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Im JJ, Na S, Jeong H, Chung YA. A Review of Neuroimaging Studies in Persistent Postural-Perceptual Dizziness (PPPD). Nucl Med Mol Imaging 2021; 55:53-60. [PMID: 33968271 DOI: 10.1007/s13139-020-00675-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/26/2020] [Accepted: 11/17/2020] [Indexed: 11/26/2022] Open
Abstract
Persistent postural-perceptual dizziness (PPPD) is a functional vestibular disease characterized by persistent dizziness, unsteadiness, and/or non-spinning vertigo, and is the most common vestibular syndrome in young adults. A stiffened postural control strategy, shift to reliance on visual over vestibular information, and hypervigilance to the environment have been suggested as possible pathophysiological mechanisms of PPPD. However, the exact mechanisms remain unclear. Recently, neuroimaging studies using magnetic resonance imaging and single photon emission computed tomography have provided pivotal insights into the pathophysiology of PPPD. The aim of this review was to evaluate and summarize the existing data on neuroimaging studies in PPPD. In summary, these studies fairly consistently reported decreased brain structure, function, and connectivity among the areas involved in multisensory vestibular processing and spatial cognition, and increased function and connectivity in the visual processing areas in patients with PPPD. The detected brain changes might reflect maladaptive and compensatory mechanisms including dysfunctional integration of multisensory vestibular information and visual dependence. Notably, various factors including personality traits (i.e., neuroticism), psychiatric comorbidities (i.e., anxiety and depression), and triggering factors (i.e., peripheral vestibular lesions) seem to modulate brain functional activity and connectivity patterns, possibly accounting for some differences across the results. Future studies should carefully control for these confounding effects in order to draw firm conclusions.
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Affiliation(s)
- Jooyeon Jamie Im
- Department of Neurology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Seunghee Na
- Department of Neurology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Hyeonseok Jeong
- Department of Nuclear Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Yong-An Chung
- Department of Nuclear Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
- Department of Radiology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
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Graham MK, Staab JP, Lohse CM, McCaslin DL. A Comparison of Dizziness Handicap Inventory Scores by Categories of Vestibular Diagnoses. Otol Neurotol 2021; 42:129-136. [PMID: 33229883 DOI: 10.1097/mao.0000000000002890] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The Dizziness Handicap Inventory (DHI) is a 25-item self-report quantifying dizziness-related physical and emotional symptoms and restrictions in daily activities. DHI scores do not correlate with severity of structural vestibular deficits; thus, high DHI scores may reflect other causes of morbidity. This study investigated the relationship between total DHI scores and the presence of structural, functional, and psychiatric disorders in tertiary neurotology patients. STUDY DESIGN Retrospective. SETTING Tertiary center. PATIENTS Eighty-five patients who underwent multidisciplinary neurotologic evaluations. INTERVENTION Diagnostic. MAIN OUTCOME MEASURE(S) Active illnesses identified by a multidisciplinary neurotology team were abstracted from medical records, cataloged as structural, functional, or psychiatric disorders, and used to group patients into diagnostic categories: structural (structural disorders only), functional (functional disorders with/without structural disorders), and psychiatric (psychiatric disorders with/without other conditions). DHI scores were compared across diagnostic categories. Sensitivities and specificities of DHI scores for identifying structural versus functional or psychiatric disorders were calculated. RESULTS Mean DHI scores differed significantly by diagnostic category (structural 35 ± 18, functional 64 ± 15, and psychiatric 65 ± 19), before and after adjusting for age and sex (p < 0.001, Hedges' g>1.62 for structural versus functional and psychiatric categories). DHI≤30 (mild handicap) had specificity = 0.98 for structural disorders alone, whereas DHI>60 (severe handicap) had specificity = 0.88 for functional or psychiatric disorders. CONCLUSIONS In this tertiary cohort, categories of illnesses had large effects on total DHI scores. Patients with scores ≤30 were likely to have structural disorders alone, whereas those with scores >60 were likely to have functional or psychiatric disorders, with or without coexisting structural conditions.
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Affiliation(s)
| | - Jeffrey P Staab
- Department of Otolaryngology-Head and Neck Surgery
- Department of Psychiatry and Psychology
| | - Christine M Lohse
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
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Herdman D, Evetovits A, Everton HD, Murdin L. Is 'persistent postural perceptual dizziness' a helpful diagnostic label? A qualitative exploratory study. J Vestib Res 2020; 31:11-21. [PMID: 33325421 DOI: 10.3233/ves-201518] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Persistent Postural Perceptual Dizziness (PPPD) is a recently defined functional syndrome. In other functional disorders there has been concern that the label itself can have negative effects, but research on patient views of PPPD is lacking. OBJECTIVE To understand patient views of the PPPD labelMETHODS:Semi-structured interviews were conducted with 13 people with PPPD and thematically analysed. RESULTS Four themes were identified. Theme 1 reflects reassurance and validation received through a 'label'. Theme 2 reflects re-evaluation of illness-beliefs, with the diagnosis giving greater perception of control but also perception of having serious consequences. Theme 3 reflects difficulty understanding terminology. Participants rarely understood "persistent", "perceptual" and "postural". They did not tend to use the term "PPPD" to others or themselves. Some interpreted "persistent" as meaning "poor prognosis". Theme 4 reflects lack of psychological attribution, since participants normalised the experience of distress, but did not view this as part of PPPD. CONCLUSIONS These data support the relevance of PPPD beyond simply classification. However patients found the components of the term itself confusing and did not tend to adopt it when relating their condition to others or themselves. Simplifying the nomenclature could facilitate shared understanding and management, even potentially influencing outcome.
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Affiliation(s)
- David Herdman
- Health Psychology Section, King's College London, London, UK.,St George's University Hospitals NHS Foundation Trust, London, UK
| | | | | | - Louisa Murdin
- Guy's & St Thomas' NHS Foundation Trust, London, UK.,Ear Institute, University College London, London, UK
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Axer H, Finn S, Wassermann A, Guntinas-Lichius O, Klingner CM, Witte OW. Multimodal treatment of persistent postural-perceptual dizziness. Brain Behav 2020; 10:e01864. [PMID: 32989916 PMCID: PMC7749543 DOI: 10.1002/brb3.1864] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 09/12/2020] [Accepted: 09/13/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Persistent postural-perceptual dizziness (PPPD) is a chronic disorder with fluctuating symptoms of dizziness, unsteadiness, or vertigo for at least three months. Its pathophysiological mechanisms give theoretical support for the use of multimodal treatment. However, there are different therapeutic programs and principles available, and their clinical effectiveness remains elusive. METHODS A database of patients who participated in a day care multimodal treatment program was analyzed regarding the therapeutic effects on PPPD. Vertigo Severity Scale (VSS) and Hospital Anxiety and Depression Scale (HADS) were assessed before and 6 months after therapy. RESULTS Of a total of 657 patients treated with a tertiary care multimodal treatment program, 46.4% met the criteria for PPPD. PPPD patients were younger than patients with somatic diagnoses and complained more distress due to dizziness. 63.6% completed the follow-up questionnaire. All patients showed significant changes in VSS and HADS anxiety, but the PPPD patients generally showed a tendency to improve more than the patients with somatic diagnoses. The change in the autonomic-anxiety subscore of VSS only reached statistical significance when comparing PPPD with somatic diagnoses (p = .002). CONCLUSIONS Therapeutic principles comprise cognitive-behavioral therapy, vestibular rehabilitation exercises, and serotonergic medication. However, large-scale, randomized, controlled trials are still missing. Follow-up observations after multimodal interdisciplinary therapy reveal an improvement in symptoms in most patients with chronic dizziness. The study was not designed to detect diagnosis-specific effects, but patients with PPPD and patients with other vestibular disorders benefit from multimodal therapies.
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Affiliation(s)
- Hubertus Axer
- Center for Vertigo and Dizziness, Department of Neurology, Jena University Hospital, Jena, Germany
| | - Sigrid Finn
- Center for Vertigo and Dizziness, Department of Neurology, Jena University Hospital, Jena, Germany
| | - Alexander Wassermann
- Center for Vertigo and Dizziness, Department of Neurology, Jena University Hospital, Jena, Germany
| | | | - Carsten M Klingner
- Center for Vertigo and Dizziness, Department of Neurology, Jena University Hospital, Jena, Germany.,Biomagnetic Center, Jena University Hospital, Jena, Germany
| | - Otto W Witte
- Center for Vertigo and Dizziness, Department of Neurology, Jena University Hospital, Jena, Germany
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Penkava J, Bardins S, Brandt T, Wuehr M, Huppert D. Spontaneous visual exploration during locomotion in patients with phobic postural vertigo. J Neurol 2020; 267:223-230. [PMID: 32852578 PMCID: PMC7718196 DOI: 10.1007/s00415-020-10151-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 07/23/2020] [Accepted: 08/07/2020] [Indexed: 11/29/2022]
Abstract
Background Earlier studies on stance and gait with posturographic and EMG-recordings and automatic gait analysis in patients with phobic postural vertigo (PPV) or visual height intolerance (vHI) revealed similar patterns of body stiffening with muscle co-contraction and a slow, cautious gait. Visual exploration in vHI patients was characterized by a freezing of gaze-in-space when standing and reduced horizontal eye and head movements during locomotion. Objective Based on the findings in vHI patients, the current study was performed with a focus on visual control of locomotion in patients with PPV while walking along a crowded hospital hallway. Methods Twelve patients with PPV and eleven controls were recruited. Participants wore a mobile infrared video eye-tracking system that continuously measured eye-in-head movements in the horizontal and vertical planes and head orientation and motion in the yaw, pitch, and roll planes. Visual exploration behavior of participants was recorded at the individually preferred speed for a total walking distance of 200 m. Gaze-in-space directions were determined by combining eye-in-head and head-in-space orientation. Walking speeds were calculated based on the trial duration and the total distance traversed. Participants were asked to rate their feelings of discomfort during the walk on a 4-point numeric rating scale. The examiners rated the crowdedness of the hospital hallway on a 4-point numeric rating scale. Results The major results of visual exploration behavior in patients with PPV in comparison to healthy controls were: eye and head positions were directed more downward in the vertical plane towards the ground ahead with increased frequency of large amplitude vertical orientation movements towards the destination, the end of the ground straight ahead. The self-adjusted speed of locomotion was significantly lower in PPV. Particularly those patients that reported high levels of discomfort exhibited a specific visual exploration of their horizontal surroundings. The durations of fixating targets in the visual surroundings were significantly shorter as compared to controls. Conclusion Gaze control of locomotion in patients with PPV is characterized by a preferred deviation of gaze more downward and by horizontal explorations for suitable auxiliary means for potential postural support in order to prevent impending falls. These eye movements have shorter durations of fixation as compared to healthy controls and patients with vHI. Finally, the pathological alterations in eye–head coordination during locomotion correlate with a higher level of discomfort and anxiety about falling.
