± 34.6, p = 0.0001). However, it was not found significant differences for rotation.

CONCLUSION

The proposed protocol has contributed to an improvement in balance and vestibular dysfunction of the aged.

A new method to analyze the subjective visual vertical in patients with bilateral vestibular dysfunction

OBJECTIVE

The aim of this study was to assess the subjective visual vertical in patients with bilateral vestibular dysfunction and to propose a new method to analyze subjective visual vertical data in these patients.

METHODS

Static subjective visual vertical tests were performed in 40 subjects split into two groups. Group A consisted of 20 healthy volunteers, and Group B consisted of 20 patients with bilateral vestibular dysfunction. Each patient performed six measurements of the subjective visual vertical test, and the mean values were calculated and analyzed.

RESULTS

Analyses of the numerical values of subjective visual vertical deviations (the conventional method of analysis) showed that the mean deviation was 0.326±1.13º in Group A and 0.301±1.87º in Group B. However, by analyzing the absolute values of the subjective visual vertical (the new method of analysis proposed), the mean deviation became 1.35±0.48º in Group A and 2.152±0.93º in Group B. The difference in subjective visual vertical deviations between groups was statistically significant (p<0.05) only when the absolute values and the range of deviations were considered.

CONCLUSION

An analysis of the absolute values of the subjective visual vertical more accurately reflected the visual vertical misperception in patients with bilateral vestibular dysfunction.

Effect of Epley's maneuver on the quality of life of paroxismal positional benign vertigo patients

Quality of life (QoL) is significantly impaired by vertigo. The effect of specific treatments on QoL deserves investigation.

AIM

To assess the effect of repositioning maneuvers on the QoL of benign paroxysmal positioning vertigo (BPPV) patients.

MATERIALS AND METHODS

A retrospective study design consiting of reviews of charts of BPPV patients in a vestibular rehabilitation unit at a teaching institution in Belo Horizonte, MG, Brazil, from 2007 to 2008. Pre- and post-therapy (Epley's repositioning maneuver) scores on the physical, functional and emotional dimensions of the Dizziness Handicap Inventory (DHI) were analyzed.

RESULTS

Twenty-one patients were included, eighteen (86%) were females; the average age was 53.2 years. Ten patients presented bilateral BPPV; in eleven it was unilateral. The mean interval between assessments (pre- and post-treatment) was 21 days. The average number of required maneuvers was 2.3 (±1.1). Pre-treatment DHI results showed a significant impact of BPPV on quality of life. Initial scores for physical (17.5), functional (17.3), emotional (13.2) dimensions decreased with therapy: respectively 3.7, 3.9, and 3.2 (p<0.001).

CONCLUSION

In the present sample, Epley's maneuver had a positive and significant effect on emotional, physical and functional dimensions of quality of life, as measured by the DHI scores before and after therapy.