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Affiliation(s)
- J Penkava
- German Center for Vertigo and Balance Disorders (DSGZ), Ludwig-Maximilians-University, Marchioninistr. 15, 81377, Munich, Germany.
| | - S Bardins
- German Center for Vertigo and Balance Disorders (DSGZ), Ludwig-Maximilians-University, Marchioninistr. 15, 81377, Munich, Germany
| | - T Brandt
- German Center for Vertigo and Balance Disorders (DSGZ), Ludwig-Maximilians-University, Marchioninistr. 15, 81377, Munich, Germany
- Institute for Clinical Neurosciences, Ludwig-Maximilians-University, Munich, Germany
| | - M Wuehr
- German Center for Vertigo and Balance Disorders (DSGZ), Ludwig-Maximilians-University, Marchioninistr. 15, 81377, Munich, Germany
| | - D Huppert
- German Center for Vertigo and Balance Disorders (DSGZ), Ludwig-Maximilians-University, Marchioninistr. 15, 81377, Munich, Germany
- Institute for Clinical Neurosciences, Ludwig-Maximilians-University, Munich, Germany
- Department of Neurology, University Hospital, Ludwig-Maximilians-University, Munich, Germany
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Consciously processing balance leads to distorted perceptions of instability in older adults. J Neurol 2020; 268:1374-1384. [PMID: 33141249 PMCID: PMC7990754 DOI: 10.1007/s00415-020-10288-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 10/15/2020] [Accepted: 10/20/2020] [Indexed: 12/13/2022]
Abstract
Background Persistent dizziness without a clear cause is common in older adults. We explored whether an anxiety-driven preoccupation with consciously processing balance may underpin the distorted perceptions of unsteadiness that characterises ‘unexplained’ dizziness in older adults. Methods We experimentally induced anxiety about losing one’s balance (through a postural threat manipulation) in a cohort of asymptomatic older adults and evaluated associated changes in perceived stability, conscious movement processing and postural control. These outcomes were also assessed when performing a distracting cognitive task designed to prevent anxiety-related conscious movement processing, in addition to during baseline conditions (ground level). Results Despite a lack of increase in postural sway amplitude (p = 0.316), participants reported reductions in perceived stability during postural threat compared to baseline (p < 0.001). A multiple linear regression revealed that anxiety-related conscious movement processing independently predicted perceptions of instability during this condition (p = 0.006). These changes were accompanied by alterations in postural control previously associated with functional dizziness, namely high-frequency postural sway and disrupted interaction between open- and closed-loop postural control (ps < 0.014). While the distraction task successfully reduced conscious processing (p = 0.012), leading to greater perceived stability (p = 0.010), further increases in both postural sway frequency (p = 0.002) and dominance of closed-loop control (p = 0.029) were observed. Conclusion These findings implicate the role of conscious movement processing in the formation of distorted perceptions of unsteadiness, suggesting that such perceptions may be modifiable by reducing an over-reliance on conscious processes to regulate balance.
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Meldrum D, Burrows L, Cakrt O, Kerkeni H, Lopez C, Tjernstrom F, Vereeck L, Zur O, Jahn K. Vestibular rehabilitation in Europe: a survey of clinical and research practice. J Neurol 2020; 267:24-35. [PMID: 33048219 PMCID: PMC7552585 DOI: 10.1007/s00415-020-10228-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 09/14/2020] [Indexed: 12/15/2022]
Abstract
Vestibular rehabilitation (VR) is practiced across Europe but little in this area has been quantified. The aim of this study was to investigate current VR assessment, treatment, education, and research practices. This was an online, cross-sectional survey with 39 VR specific questions and four sections: demographics, current practice, education, and research. The survey was disseminated through the Dizzynet network to individual therapists through country-specific VR special interest groups. Results were analysed descriptively. A thematic approach was taken to analyse open questions. A total of 471 individuals (median age 41, range 23 - 68 years, 73.4% women), predominately physiotherapists (89.4%) from 20 European countries responded to the survey. They had worked for a median of 4 years (range < 1 - 35) in VR. The majority (58.7%) worked in hospital in-patient or out-patient settings and 21.4% in dedicated VR services. Most respondents specialized in neurology, care of the elderly (geriatrics), or otorhinolaryngology. VR was reported as hard/very hard to access by 48%, with the main barriers to access identified as lack of knowledge of health care professionals (particularly family physicians), lack of trained therapists, and lack of local services. Most respondents reported to know and treat benign paroxysmal positional vertigo (BPPV 87.5%), unilateral vestibular hypofunction (75.6%), and cervicogenic dizziness (63%). The use of vestibular assessment equipment varied widely. Over 70% used high-density foam and objective gait speed testing. Over 50% used dynamic visual acuity equipment. Infrared systems, Frenzel lenses, and dynamic posturography were not commonly employed (< 20%). The most frequently used physical outcome measures were the Clinical Test of the Sensory Interaction of Balance, Functional Gait Assessment/Dynamic Gait Index, and Romberg/Tandem Romberg. The Dizziness Handicap Inventory, Visual Analogue Scale, Falls Efficacy Scale, and the Vertigo Symptom Scale were the most commonly used patient reported outcome measures. Adaptation, balance, and habituation exercises were most frequently used (> 80%), with virtual reality used by 15.6%. Over 70% reported knowledge/use of Semont, Epley and Barbeque-Roll manoeuvres for the treatment of BPPV. Most education regarding VR was obtained at post-registration level (89.5%) with only 19% reporting pre-registration education. There was strong (78%) agreement that therapists should have professionally accredited postgraduate certification in VR, with blended learning the most popular mode. Three major research questions were identified for priority: management of specific conditions, effectiveness of VR, and mechanisms/factors influencing vestibular compensation and VR. In summary, the survey quantified current clinical practice in VR across Europe. Knowledge and treatment of common vestibular diseases was high, but use of published subjective and objective outcome measures as well as vestibular assessment varied widely. The results stress the need of improving both training of therapists and standards of care. A European approach, taking advantage of best practices in some countries, seems a reasonable approach.
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Affiliation(s)
- Dara Meldrum
- Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Lisa Burrows
- Southport and Ormskirk Ear Nose and Throat Balance Clinic Service, Southport, UK
| | - Ondrej Cakrt
- Department of Rehabilitation and Sports Medicine, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Hassen Kerkeni
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Frederik Tjernstrom
- Department of Otorhinolaryngology, Head and Neck Surgery, Lund University, Lund, Sweden
| | - Luc Vereeck
- Department of Rehabilitation Sciences and Physiotherapy/Movant, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerpen, Belgium
| | - Oz Zur
- Ben-Gurion University of the Negev, Beersheba, Israel
| | - Klaus Jahn
- Department of Neurology and German Center for Vertigo and Balance Disorders, Schoen Clinic Bad Aibling and LMU Munich, Kolbermoorer Strasse 72, 83043, Bad Aibling, Germany.
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The Role of Prediagnosis Audiovestibular Dysfunction Versus Distress, Illness-Related Cognitions, and Behaviors in Predicted Ongoing Dizziness Handicap. Psychosom Med 2020; 82:787-795. [PMID: 33009294 PMCID: PMC7535093 DOI: 10.1097/psy.0000000000000857] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE People with chronic vestibular diseases experience variable degrees of self-perceived disability. However, longitudinal data examining the predictive validity of relevant clinical variables alongside psychological variables are limited. The present study examined whether these factors predict self-reported dizziness handicap 3 months after assessment and diagnosis. METHODS Patients were recruited from a waiting list of a tertiary neuro-otology clinic and completed standardized mood, cognitive, behavioral, and dizziness handicap questionnaires before and 3 months after their initial consultation and diagnosis. All patients were clinically assessed and underwent comprehensive audiovestibular investigations. RESULTS Seventy-three percent of participants responded at follow-up (n = 135, 73% female, mean [standard deviation] age = 54.23 [17.53] years), of whom 88% were diagnosed with a neurotological condition. There were significant improvements in handicap, depression, and anxiety at 3 months. Thirty (22%) of 135 showed clinically meaningful improvement in handicap. The percentage of case-level depression and anxiety remained the same. Negative illness perceptions and symptom responses reduced, although participants still tended to view their condition negatively. Vestibular tests and type of diagnosis were not associated with self-reported handicap. Most baseline psychological variables significantly correlated with handicap at 3 months. When adjusting for baseline handicap and demographics, the baseline psychological variables only explained a significant ~3% of the variance in dizziness handicap at follow-up, with baseline handicap explaining most of the variance. All-or-nothing behavior was the most significant predictor. CONCLUSIONS Tertiary patients with vertigo and dizziness report negative illness perceptions and cognitive and behavioral responses to symptoms that are associated with self-reported handicap over time. Future studies are needed to investigate whether targeting these factors alongside traditional treatment approaches improves handicap in patients with chronic dizziness.
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Sun L, Xiang K. A review on the alterations in the brain of persistent postural-perceptual dizziness patients and non-pharmacological interventions for its management. Rev Neurosci 2020; 31:675-680. [PMID: 32286251 DOI: 10.1515/revneuro-2019-0109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 02/01/2020] [Indexed: 12/17/2022]
Abstract
Persistent postural perceptual dizziness (PPPD) is a relatively newer term, and this term is included in the International Classification of Diseases in its 11th revision. The typical features of PPPD include the presence of persistent dizziness, non-spinning vertigo, and unsteadiness, and these symptoms are exacerbated during upright posture, movement, or visual stimuli. Moreover, the structural changes have also been identified in the brains of PPPD patients, particularly in visual, vestibular, and limbic areas. These include a decrease in the volume and gyration of gray matter, a decrease in the blood flow to the cortex region, and alterations in the structural and functional connectivity, particularly in the visual-vestibular networks. Moreover, the impairment in sensory processing is restricted not only to the vestibular and visual regions; instead, there is a generalized impairment in the sensory processing, and thus, there is a multisensory dimension of sensory impairment. Selective serotonin uptake inhibitors and serotonin-norepinephrine reuptake inhibitors are the mainstay drugs for the management of PPPD patients. However, a significant proportion of PPPD patients do not show improvement in response to standard drug therapy. The employment of alternative and complementary treatment strategies, including vestibular rehabilitation therapy, cognitive behavioral therapy, and non-invasive vagal nerve stimulation, is effective in the management of PPPD patients. The present review discusses the alterations in the brains of PPPD patients along with the possible non-pharmacological treatment options in these types of patients.
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Affiliation(s)
- Li Sun
- Dizziness Clinic, Jilin Provincial Academy of Chinese Medicine Sciences, No. 20 Gongnong Street, Changchun 130000, Jilin, China
| | - Ke Xiang
- Dizziness Clinic, Jilin Provincial Academy of Chinese Medicine Sciences, No. 20 Gongnong Street, Changchun 130000, Jilin, China
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Habs M, Strobl R, Grill E, Dieterich M, Becker-Bense S. Primary or secondary chronic functional dizziness: does it make a difference? A DizzyReg study in 356 patients. J Neurol 2020; 267:212-222. [PMID: 32852579 PMCID: PMC7718176 DOI: 10.1007/s00415-020-10150-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 08/03/2020] [Accepted: 08/07/2020] [Indexed: 12/20/2022]
Abstract
In 2017, the term “persistent postural-perceptual dizziness” (PPPD) was coined by the Bárány Society, which provided explicit criteria for diagnosis of functional vertigo and dizziness disorders. PPPD can originate secondarily after an organic disorder (s-PPPD) or primarily on its own, in the absence of somatic triggers (p-PPPD). The aim of this database-driven study in 356 patients from a tertiary vertigo center was to describe typical demographic and clinical features in p-PPPD and s-PPPD patients. Patients underwent detailed vestibular testing with neurological and neuro-orthoptic examinations, video-oculography during water caloric stimulation, video head-impulse test, assessment of the subjective visual vertical, and static posturography. All patients answered standardized questionnaires (Dizziness Handicap Inventory, DHI; Vestibular Activities and Participation, VAP; and Euro-Qol-5D-3L). One hundred and ninety-five patients (55%) were categorized as p-PPPD and 162 (45%) as s-PPPD, with female gender slightly predominating (♀:♂ = 56%:44%), particularly in the s-PPPD subgroup (64%). The most common somatic triggers for s-PPPD were benign paroxysmal positional vertigo (27%), and vestibular migraine (24%). Overall, p-PPPD patients were younger than s-PPPD patients (44 vs. 48 years) and showed a bimodal age distribution with an additional early peak in young adults (about 30 years of age) beside a common peak at the age of 50–55. The most sensitive diagnostic tool was posturography, revealing a phobic sway pattern in 50% of cases. s-PPPD patients showed higher handicap and functional impairment in DHI (47 vs. 42) and VAP (9.7 vs. 8.9). There was no difference between both groups in EQ-5D-3L. In p-PPPD, anxiety (20% vs. 10%) and depressive disorders (25% vs. 9%) were more frequent. This retrospective study in a large cohort showed relevant differences between p- and s-PPPD patients in terms of demographic and clinical features, thereby underlining the need for careful syndrome subdivision for further prospective studies.
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Affiliation(s)
- Maximilian Habs
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-Universität München, Munich, Germany.
- Department of Neurology, Ludwig-Maximilians-Universität München, Marchioninistrasse 15, 81377, Munich, Germany.
| | - Ralf Strobl
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Eva Grill
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Marianne Dieterich
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-Universität München, Munich, Germany
- Department of Neurology, Ludwig-Maximilians-Universität München, Marchioninistrasse 15, 81377, Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Sandra Becker-Bense
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-Universität München, Munich, Germany
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61
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Cross-Sectional Analysis of Cognitive Dysfunction in Patients With Vestibular Disorders. Ear Hear 2020; 41:1020-1027. [DOI: 10.1097/aud.0000000000000825] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Schmid DA, Allum JHJ, Sleptsova M, Welge-Lüssen A, Schaefert R, Meinlschmidt G, Langewitz W. Relation of anxiety and other psychometric measures, balance deficits, impaired quality of life, and perceived state of health to dizziness handicap inventory scores for patients with dizziness. Health Qual Life Outcomes 2020; 18:204. [PMID: 32590995 PMCID: PMC7320574 DOI: 10.1186/s12955-020-01445-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 06/09/2020] [Indexed: 12/12/2022] Open
Abstract
Background An important question influencing therapy for dizziness is whether the strengths of the relationships of emotional and functional aspects of dizziness to 1) anxiety and other mental states, 2) perceived state of health (SoH) and quality of life (QoL) are different in patients with and without normal balance control. We attempted to answer this question by examining these dimensions’ regression strengths with Dizziness Handicap Inventory (DHI) scores. Methods We divided 40 patients receiving group cognitive behavioural therapy (CBT) and vestibular rehabilitation for dizziness, into 2 groups: dizziness only (DO) and normal balance control; dizziness and a quantified balance deficit (QBD). Group-wise, we first performed stepwise multivariate regression analysis relating total DHI scores with Brief Symptom Inventory (BSI) sub-scores obtained pre- and post-therapy. Then, regression analysis was expanded to include SoH, QoL, and balance scores. Finally, we performed regressions with DHI sub-scores. Results In both groups, the BSI phobic anxiety state score was selected first in the multivariate regression analysis. In the DO group, obsessiveness/compulsiveness was also selected. The correlation coefficient, R, was 0.74 and 0.55 for the DO and QBD groups, respectively. When QoL and SoH scores were included, R values increased to 0.86 and 0.74, explaining in total 74, and 55% of the DHI variance for DO and QBD groups, respectively. Correlations with balance scores were not significant (R ≤ 0.21). The psychometric scores selected showed the strongest correlations with emotional DHI sub-scores, and perceived QoL and SoH scores with functional DHI sub-scores. Conclusions Our findings suggest that reducing phobic anxiety and obsessiveness/compulsiveness during CBT may improve emotional aspects of dizziness and targeting perceived SoH and QoL may improve functional aspects of dizziness for those with and without normal balance control.
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Affiliation(s)
- D A Schmid
- Department of Psychosomatic Medicine, Faculty of Medicine, University of Basel and University Hospital Basel, Hebelstr 2, CH-4031, Basel, Switzerland.,Department of Psychosomatic Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - J H J Allum
- Department of Psychosomatic Medicine, Faculty of Medicine, University of Basel and University Hospital Basel, Hebelstr 2, CH-4031, Basel, Switzerland. .,Department of ORL, Faculty of Medicine, University of Basel and University Hospital Basel, Basel, Switzerland.
| | - M Sleptsova
- Department of Psychosomatic Medicine, Faculty of Medicine, University of Basel and University Hospital Basel, Hebelstr 2, CH-4031, Basel, Switzerland
| | - A Welge-Lüssen
- Department of ORL, Faculty of Medicine, University of Basel and University Hospital Basel, Basel, Switzerland
| | - R Schaefert
- Department of Psychosomatic Medicine, Faculty of Medicine, University of Basel and University Hospital Basel, Hebelstr 2, CH-4031, Basel, Switzerland
| | - G Meinlschmidt
- Department of Psychosomatic Medicine, Faculty of Medicine, University of Basel and University Hospital Basel, Hebelstr 2, CH-4031, Basel, Switzerland.,Division of Clinical Psychology and Cognitive Behavioral Therapy, International Psychoanalytic University, Berlin, Germany.,Division of Clinical Psychology and Epidemiology, Department of Psychology, University of Basel, Basel, Switzerland
| | - W Langewitz
- Department of Psychosomatic Medicine, Faculty of Medicine, University of Basel and University Hospital Basel, Hebelstr 2, CH-4031, Basel, Switzerland
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Kim HA, Bisdorff A, Bronstein AM, Lempert T, Rossi-Izquierdo M, Staab JP, Strupp M, Kim JS. Hemodynamic orthostatic dizziness/vertigo: Diagnostic criteria. J Vestib Res 2020; 29:45-56. [PMID: 30883381 PMCID: PMC9249281 DOI: 10.3233/ves-190655] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 02/25/2019] [Indexed: 11/15/2022]
Abstract
This paper presents the diagnostic criteria for hemodynamic orthostatic dizziness/vertigo to be included in the International Classification of Vestibular Disorders (ICVD). The aim of defining diagnostic criteria of hemodynamic orthostatic dizziness/vertigo is to help clinicians to understand the terminology related to orthostatic dizziness/vertigo and to distinguish orthostatic dizziness/vertigo due to global brain hypoperfusion from that caused by other etiologies. Diagnosis of hemodynamic orthostatic dizziness/vertigo requires: A) five or more episodes of dizziness, unsteadiness or vertigo triggered by arising or present during upright position, which subsides by sitting or lying down; B) orthostatic hypotension, postural tachycardia syndrome or syncope documented on standing or during head-up tilt test; and C) not better accounted for by another disease or disorder. Probable hemodynamic orthostatic dizziness/vertigo is defined as follows: A) five or more episodes of dizziness, unsteadiness or vertigo triggered by arising or present during upright position, which subsides by sitting or lying down; B) at least one of the following accompanying symptoms: generalized weakness/tiredness, difficulty in thinking/concentrating, blurred vision, and tachycardia/palpitations; and C) not better accounted for by another disease or disorder. These diagnostic criteria have been derived by expert consensus from an extensive review of 90 years of research on hemodynamic orthostatic dizziness/vertigo, postural hypotension or tachycardia, and autonomic dizziness. Measurements of orthostatic blood pressure and heart rate are important for the screening and documentation of orthostatic hypotension or postural tachycardia syndrome to establish the diagnosis of hemodynamic orthostatic dizziness/vertigo.
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Affiliation(s)
- Hyun Ah Kim
- Department of Neurology, Keimyung University Dongsan Hospital, Daegu, South Korea
| | - Alexandre Bisdorff
- Department of Neurology, Centre Hospitalier Emile Mayrisch, Esch-sur-Alzette, Luxembourg
| | - Adolfo M. Bronstein
- Department of Neuro-otology, Division of Brain Sciences, Imperial College London, Charing Cross Hospital Campus, London, UK
| | - Thomas Lempert
- Department of Neurology, Schlosspark-Klinik, Berlin, Germany
| | | | - Jeffrey P. Staab
- Departments of Psychiatry and Psychology and Otorhinolaryngology – Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA
| | - Michael Strupp
- Department of Neurology and German Center for Vertigo and Balance Disorders, Ludwig Maximilians University, Munich, Germany
| | - Ji-Soo Kim
- Department of Neurology, Seoul National University College of Medicine, Dizziness Center, Seoul National University Bundang Hospital, Seongnam, South Korea
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64
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Huber J, Flanagin VL, Popp P, Zu Eulenburg P, Dieterich M. Network changes in patients with phobic postural vertigo. Brain Behav 2020; 10:e01622. [PMID: 32304361 PMCID: PMC7303402 DOI: 10.1002/brb3.1622] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 01/29/2020] [Accepted: 03/15/2020] [Indexed: 01/16/2023] Open
Abstract
INTRODUCTION Functional dizziness comprises a class of dizziness disorders, including phobic postural vertigo (PPV), that cause vestibular symptoms in the absence of a structural organic origin. For this reason, functional brain mechanisms have been implicated in these disorders. METHODS Here, functional network organization was investigated in 17 PPV patients and 18 healthy controls (HCs) during functional magnetic resonance imaging with a visual motion stimulus, data initially collected and described by Popp et al. (2018). Graph theoretical measures (degree centrality [DC], clustering coefficient [CC], and eccentricity) of 160 nodes within six functional networks were compared between HC and PPV patients during visual motion and static visual patterns. RESULTS Graph theoretical measures analyzed during the static condition revealed significantly different DC in the default-mode, sensorimotor, and cerebellar networks. Furthermore, significantly different group differences in network organization changes between static visual and visual motion stimulation were observed. In PPV, DC and CC showed a significantly stronger increase in the sensorimotor network during visual stimulation, whereas cerebellar network showed a significantly stronger decrease in DC. CONCLUSION These results suggest that the altered visual motion processing seen in PPV patients may arise from a modified state of sensory and cerebellar network connectivity.
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Affiliation(s)
- Judita Huber
- Graduate School of Systemic Neurosciences, Department Biology II Neurobiology, Ludwig-Maximilians-Universität München, Planegg-Martinsried, Germany.,Research Training Grant 2175, Department Biology II, LMU Munich, Ludwig-Maximilians-Universität München, Planegg-Martinsried, Germany
| | - Virginia L Flanagin
- Graduate School of Systemic Neurosciences, Department Biology II Neurobiology, Ludwig-Maximilians-Universität München, Planegg-Martinsried, Germany.,Research Training Grant 2175, Department Biology II, LMU Munich, Ludwig-Maximilians-Universität München, Planegg-Martinsried, Germany.,German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-Universität München, Klinikum Großhadern, München, Germany
| | - Pauline Popp
- Graduate School of Systemic Neurosciences, Department Biology II Neurobiology, Ludwig-Maximilians-Universität München, Planegg-Martinsried, Germany.,German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-Universität München, Klinikum Großhadern, München, Germany
| | - Peter Zu Eulenburg
- Graduate School of Systemic Neurosciences, Department Biology II Neurobiology, Ludwig-Maximilians-Universität München, Planegg-Martinsried, Germany.,German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-Universität München, Klinikum Großhadern, München, Germany.,Neurologische Klinik und Poliklinik (Department of Neurology), Ludwig-Maximilians-Universität München, Klinikum Großhadern, München, Germany
| | - Marianne Dieterich
- Graduate School of Systemic Neurosciences, Department Biology II Neurobiology, Ludwig-Maximilians-Universität München, Planegg-Martinsried, Germany.,Research Training Grant 2175, Department Biology II, LMU Munich, Ludwig-Maximilians-Universität München, Planegg-Martinsried, Germany.,German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-Universität München, Klinikum Großhadern, München, Germany.,Neurologische Klinik und Poliklinik (Department of Neurology), Ludwig-Maximilians-Universität München, Klinikum Großhadern, München, Germany.,Munich Cluster of Systems Neurology (SyNergy), München, Germany
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65
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Williams CYK, Knight R, Donnelly N, Bance M. Prevalence and treatment of co-morbid anxiety and depression among 352 dizzy patients: A retrospective study. Clin Otolaryngol 2020; 45:832-836. [PMID: 32469463 DOI: 10.1111/coa.13590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 05/17/2020] [Indexed: 11/27/2022]
Affiliation(s)
| | - Richard Knight
- Department of Audiology, Addenbrooke's Hospital, Cambridge, UK
| | - Neil Donnelly
- Department of Otolaryngology-Head and Neck Surgery, Addenbrooke's Hospital, Cambridge, UK
| | - Manohar Bance
- Department of Otolaryngology-Head and Neck Surgery, Addenbrooke's Hospital, Cambridge, UK
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66
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Strupp M, Dlugaiczyk J, Ertl-Wagner BB, Rujescu D, Westhofen M, Dieterich M. Vestibular Disorders. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 117:300-310. [PMID: 32530417 PMCID: PMC7297064 DOI: 10.3238/arztebl.2020.0300] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 05/11/2019] [Accepted: 10/16/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Recent research findings have improved the understanding of the diagnosis, pathophysiology, genetics, etiology, and treatment of peripheral, central, and functional vestibular vertigo syndromes. METHOD A literature search, with special attention to the current classification, treatment trials, Cochrane analyses, and other meta-analyses. RESULTS There are internationally accepted diagnostic criteria for benign positional paroxysmal vertigo, Menière's disease, bilateral vestibulopathy, vestibular paroxysmia, and functional dizziness. Whether an acute vestibular syndrome is central or peripheral can usually be determined rapidly on the basis of the history and the clinical examination. "Cere - bellar vertigo" is a clinically important entity. For bilateral vestibulopathy, balance training is an effective treatment. For Menière's disease, preventive treatment with betahistine (48 mg and 144 mg per day) is not superior to placebo. For vestibular paroxysmia, oxcarbazepine has been shown to be effective. Treatments that are probably effective for functional dizziness include vestibular rehabilitation, cognitive behavioral therapy, and serotonin reuptake inhibitors. CONCLUSION The diagnostic assessment of vestibular syndromes is much easier for clinicians now that it has been internationally standardized. There is still a lack of randomized, controlled trials on the treatment of, for example, Menière's disease, vestibular migraine, and "cerebellar vertigo."
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Affiliation(s)
- Michael Strupp
- Department of Neurology, Ludwig Maximilians University, Munich (LMU); German Center for Dizziness and Balance Disorders, Ludwig Maximilians University, Munich (LMU); Medical Imaging, University of Toronto, Canada; University Clinic and Outpatient Department for Psychiatry, Psychotherapy and Psychosomatics, University of Halle-Wittenberg; Department of Otorhinolaryngology and Plastic Head and Neck Surgery, University Medical Center, RWTH Aachen; Munich Cluster for Systems Neurology (SyNergy), Munich
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67
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Powell G, Derry-Sumner H, Rajenderkumar D, Rushton SK, Sumner P. Persistent postural perceptual dizziness is on a spectrum in the general population. Neurology 2020; 94:e1929-e1938. [PMID: 32300064 PMCID: PMC7274923 DOI: 10.1212/wnl.0000000000009373] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 11/14/2019] [Indexed: 11/29/2022] Open
Abstract
Objective To examine the idea that symptoms of persistent postural perceptual dizziness (PPPD) are more common than previously assumed and lie on a spectrum in the general population, thus challenging current theories that PPPD is only a consequence of a vestibular insult. Methods We collected 2 common clinical questionnaires of PPPD (Visual Vertigo Analogue Scale [VVAS] and Situational Characteristics Questionnaire [SCQ]) in 4 cohorts: community research volunteers (n = 1941 for VVAS, n = 1,474 for SCQ); paid online participants (n = 190 for VVAS, n = 125 for SCQ); students (n = 204, VVAS only); and patients diagnosed with PPPD (n = 25). Results We found that around 9%, 4%, and 11%, respectively, of the 3 nonclinical cohorts scored above the 25th percentile patient score on 1 PPPD measure (VVAS) and 49% and 54% scored above the 25th percentile patient score on the other measure (SCQ). Scores correlated negatively with age (counter to expectation). As expected, scores correlated with migraine in 2 populations, but this only explained a small part of the variance, suggesting that migraine is not the major factor underlying the spectrum of PPPD symptoms in the general population. Conclusion We found high levels of PPPD symptoms in nonclinical populations, suggesting that PPPD is a spectrum that preexists in the population, rather than only being a consequence of vestibular insult. Atypical visuo-vestibular processing predisposes some individuals to visually induced dizziness, which is then exacerbated should vestibular insult (or more generalized insult) occur.
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Affiliation(s)
- Georgina Powell
- From the School of Psychology (G.P., S.K.R., P.S.), Cardiff University; and University Hospital of Wales (H.D.-S., D.R.), Cardiff, UK.
| | - Hannah Derry-Sumner
- From the School of Psychology (G.P., S.K.R., P.S.), Cardiff University; and University Hospital of Wales (H.D.-S., D.R.), Cardiff, UK
| | - Deepak Rajenderkumar
- From the School of Psychology (G.P., S.K.R., P.S.), Cardiff University; and University Hospital of Wales (H.D.-S., D.R.), Cardiff, UK
| | - Simon K Rushton
- From the School of Psychology (G.P., S.K.R., P.S.), Cardiff University; and University Hospital of Wales (H.D.-S., D.R.), Cardiff, UK
| | - Petroc Sumner
- From the School of Psychology (G.P., S.K.R., P.S.), Cardiff University; and University Hospital of Wales (H.D.-S., D.R.), Cardiff, UK
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68
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Zachou A, Anagnostou E. Diagnostic value of key signs in persistent postural-perceptual dizziness. J Neurol 2020; 267:1846-1848. [DOI: 10.1007/s00415-020-09820-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/01/2020] [Accepted: 04/02/2020] [Indexed: 10/24/2022]
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[The Bárány Classification of vestibular disorders, its clinical implementation and future prospects]. HNO 2020; 68:304-312. [PMID: 32193582 DOI: 10.1007/s00106-020-00847-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Vestibular diseases often have no or only nonspecific biomarkers. It is therefore necessary to define these disorders using operational criteria based on patterns of symptoms, i.e., the presence of inclusion and exclusion criteria, similar to the situation with headaches or psychiatric diseases. Ten years ago, the Bárány Society embarked upon development of the International Classification of Vestibular Disorders (ICVD). This entails producing the different definitions iteratively according to a structured procedure with an internal review process, resulting in an open-access publication on the diagnostic criteria in each case. It is a multidisciplinary effort, and depending on the topic, cooperation with other scientific societies is sought. The classification encompasses primary vestibular disorders and non-vestibular disorders that may manifest with prominent vestibular symptoms. The following paper describes the procedure and briefly presents definitions which have already been published as well as those presently in elaboration.
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Abstract
The diagnosis and management of vertigo remains a challenge for clinicians, including general neurology. In recent years there have been advances in the understanding of established vestibular syndromes, and the development of treatments for existing vestibular diagnoses. In this 'update' I will review how our understanding of previously "unexplained" dizziness in the elderly is changing, explore novel insights into the pathophysiology of vestibular migraine, and its relationship to the newly coined term 'persistent postural perceptual dizziness', and finally discuss how a simple bedside oculomotor assessment may help identify vestibular presentations of stroke.
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Affiliation(s)
- Diego Kaski
- Department of Neurology, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK. .,Centre for Vestibular and Behavioural Neurosciences, Department of Clinical and Motor Neurosciences, University College London, 33 Queen Square, London, WC1N 3BG, UK.
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71
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Abstract
PURPOSE OF REVIEW This article reviews the diagnosis and management of the most common disorders of orthostatic intolerance: postural tachycardia syndrome (POTS) and neurally mediated syncope. RECENT FINDINGS POTS is a heterogeneous syndrome caused by several pathophysiologic mechanisms that may coexist (limited autonomic neuropathy, hyperadrenergic state, hypovolemia, venous pooling, joint hypermobility, deconditioning). Neurally mediated syncope occurs despite intact autonomic reflexes. Management of orthostatic intolerance aims to increase functional capacity, including standing time, performance of daily activities, and exercise tolerance. Nonpharmacologic strategies (fluid and salt loading, physical countermaneuvers, compression garments, exercise training) are fundamental for patients with POTS, occasionally complemented by medications to raise blood pressure or slow heart rate. Neurally mediated syncope is best managed by recognition and avoidance of triggers. SUMMARY Significant negative effects on quality of life occur in patients with POTS and in patients with recurrent neurally mediated syncope, which can be mitigated through targeted evaluation and thoughtful management.
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Breinbauer HA, Contreras MD, Lira JP, Guevara C, Castillo L, Ruëdlinger K, Muñoz D, Delano PH. Spatial Navigation Is Distinctively Impaired in Persistent Postural Perceptual Dizziness. Front Neurol 2020; 10:1361. [PMID: 31998220 PMCID: PMC6970195 DOI: 10.3389/fneur.2019.01361] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 12/10/2019] [Indexed: 11/24/2022] Open
Abstract
Objective: To determine whether performance in a virtual spatial navigational task is poorer in persistent postural perceptual dizziness (PPPD) patients than in healthy volunteers and patients suffering other vestibular disorders. Methods: Subjects were asked to perform three virtual Morris water maze spatial navigational tasks: (i) with a visible target, (ii) then with an invisible target and a fixed starting position, and finally (iii) with an invisible target and random initial position. Data were analyzed using the cumulative search error (CSE) index. Results: While all subjects performed equally well with a visible target, the patients with PPPD (n = 19) performed poorer (p < 0.004) in the invisible target/navigationally demanding tasks (CSE median of 8) than did the healthy controls (n = 18; CSE: 3) and vestibular controls (n = 19; CSE: 4). Navigational performance in the most challenging setting allowed us to discriminate PPPD patients from controls with an area under the receiver operating characteristic curve of 0.83 (sensitivity 78.1%; specificity 83.3%). PPPD patients manifested more chaotic and disorganized search strategies, with more dispersion in the navigational pool than those of the non-PPPD groups (standard distance deviation of 0.97 vs. 0.46 in vestibular controls and 0.20 in healthy controls; p < 0.001). Conclusions: While all patients suffering a vestibular disorder had poorer navigational abilities than healthy controls did, patients with PPPD showed the worst performance, to the point that this variable allowed the discrimination of PPPD from non-PPPD patients. This distinct impairment in spatial navigation abilities offers new insights into PPPD pathophysiology and may also represent a new biomarker for diagnosing this entity.
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Affiliation(s)
- Hayo A Breinbauer
- Department of Otolaryngology, Facultad de Medicina, Universidad de Chile, Santiago, Chile.,Department of Neurocience, Facultad de Medicina, Universidad de Chile, Santiago, Chile.,Department of Otolaryngology, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Maria Daniela Contreras
- Department of Otolaryngology, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Juan P Lira
- Department of Otolaryngology, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Claudia Guevara
- Department of Otolaryngology, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Leslie Castillo
- Department of Otolaryngology, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Katherine Ruëdlinger
- Department of Otolaryngology, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Daniel Muñoz
- Department of Otolaryngology, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Paul H Delano
- Department of Otolaryngology, Facultad de Medicina, Universidad de Chile, Santiago, Chile.,Department of Neurocience, Facultad de Medicina, Universidad de Chile, Santiago, Chile
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Kim HJ, Song JM, Zhong L, Yang X, Kim JS. Questionnaire-based diagnosis of benign paroxysmal positional vertigo. Neurology 2019; 94:e942-e949. [PMID: 31888973 DOI: 10.1212/wnl.0000000000008876] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 08/29/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES To develop a simple questionnaire for self-diagnosis of benign paroxysmal positional vertigo (BPPV). METHODS We developed a questionnaire that consisted of 6 questions, the first 3 to diagnose BPPV and the next 3 to determine the involved canal and type of BPPV. From 2016 to 2017, 578 patients with dizziness completed the questionnaire before the positional tests, a gold standard for diagnosis of BPPV, at the Dizziness Clinic of Seoul National University Bundang Hospital. RESULTS Of the 578 patients, 200 were screened to have BPPV and 378 were screened to have dizziness/vertigo due to disorders other than BPPV. Of the 200 patients with a questionnaire-based diagnosis of BPPV, 160 (80%) were confirmed to have BPPV with positional tests. Of the 378 patients with a questionnaire-based diagnosis of non-BPPV, 24 (6.3%) were found to have BPPV with positional tests. Thus, the sensitivity, specificity, and precision of the questionnaires for the diagnosis of BPPV were 87.0%, 89.8%, and 80.0% (121 of 161, 95% confidence interval 74.5%-85.5%). Of the 200 patients with a questionnaire-based diagnosis of BPPV, 30 failed to respond to the questions 4 through 6 to determine the involved canal and type of BPPV. The questionnaire and positional tests showed the same results for the subtype and affected side of BPPV in 121 patients (121 of 170, 71.2%). CONCLUSION The accuracy of questionnaire-based diagnosis of BPPV is acceptable. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that, in patients with dizziness, a questionnaire can diagnose BPPV with a sensitivity of 87.0% and a specificity of 89.8%.
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Affiliation(s)
- Hyo-Jung Kim
- From the Research Administration Team (H.-J.K.) and Department of Neurology (J.-M.S., J.-S.K.), Dizziness Center, Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seongnam, Korea; Department of Neurology (L.Z.), Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine; Department of Neurology (X.Y.), Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, China; and Department of Neurology (J.-S.K.), College of Medicine, Seoul National University, Korea
| | - Jeong-Mi Song
- From the Research Administration Team (H.-J.K.) and Department of Neurology (J.-M.S., J.-S.K.), Dizziness Center, Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seongnam, Korea; Department of Neurology (L.Z.), Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine; Department of Neurology (X.Y.), Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, China; and Department of Neurology (J.-S.K.), College of Medicine, Seoul National University, Korea
| | - Liqun Zhong
- From the Research Administration Team (H.-J.K.) and Department of Neurology (J.-M.S., J.-S.K.), Dizziness Center, Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seongnam, Korea; Department of Neurology (L.Z.), Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine; Department of Neurology (X.Y.), Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, China; and Department of Neurology (J.-S.K.), College of Medicine, Seoul National University, Korea
| | - Xu Yang
- From the Research Administration Team (H.-J.K.) and Department of Neurology (J.-M.S., J.-S.K.), Dizziness Center, Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seongnam, Korea; Department of Neurology (L.Z.), Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine; Department of Neurology (X.Y.), Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, China; and Department of Neurology (J.-S.K.), College of Medicine, Seoul National University, Korea
| | - Ji-Soo Kim
- From the Research Administration Team (H.-J.K.) and Department of Neurology (J.-M.S., J.-S.K.), Dizziness Center, Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seongnam, Korea; Department of Neurology (L.Z.), Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine; Department of Neurology (X.Y.), Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, China; and Department of Neurology (J.-S.K.), College of Medicine, Seoul National University, Korea.
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Antonenko LM, Zastenskaya EN. Persistent postural-perceptual dizziness: current approaches to diagnosis and treatment. ACTA ACUST UNITED AC 2019. [DOI: 10.14412/2074-2711-2019-4-136-140] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The cause of persistent postural-perceptual dizziness (PPPD) is considered to be chronic dysfunction of the regulatory system for maintaining equilibrium in general and that of the vestibular system in particular, which causes a persistent sensation of dizziness and/or unsteadiness. The pathogenetic mechanisms of PPPD are associated with impaired adaptation to an acute vertigo or unsteadiness episode due to various causes (vestibular, lipothymic, or emotional). Patients severely experience PPPD, which often leads to avoidant behavior and even disability. The timely diagnosis of this disorder and the use of right treatment, including vestibular rehabilitation, antidepressants, and cognitive behavioral therapy, are of great importance. Currently developed new treatments for PPPD are highly therapeutically effective. Among the medicines, Ginkgo biloba extract has been shown to be effective in improving vestibular compensation.
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Affiliation(s)
- L. M. Antonenko
- Department of Nervous System Diseases and Neurosurgery, I.M. Sechenov First Moscow State Medical University (Sechenov University), Ministry of Health of Russia
| | - E. N. Zastenskaya
- Department of Nervous System Diseases and Neurosurgery, I.M. Sechenov First Moscow State Medical University (Sechenov University), Ministry of Health of Russia
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Functional Head Impulse Test With and Without Optokinetic Stimulation in Subjects With Persistent Postural Perceptual Dizziness (PPPD): Preliminary Report. Otol Neurotol 2019; 41:e70-e75. [PMID: 31789799 DOI: 10.1097/mao.0000000000002446] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Persistent postural perceptual dizziness (PPPD) is a clinical condition characterized by unsteadiness present on most days for a period of at least 3 months. The aim of our work was to assess vestibular function, the role of anxiety, and possible interactions between visual and vestibular systems in patients with PPPD. STUDY DESIGN Cross-sectional prospective study. SETTING Tertiary referral center. PATIENTS Twenty-five PPPD patients. INTERVENTIONS Clinical history was collected before examination; vestibular function was assessed through bedside examination, video and functional head impulse test (video-HIT, f-HIT). The latter test was based on having the patient identify an optotype displayed on a computer screen during passive head rotations. The test was repeated while optokinetic stimulation (OKS) was given on the screen. Results were compared with those of 25 controls. State and trait anxiety levels were measured with the State-Trait Anxiety Inventory (STAI) questionnaire. Anxiety before and after vestibular examination was assessed using a VAS scale. MAIN OUTCOME MEASURE Results of video and functional HIT with and without OKS. RESULTS Video-HIT and f-HIT showed normal values in all subjects. f-HIT with OKS provoked more reading errors in patients than in controls. The interaction of group per time detected different decreasing trends between the two groups (p = 0.0002).Patients presented a reduction in anxiety levels after examination. Nine patients fulfilled diagnostic criteria for vestibular migraine, eight of whom presented nystagmus either to positional tests or vibration test. Only anxiety levels before testing were predictive of worsening of f-HIT with optokinetic stimulation (p = 0.0007). CONCLUSIONS Our data support the hypothesis that increased anxiety may play a role in visuo-vestibular interactions; moreover, they are not inconsistent with the hypothesis that OKS might provoke a "threatening effect," leading to gaze bias during examination.
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Reduced cortical folding in multi-modal vestibular regions in persistent postural perceptual dizziness. Brain Imaging Behav 2019; 13:798-809. [PMID: 29860587 PMCID: PMC6538588 DOI: 10.1007/s11682-018-9900-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Persistent postural perceptual dizziness (PPPD) is a common functional vestibular disorder that is triggered and sustained by a complex interaction between physiological and psychological factors affecting spatial orientation and postural control. Past functional neuroimaging research and one recent structural (i.e., voxel-based morphometry-VBM) study have identified alterations in vestibular, visuo-spatial, and limbic brain regions in patients with PPPD and anxiety-prone normal individuals. However, no-one thus far has employed surface based morphometry (SBM) to explore whether cortical morphology in patients with PPPD differs from that of healthy people. We calculated SBM measures from structural MR images in 15 patients with PPPD and compared them to those from 15 healthy controls matched for demographics, personality traits known to confer risk for PPPD as well as anxiety and depressive symptoms that are commonly comorbid with PPPD. We tested for associations between SBM measures and dizziness severity in patients with PPPD. Relative to controls, PPPD patients showed significantly decreased local gyrification index (LGI) in multi-modal vestibular regions bilaterally, specifically the posterior insular cortices, supra-marginal gyri, and posterior superior temporal gyri (p < 0.001). Within the PPPD group, dizziness severity positively correlated with LGI in visual areas and negatively with LGI in the right superior parietal cortex. These findings demonstrate abnormal cortical folding in vestibular cortices and correlations between dizziness severity and cortical folding in visual and somatosensory spatial association areas in PPPD patients, which provides new insights into the pathophysiological mechanisms underlying this disorder.
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Persistent Postural-Perceptual Dizziness-A Systematic Review of the Literature for the Balance Specialist. Otol Neurotol 2019; 39:1291-1303. [PMID: 30289841 DOI: 10.1097/mao.0000000000002010] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To present a systematic review of the current data on persistent postural-perceptual dizziness (PPPD), a useful and relatively new diagnosis for a disorder that has previously been known by many different names. In addition, to discuss diagnostic criteria and management strategies for this condition with the otologist in mind. DATA SOURCES CINAHL, Embase, PubMed, Medline, PsycINFO, PubMed, Google Scholar. REVIEW METHOD The phrase "persistent postural-perceptual dizziness" and its acronym "PPPD" were used. RESULTS From 318 articles, 15 were selected for full analysis with respect to PPPD. Most were case-control studies, with one consensus paper from the Bárány Society available. Overall, the pathophysiology of PPPD remains relatively poorly understood, but is likely to be a maladaptive state to a variety of insults, including vestibular dysfunction and not a structural or psychiatric one. Cognitive behavioral therapy, vestibular rehabilitation, selective serotonin uptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs) all seem to have a role in its management. CONCLUSIONS PPPD is useful as a diagnosis for those treating dizziness as it helps to define a conglomeration of symptoms that can seem otherwise vague and allows for more structured management plans in those suffering from it.
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Espay AJ, Aybek S, Carson A, Edwards MJ, Goldstein LH, Hallett M, LaFaver K, LaFrance WC, Lang AE, Nicholson T, Nielsen G, Reuber M, Voon V, Stone J, Morgante F. Current Concepts in Diagnosis and Treatment of Functional Neurological Disorders. JAMA Neurol 2019; 75:1132-1141. [PMID: 29868890 DOI: 10.1001/jamaneurol.2018.1264] [Citation(s) in RCA: 394] [Impact Index Per Article: 78.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Functional neurological disorders (FND) are common sources of disability in medicine. Patients have often been misdiagnosed, correctly diagnosed after lengthy delays, and/or subjected to poorly delivered diagnoses that prevent diagnostic understanding and lead to inappropriate treatments, iatrogenic harm, unnecessary and costly evaluations, and poor outcomes. Observations Functional Neurological Symptom Disorder/Conversion Disorder was adopted by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, replacing the term psychogenic with functional and removing the criterion of psychological stress as a prerequisite for FND. A diagnosis can now be made in an inclusionary manner by identifying neurological signs that are specific to FNDs without reliance on presence or absence of psychological stressors or suggestive historical clues. The new model highlights a wider range of past sensitizing events, such as physical trauma, medical illness, or physiological/psychophysiological events. In this model, strong ideas and expectations about these events correlate with abnormal predictions of sensory data and body-focused attention. Neurobiological abnormalities include hypoactivation of the supplementary motor area and relative disconnection with areas that select or inhibit movements and are associated with a sense of agency. Promising evidence has accumulated for the benefit of specific physical rehabilitation and psychological interventions alone or in combination, but clinical trial evidence remains limited. Conclusions and Relevance Functional neurological disorders are a neglected but potentially reversible source of disability. Further research is needed to determine the dose and duration of various interventions, the value of combination treatments and multidisciplinary therapy, and the therapeutic modality best suited for each patient.
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Affiliation(s)
- Alberto J Espay
- University of Cincinnati Gardner Neuroscience Institute, Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, Ohio
| | - Selma Aybek
- Department of Neurology, University Hospital Inselspital, Bern, Switzerland
| | - Alan Carson
- Neuropsychiatry, Centre for Clinical Brain Studies, University of Edinburgh, Edinburgh, United Kingdom
| | - Mark J Edwards
- Motor Control and Movement Disorders Group, Institute of Molecular and Clinical Sciences, St George's University of London, London, United Kingdom
| | - Laura H Goldstein
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Mark Hallett
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | - Kathrin LaFaver
- Department of Neurology, University of Louisville, Louisville, Kentucky
| | - W Curt LaFrance
- Department of Psychiatry, Alpert Medical School of Brown University, Providence, Rhode Island.,Department of Neurology, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Anthony E Lang
- Morton and Gloria Shulman Movement Disorders Centre, Toronto Western Hospital and Edmond J. Safra Program in Parkinson Disease, University of Toronto, Toronto, Ontario, Canada
| | - Tim Nicholson
- Section of Cognitive Neuropsychiatry, Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Glenn Nielsen
- Motor Control and Movement Disorders Group, Institute of Molecular and Clinical Sciences, St George's University of London, London, United Kingdom
| | - Markus Reuber
- Academic Neurology Unit, University of Sheffield, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Valerie Voon
- Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
| | - Jon Stone
- Centre for Clinical Brain Sciences, University of Edinburgh, Western General Hospital, Edinburgh, United Kingdom
| | - Francesca Morgante
- Motor Control and Movement Disorders Group, Institute of Molecular and Clinical Sciences, St George's University of London, London, United Kingdom.,Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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Benign Paroxysmal Positional Vertigo (BPPV) in Children and Adolescents: Clinical Features and Response to Therapy in 110 Pediatric Patients. Otol Neurotol 2019; 39:344-350. [PMID: 29287036 DOI: 10.1097/mao.0000000000001673] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE This study aimed to characterize the clinical features and outcomes of benign paroxysmal positional vertigo (BPPV) in the pediatric population. STUDY DESIGN Retrospective case review. SETTING Tertiary care center. PATIENTS One hundred ten patients, aged 5 to 19 years old, diagnosed with BPPV. MAIN OUTCOME MEASURES Patient demographics, comorbidities, canal involvement, response to treatment, and incidence of recurrence. RESULTS BPPV was diagnosed in 19.8% of patients seen for dizziness during the study period. Patient age ranged 5 to 19 years old (mean =13.4 ± 3.4 yr). Female:male ratio was 3:2. The most prevalent comorbidities were concussion (n = 42, 38.2%) and migraine disorders (n = 33, 30.0%). Average time to diagnosis from symptom onset was 178.2 ± 190.8 days. The posterior canal was most frequently affected (n = 80, 72.7%), followed by the lateral canal (n = 37, 33.6%) and superior canal (n = 21, 19.1%), and 36.4% (n = 40) of patients had multiple canals affected. Treatment requiring more than or equal to five maneuvers to achieve resolution was observed in 11.8% of cases (n = 13). Recurrence was observed in 18.2% of cases. A logistic regression analysis demonstrated that patients with vestibular migraine or benign paroxysmal vertigo of childhood had five times higher odds of recurrence of BPPV, p = 0.003, 95% [1.735, 15.342], than those who did not have either. CONCLUSIONS BPPV is a relatively common cause of dizziness in the pediatric population. Children and adolescents with BPPV can be successfully treated with repositioning maneuvers but may be at risk for treatment resistance and recurrence. Increased awareness of BPPV in pediatric patients may reduce delays in identification and treatment.
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Cui L, Yan Z, Gong L, Tang J, Kong M, Sun F, Yu Q, Liang H, Chen C. Association between dopamine receptor D2 Taq IA gene polymorphism and persistent postural-perceptual dizziness. J Vestib Res 2019; 29:131-136. [PMID: 31356223 PMCID: PMC9249288 DOI: 10.3233/ves-190669] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND: Persistent postural-perceptual dizziness (PPPD) is a chronic dizziness, its pathogenesis is unknown by now. OBJECTIVE: To study the relationship between the DRD2 gene TaqIA polymorphisms and PPPD, and further to explore the molecular mechanism underlying this disease. METHODS: 43 patients diagnosed with PPPD and 45 randomly selected cases (matched by age and sex) were included in the study and control group, respectively. DRD2 gene TaqIA polymorphisms were detected in all participants by polymerase chain reaction (PCR)combined with the restriction fragment length polymorphism (RFLP) method. RESULTS: In the study group, frequencies of the A1 and A2 TaqIA alleles (65.1% and 34.9%, respectively) were significantly different to those in the control group (46.7% and 53.3%, respectively; P < 0.05). The allele frequency in the study group for the A1/A1 genotype was 34.9%, for A1/A2 was 60.5%, and for A2/A2 was 4.6%, all of which were significantly higher than the control group (24.4%, 44.5%. and 31.1%, respectively; P < 0.01). CONCLUSIONS: Our findings indicate that the DRD2 TaqIA A1 allele is possibly the susceptibility polymorphism for PPPD, and that the A2/A2 genotype has a potentially protective role for PPPD. However, larger independent studies are required for further validation.
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Affiliation(s)
- Liping Cui
- Shandong Yantai Nursing School, Yantai, Shandong, China
| | - Zhihui Yan
- Department of Neurology, Yantaishan Hospital, Yantai, Shandong, China
| | - Lifeng Gong
- Shandong Yantai Nursing School, Yantai, Shandong, China
| | - Jianhua Tang
- Department of Neurology, Yantaishan Hospital, Yantai, Shandong, China
| | - Min Kong
- Department of Neurology, Yantaishan Hospital, Yantai, Shandong, China
| | - Fengnan Sun
- Department of Neurology, Yantaishan Hospital, Yantai, Shandong, China
| | - Quntao Yu
- Department of Neurology, Yantaishan Hospital, Yantai, Shandong, China
| | - Hui Liang
- Department of Neurology, Yantaishan Hospital, Yantai, Shandong, China
| | - Chunfu Chen
- Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China
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Zwergal A, Strupp M, Brandt T. Advances in pharmacotherapy of vestibular and ocular motor disorders. Expert Opin Pharmacother 2019; 20:1267-1276. [PMID: 31030580 DOI: 10.1080/14656566.2019.1610386] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Vertigo and dizziness are common chief complaints of vestibular and ocular motor disorders (lifetime prevalence 30%). Treatment relies on physical, pharmacological, psychological and rarely surgical approaches. Eight groups of drugs are currently used in vestibular and ocular motor disorders, namely anti-vertiginous, anti-inflammatory, anti-menière's, anti-migrainous medications, anti-depressants, anti-convulsants, aminopyridines and agents that enhance vestibular plasticity. AREAS COVERED The purpose of this review is to summarize the pharmacological characteristics and clinical applications of medications that are used for peripheral, central and functional vestibular and ocular motor disorders. The level of evidence for the respective drugs is described alongside the pathophysiological premises supporting their use. The authors place particular focus on translation and back-translation in vestibular pharmacological research and the repurposing of known drugs for new indications and rare disorders. EXPERT OPINION The use of drugs in vestibular and ocular motor disorders is often based on open-label, non-controlled studies and expert opinion. In the future, strong evidence derived from RCTs is needed to support the effectiveness and tolerability of these therapies in well-defined vestibular and ocular motor disorders. Vestibular pharmacological research must be guided by a better understanding of the molecular targets relevant in the pathophysiology of vestibular and ocular motor disorders.
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Affiliation(s)
- Andreas Zwergal
- a Department of Neurology , University Hospital LMU , Munich , Germany.,b German Center for Vertigo and Balance Disorders , DSGZ, LMU Munich , Munich , Germany
| | - Michael Strupp
- a Department of Neurology , University Hospital LMU , Munich , Germany.,b German Center for Vertigo and Balance Disorders , DSGZ, LMU Munich , Munich , Germany
| | - Thomas Brandt
- b German Center for Vertigo and Balance Disorders , DSGZ, LMU Munich , Munich , Germany.,c Clinical Neurosciences , LMU Munich , Munich , Germany
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Limburg K, Schmid-Mühlbauer G, Sattel H, Dinkel A, Radziej K, Gonzales M, Ronel J, Lahmann C. Potential effects of multimodal psychosomatic inpatient treatment for patients with functional vertigo and dizziness symptoms - A pilot trial. Psychol Psychother 2019; 92:57-73. [PMID: 29603590 DOI: 10.1111/papt.12177] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 02/26/2018] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Functional vertigo and dizziness (VD) are frequent and severely distressing complaints that are often described as hard to treat. Our aim was to provide preliminary data on potential effects of multimodal psychosomatic inpatient therapy for patients with functional VD symptoms in reducing vertigo-related handicap and related psychopathology, and to evaluate the role of symptom burden and body-related locus of control in predicting vertigo-related handicap at follow-up. DESIGN We conducted an uncontrolled clinical pilot trial. METHODS We included data of n = 72 inpatients with functional VD as a primary symptom and various psychopathological and/or physical comorbidities admitted for multimodal psychosomatic inpatient treatment. Patients completed self-report questionnaires assessing vertigo-related handicap (VHQ), somatization (PHQ-15), depression (BDI-II), anxiety (BAI), health-related quality of life (HRQOL; SF-36), and body-related locus of control (KLC) at admission (T0), discharge (T1), and 6 months after discharge (T2). RESULTS We observed medium effects for the change of vertigo-related handicap (T0-T1: g = -0.60, T0-T2: g = -0.67) and small effects for the change of somatization (T0-T1: g = -0.29, T0-T2: g = -0.24), mental HRQOL (T0-T1: g = 0.43, T0-T2: g = 0.49), and depression (T0-T1: g = -0.41, T0-T2: g = -0.28) from admission to discharge and admission to follow-up. Body-related locus of control did not predict vertigo-related handicap at follow-up. CONCLUSIONS Findings provide preliminary evidence for the beneficial role of psychosomatic inpatient treatment for patients with functional VD symptoms. Potentially relevant predictors of outcome at follow-up are discussed. PRACTITIONER POINTS The change of vertigo-related handicap and related variables through multimodal psychosomatic inpatient treatment was evaluated in a clinical pilot trial in patients with functional vertigo and dizziness. We observed medium effects for the change of vertigo-related handicap and small effects for the change of somatization, mental health-related quality of life, and depression. Internal body-related locus of control at admission did not predict vertigo-related handicap at follow-up.
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Affiliation(s)
- Karina Limburg
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital of the Technical University of Munich, Germany
| | | | - Heribert Sattel
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital of the Technical University of Munich, Germany
| | - Andreas Dinkel
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital of the Technical University of Munich, Germany
| | - Katharina Radziej
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital of the Technical University of Munich, Germany
| | - Melanie Gonzales
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital of the Technical University of Munich, Germany
| | - Joram Ronel
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital of the Technical University of Munich, Germany
| | - Claas Lahmann
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Freiburg, Germany
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Transcranial direct current stimulation (tDCS) for treatment of phobic postural vertigo: an open label pilot study. Eur Arch Psychiatry Clin Neurosci 2019; 269:269-272. [PMID: 29626226 DOI: 10.1007/s00406-018-0894-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 04/03/2018] [Indexed: 10/17/2022]
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84
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Vestibular rehabilitation: advances in peripheral and central vestibular disorders. Curr Opin Neurol 2019; 32:137-144. [DOI: 10.1097/wco.0000000000000632] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Community-dwelling adults with a history of falling report lower perceived postural stability during a foam eyes closed test than non-fallers. Exp Brain Res 2019; 237:769-776. [PMID: 30604020 DOI: 10.1007/s00221-018-5458-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 12/18/2018] [Indexed: 01/27/2023]
Abstract
Perceived postural stability has been reported to decrease as sway area increases on firm surfaces. However, changes in perceived stability under increasingly challenging conditions (e.g., removal of sensory inputs) and the relationship with sway area are not well characterized. Moreover, whether perceived stability varies as a function of age or history of falls is unknown. Here we investigate how perceived postural stability is related to sway area and whether this relationship varies as a function of age and fall history while vision and proprioceptive information are manipulated. Sway area was measured in 427 participants from the Baltimore Longitudinal Study of Aging while standing with eyes open and eyes closed on the floor and a foam cushion. Participants rated their stability [0 (completely unstable) to 10 (completely stable)] after each condition, and reported whether they had fallen in the past year. Perceived stability was negatively associated with sway area (cm2) such that individuals who swayed more felt less stable across all conditions (β = - 0.53, p < 0.001). Perceived stability decreased with increasing age (β = - 0.019, p < 0.001), independent of sway area. Fallers had a greater decline in perceived stability across conditions (F = 2.76, p = 0.042) compared to non-fallers, independent of sway area. Perceived postural stability declined as sway area increased during a multisensory balance test. A history of falling negatively impacts perceived postural stability when vision and proprioception are simultaneously challenged. Perceived postural stability may provide additional information useful for identifying individuals at risk of falls.
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Kunel'skaya NL, Baybakova EV, Zaoeva ZO. Psychogenic vertigo. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 119:89-93. [DOI: 10.17116/jnevro201911910189] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Cutsforth-Gregory JK, Sandroni P. Clinical neurophysiology of postural tachycardia syndrome. HANDBOOK OF CLINICAL NEUROLOGY 2019; 161:429-445. [PMID: 31307619 DOI: 10.1016/b978-0-444-64142-7.00066-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Postural tachycardia syndrome (POTS) is one of several disorders of orthostatic intolerance (OI). It is defined by the development of symptoms of cerebral hypoperfusion or sympathetic activation and a sustained heart rate increment of 30 beats/min or more (40 beats/min for teenagers) within 10min of standing or head-up tilt in the absence of orthostatic hypotension; the standing heart rate is often 120 beats/min or higher. POTS is approximately five times more common in women than men. This heterogeneous syndrome is caused by several pathophysiologic mechanisms (limited autonomic neuropathy, hyperadrenergic state, hypovolemia, venous pooling, deconditioning), which are not mutually exclusive. Anxiety and somatic hypervigilance play significant roles in POTS. Common comorbidities include visceral pain and dysmotility, chronic fatigue and fibromyalgia, migraine, joint hypermobility, mitral valve prolapse, and inappropriate sinus tachycardia. Patients with suspected POTS should undergo comprehensive cardiac and neurologic examinations and autonomic and laboratory tests to determine the most likely pathophysiologic basis of OI. The objectives of POTS management are to (1) increase the time that patients can stand, perform daily activities, and exercise and (2) avoid syncope. Management involves nonpharmacologic (fluid and salt loading, physical countermaneuvers, compression garments, exercise training) and pharmacologic (β-blockers, pyridostigmine, fludrocortisone, midodrine) approaches.
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Affiliation(s)
| | - Paola Sandroni
- Department of Neurology, Mayo Clinic, Rochester, MN, United States.
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Limburg K, Dinkel A, Schmid-Mühlbauer G, Sattel H, Radziej K, Becker-Bense S, Henningsen P, Dieterich M, Lahmann C. Neurologists' Assessment of Mental Comorbidity in Patients With Vertigo and Dizziness in Routine Clinical Care-Comparison With a Structured Clinical Interview. Front Neurol 2018; 9:957. [PMID: 30483214 PMCID: PMC6242889 DOI: 10.3389/fneur.2018.00957] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 10/25/2018] [Indexed: 12/20/2022] Open
Abstract
Background: Mental health comorbidities are frequent in patients with vertigo and dizziness. The current study was conducted in a specialized interdisciplinary university center for vertigo and dizziness. Clinical routines consist of a structured work-up in which neuro-otological and neurological tests are performed to first detect possible organic vestibular deficits. In addition, psychiatric disorders and comorbidities are considered. The study aimed to evaluate neurologists' awareness of psychiatric next to somatic disorders within patients' first examination in terms of diagnostic congruence between neurologists' diagnoses and structured clinical assessment of mental disorders. Methods: The study involved 392 patients. Diagnostic evaluation included (a) structured history-taking (including psychosocial anamnesis), neurological, and neuro-otological diagnostics conducted by neurologists and (b) a structured clinical interview for mental disorders (SCID-I) conducted by psychologists and final-year medical or psychology students. Cohen's Kappa was calculated to determine agreement rates regarding depression and anxiety disorders; additionally, sensitivity and specificity were evaluated. Results: Neurologists' assessments led to at least one psychiatric diagnosis among the main diagnoses in 40 (10.2 %) patients, whereas the structured clinical interview led to at least one DSM-IV psychiatric diagnosis in 174 (44.4%) of the patients. Agreement was low (κ < 0.2); sensitivity was low (15%) but specificity was high (98%). Conclusions: Agreement between the diagnosis of neurologists and structured clinical interviews for psychiatric disorders is low. Since psychiatric disorders are frequent in vertigo and dizziness and tend to take a chronic course, improving early recognition and implementing appropriate care concepts is vital.
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Affiliation(s)
| | - Andreas Dinkel
- Department of Psychosomatic Medicine and Psychotherapy, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany
| | | | - Heribert Sattel
- Department of Psychosomatic Medicine and Psychotherapy, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany
| | - Katharina Radziej
- Department of Psychosomatic Medicine and Psychotherapy, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany
| | - Sandra Becker-Bense
- German Center for Vertigo and Balance Disorders, University Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Peter Henningsen
- Department of Psychosomatic Medicine and Psychotherapy, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany
| | - Marianne Dieterich
- German Center for Vertigo and Balance Disorders, University Hospital, Ludwig-Maximilians-University, Munich, Germany.,Department of Neurology, University Hospital, Ludwig-Maximilians University, Munich, Germany.,Cluster of Systems Neurology-SyNergy, Munich, Germany
| | - Claas Lahmann
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Freiburg, Freiburg, Germany
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Cerebral perfusion abnormalities in patients with persistent postural-perceptual dizziness (PPPD): a SPECT study. J Neural Transm (Vienna) 2018; 126:123-129. [PMID: 30382406 DOI: 10.1007/s00702-018-1948-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 10/23/2018] [Indexed: 10/28/2022]
Abstract
Persistent postural-perceptual dizziness (PPPD) is a recently defined syndrome with chronic dizziness interrupting daily life. Although the high levels of anxiety and functional changes in postural control strategy and multi-sensory information processing and integration may be underlying the pathophysiology, its neural mechanisms are poorly understood. The aim of this study was to examine the regional cerebral blood flow (rCBF) in patients with PPPD using single photon emission computed tomography (SPECT). A total of 25 patients with PPPD and 25 healthy controls participated in the study. All participants underwent brain SPECT and the patients completed the Dizziness Handicap Inventory. SPECT images were compared between the groups, and the correlation of rCBF and disease severity/duration was assessed in patients. Compared with controls, PPPD patients showed a significantly decreased rCBF in the insula and frontal lobe, mainly in the left posterior insula, bilateral superior frontal gyrus, right inferior frontal gyrus, right precentral gyrus, and left medial orbital gyrus. Additionally, PPPD patients showed a significant rCBF increase in the bilateral cerebellum compared with controls. The results of our study suggest that the altered rCBF in the insular, frontal, and cerebellar cortices might be reflecting the process of maladaptation and the compensatory responses for the changes in PPPD.
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91
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Dietzek M, Finn S, Karvouniari P, Zeller MA, Klingner CM, Guntinas-Lichius O, Witte OW, Axer H. In Older Patients Treated for Dizziness and Vertigo in Multimodal Rehabilitation Somatic Deficits Prevail While Anxiety Plays a Minor Role Compared to Young and Middle Aged Patients. Front Aging Neurosci 2018; 10:345. [PMID: 30425637 PMCID: PMC6218593 DOI: 10.3389/fnagi.2018.00345] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 10/11/2018] [Indexed: 01/20/2023] Open
Abstract
Objective: Many patients with dizziness and vertigo are of older age. It is still unclear which age-associated factors play a role in the treatment of dizziness and vertigo. Therefore, age-associated characteristics of patients subjected to an interdisciplinary day care approach for chronic vertigo and dizziness were analyzed. Subjects and Methods: 650 patients with chronic dizziness/vertigo subjected to a multimodal vestibular rehabilitation day care program were analyzed. Information concerning age, gender, medical diagnosis, medical consultations, technical diagnostics performed and therapy achieved before attending the clinic were collected. Furthermore, data were gathered using the Vertigo Severity Scale (VSS), Hospital Anxiety and Depression Scale (HADS), Mobility Inventory (MI), as well as the intensity of and the distress due to vertigo/dizziness using visual analog scales. As a follow-up, the VSS, HADS, MI, and the visual analog scales were collected again 6 months after attending the therapy program. Three age groups were compared to each other (<41, 41–65, and >65 years of age). Results: One-third of the patients were older than 65 years. This group had typical diagnoses with mainly organic deficits. In contrast to the dominance of mainly multifactorial, organic deficits the older patients reported less medical consultations, fewer technical diagnostics and even fewer treatments than the younger patients. The elderly scored significantly lower in total VSS, in VSS-V (vestibular-balance subscale), in VSS-A (autonomic-anxiety subscale) and in HADS-anxiety. Psychological diagnoses were clearly associated to the younger patients. 424 patients (65.2%) completed the follow-up questionnaire 6 months after attending the therapy week. The older patients revealed improvements of VSS-V and the Avoidance Alone scale of MI as well as decreased distress due to vertigo/dizziness. Conclusion: In the older patients, who took part in our vestibular rehabilitation program, mainly somatic deficits prevail while anxiety plays a minor role compared to young and middle aged patients. Older patients profited from vestibular rehabilitation especially in mobility and vestibular-balance. Therefore, vestibular rehabilitation programs for the elderly with a focus on physio- and occupational therapeutic interventions and less cognitive behavioral therapy may be reasonable.
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Affiliation(s)
- Maren Dietzek
- Center for Vertigo and Dizziness, Hans-Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Sigrid Finn
- Center for Vertigo and Dizziness, Hans-Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Panagiota Karvouniari
- Center for Vertigo and Dizziness, Hans-Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Maja A Zeller
- Center for Vertigo and Dizziness, Hans-Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Carsten M Klingner
- Center for Vertigo and Dizziness, Hans-Berger Department of Neurology, Jena University Hospital, Jena, Germany.,Biomagnetic Center, Jena University Hospital, Jena, Germany
| | | | - Otto W Witte
- Center for Vertigo and Dizziness, Hans-Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Hubertus Axer
- Center for Vertigo and Dizziness, Hans-Berger Department of Neurology, Jena University Hospital, Jena, Germany
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92
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Popkirov S, Stone J, Holle-Lee D. Treatment of Persistent Postural-Perceptual Dizziness (PPPD) and Related Disorders. Curr Treat Options Neurol 2018; 20:50. [PMID: 30315375 DOI: 10.1007/s11940-018-0535-0] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Persistent postural-perceptual dizziness (PPPD) is a newly defined disorder of functional dizziness that in the International Classification of Diseases in its 11th revision (ICD-11) supersedes phobic postural vertigo and chronic subjective dizziness. Despite efforts to unify the diagnosis of functional (somatoform) dizziness, patients will present with a variety of triggers, perpetuating factors, and comorbidities, requiring individualized treatment. This article will review different treatment strategies for this common functional neurological disorder and provide practical recommendations for tailored therapy. RECENT FINDINGS An emerging understanding of the underlying pathophysiology that considers vestibular, postural, cognitive, and emotional aspects can enable patients to profit from vestibular rehabilitation, as well as cognitive-behavioral therapy (CBT). Crucially, approaches from CBT should inform and augment physiotherapeutic techniques, and, on the other hand, vestibular exercises or relaxation techniques can be integrated into CBT programs. Antidepressant medication might further facilitate rehabilitation, though the mechanisms are yet to be elucidated, and the level of evidence is low. In PPPD and related disorders, vestibular rehabilitation combined with CBT, and possibly supported by medication, can help patients escape a cycle of maladaptive balance control, recalibrate vestibular systems, and regain independence in everyday life.
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Affiliation(s)
- Stoyan Popkirov
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany.
| | - Jon Stone
- Centre for Clinical Brain Sciences, Western General Hospital, University of Edinburgh, Edinburgh, UK
| | - Dagny Holle-Lee
- Dizziness and Vertigo Center Essen and Department of Neurology, University of Duisburg-Essen, Essen, Germany
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93
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Gordon CR, Tamir R, Furas R, Klein C, Roth R. A pilot study of a novel specs for chronic dizziness. Acta Neurol Scand 2018; 138:344-351. [PMID: 29862507 DOI: 10.1111/ane.12968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVE A pilot study to assess the efficacy and safety of a novel specs device developed to alleviate chronic dizziness using eyeglasses with referential marks fixed on the lenses. MATERIALS AND METHODS Forty patients with stable symptoms of chronic dizziness for more than 3 months participated in a 4-week, double-blind, randomized treatment with Active-Specs or Sham-Specs. Efficacy was assessed using validated semiquantitative scales and questionnaires of vertigo, dizziness and anxiety. Safety evaluation included monitoring of any adverse event. RESULTS Thirty-six participants were included in the efficacy analysis, 18 in each group. Twelve of 18 subjects (67%) treated with Active-Specs reported substantial improvement of symptoms compared to six (33%) with Sham-Specs showing a significant improvement on Clinical Global Impressions scale (P = .017). The Active-Specs group showed significant reduction in the Vertigo Visual Analogue Scale (P = .017) and a nonsignificant but consistent trend of improvement measured by the Dizziness Handicap Inventory and Beck Anxiety Inventory. There were no adverse events related to the treatment. CONCLUSIONS This novel specs device seems to be a safe and promising novel treatment for chronic dizziness. We hypothesize that marks in specific zones of the peripheral visual field could strengthen information of real head motion counteracting the mismatch sensory and locomotor information causing chronic dizziness. The results of this pilot study should be followed up by additional studies aimed at confirming the present encouraging findings.
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Affiliation(s)
- C. R. Gordon
- Department of Neurology; Meir Medical Center; Kfar-Saba Israel
- Sackler Faculty of Medicine; Tel Aviv University; Tel-Aviv Israel
- Sagol School of Neuroscience; Tel Aviv University; Tel-Aviv Israel
| | - R. Tamir
- Department of Physical Therapy; Meir Medical Center; Kfar-Saba Israel
| | - R. Furas
- Department of Physical Therapy; Meir Medical Center; Kfar-Saba Israel
| | - C. Klein
- Department of Neurology; Meir Medical Center; Kfar-Saba Israel
- Sackler Faculty of Medicine; Tel Aviv University; Tel-Aviv Israel
| | - R. Roth
- SpotOn Therapeutics Ltd; Tel-Aviv Israel
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94
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Adkin AL, Carpenter MG. New Insights on Emotional Contributions to Human Postural Control. Front Neurol 2018; 9:789. [PMID: 30298048 PMCID: PMC6160553 DOI: 10.3389/fneur.2018.00789] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 08/31/2018] [Indexed: 12/15/2022] Open
Abstract
It has been just over 20 years since the effects of height-induced threat on human postural control were first investigated. Raising the height of the support surface on which individuals stood increased the perceived consequences of instability and generated postural control changes. Since this initial work, converging evidence has accumulated supporting the efficacy of using height-induced threat to study the effects of emotions on postural control and confirming a direct influence of threat-related changes in arousal, anxiety, and fear of falling on all aspects of postural control, including standing, anticipatory, and reactive balance. In general, threat-related postural changes promote a greater physical safety margin while maintaining upright stance. We use the static balance literature to critically examine the current state of knowledge regarding: (1) the extent to which threat-related changes in postural control are sensitive to threat-related changes in emotions; (2) the underlying neurophysiological and cognitive mechanisms that may contribute to explaining the relationship between emotions and postural control; and (3) the generalizability of threat-related changes across different populations and types of threat. These findings have important implications for understanding the neuromechanisms that control healthy balance, and highlight the need to recognize the potential contributions of psychological and physiological factors to balance deficits associated with age or pathology. We conclude with a discussion of the practical significance of this research, its impact on improving diagnosis and treatment of postural control deficits, and potential directions for future research.
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Affiliation(s)
- Allan L Adkin
- Department of Kinesiology, Brock University, St. Catharines, ON, Canada
| | - Mark G Carpenter
- School of Kinesiology, University of British Columbia, Vancouver, BC, Canada.,Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada.,International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada
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95
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Lopez C, Elzière M. Out-of-body experience in vestibular disorders – A prospective study of 210 patients with dizziness. Cortex 2018; 104:193-206. [DOI: 10.1016/j.cortex.2017.05.026] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Revised: 05/11/2017] [Accepted: 05/30/2017] [Indexed: 11/17/2022]
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96
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Popp P, Zu Eulenburg P, Stephan T, Bögle R, Habs M, Henningsen P, Feuerecker R, Dieterich M. Cortical alterations in phobic postural vertigo - a multimodal imaging approach. Ann Clin Transl Neurol 2018; 5:717-729. [PMID: 29928655 PMCID: PMC5989755 DOI: 10.1002/acn3.570] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 03/22/2018] [Accepted: 03/22/2018] [Indexed: 01/29/2023] Open
Abstract
Objective Functional dizziness syndromes are among the most common diagnoses made in patients with chronic dizziness, but their underlying neural characteristics are largely unknown. The aim of this neuroimaging study was to analyze the disease‐specific brain changes in patients with phobic postural vertigo (PPV). Methods We measured brain morphology, task response, and functional connectivity in 44 patients with PPV and 44 healthy controls. Results The analyses revealed a relative structural increase in regions of the prefrontal cortex and the associated thalamic projection zones as well as in the primary motor cortex. Morphological increases in the ventrolateral prefrontal cortex positively correlated with disease duration, whereas increases in dorsolateral, medial, and ventromedial prefrontal areas positively correlated with the Beck depression index. Visual motion stimulation caused an increased task‐dependent activity in the subgenual anterior cingulum and a significantly longer duration of the motion aftereffect in the patients. Task‐based functional connectivity analyses revealed aberrant involvement of interoceptive, fear generalization, and orbitofrontal networks. Interpretation Our findings agree with some of the typical characteristics of functional dizziness syndromes, for example, excessive self‐awareness, anxious appraisal, and obsessive controlling of posture. This first evidence indicates that the disease‐specific mechanisms underlying PPV are related to networks involved in mood regulation, fear generalization, interoception, and cognitive control. They do not seem to be the result of aberrant processing in cortical visual, visual motion, or vestibular regions.
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Affiliation(s)
- Pauline Popp
- Department of Neurology Ludwig-Maximilians Universität Munich Germany.,Graduate School of Systemic Neurosciences Ludwig-Maximilians Universität Munich Germany
| | - Peter Zu Eulenburg
- Department of Neurology Ludwig-Maximilians Universität Munich Germany.,Graduate School of Systemic Neurosciences Ludwig-Maximilians Universität Munich Germany.,German Center for Vertigo and Balance Disorders Ludwig-Maximilians Universität Munich Germany
| | - Thomas Stephan
- Department of Neurology Ludwig-Maximilians Universität Munich Germany.,Graduate School of Systemic Neurosciences Ludwig-Maximilians Universität Munich Germany.,German Center for Vertigo and Balance Disorders Ludwig-Maximilians Universität Munich Germany
| | - Rainer Bögle
- Department of Neurology Ludwig-Maximilians Universität Munich Germany.,Graduate School of Systemic Neurosciences Ludwig-Maximilians Universität Munich Germany.,German Center for Vertigo and Balance Disorders Ludwig-Maximilians Universität Munich Germany
| | - Maximilian Habs
- Department of Neurology Ludwig-Maximilians Universität Munich Germany.,German Center for Vertigo and Balance Disorders Ludwig-Maximilians Universität Munich Germany
| | - Peter Henningsen
- German Center for Vertigo and Balance Disorders Ludwig-Maximilians Universität Munich Germany.,Department of Psychosomatic Medicine and Psychotherapy Technical University Munich Germany
| | - Regina Feuerecker
- Department of Neurology Ludwig-Maximilians Universität Munich Germany.,German Center for Vertigo and Balance Disorders Ludwig-Maximilians Universität Munich Germany
| | - Marianne Dieterich
- Department of Neurology Ludwig-Maximilians Universität Munich Germany.,Graduate School of Systemic Neurosciences Ludwig-Maximilians Universität Munich Germany.,German Center for Vertigo and Balance Disorders Ludwig-Maximilians Universität Munich Germany.,SyNergy Munich Cluster of Systems Neurology Munich Germany
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97
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Cha YH, Cui YY, Baloh RW. Comprehensive Clinical Profile of Mal De Debarquement Syndrome. Front Neurol 2018; 9:261. [PMID: 29867709 PMCID: PMC5950831 DOI: 10.3389/fneur.2018.00261] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 04/04/2018] [Indexed: 01/03/2023] Open
Abstract
Background There has been increasing awareness that post-motion triggered rocking self-vertigo can last for months or years, a disorder known as Mal de Debarquement Syndrome (MdDS). A similar feeling of oscillating self-motion can occur without a motion trigger in some individuals, leading to controversy about whether motion triggered (MT) and non-motion triggered (non-MT) symptoms ultimately represent the same disorder. Recognizing the similarities and differences between MT and non-MT MdDS can prevent unnecessary diagnostic testing and lead to earlier and more effective treatments. Methods Standardized questionnaire assessment and follow-up interviews of individuals with persistent MT or non-MT MdDS (>1 month) examined at a University Dizziness Clinic. Findings Questionnaires were available on 80 individuals with persistent MT MdDS and 42 with non-MT MdDS. Sex distribution (81% female) and age of onset (mean 43.4 ± 12.2 years MT; 42.1 ± 15.2 years non-MT) were comparable between MT and non-MT MdDS (p > 0.05). Mean duration of illness was significantly longer in the non-MT group (82.8 ± 64.2 months) than the MT group (35.4 ± 46.4 months) (p < 0.001). There was no correlation between trigger type and age of onset or duration of illness for MT MdDS. Improvement with re-exposure to motion (driving) was typical for both (MT = 89%, non-MT = 64%), but non-MT individuals more frequently had symptoms exacerbated with motion (MT = 0%; non-MT = 10%). Peri-menstrual and menstrual worsening of symptoms was typical in both MT and non-MT MdDS (each 71%). Both MT and non-MT MdDS exhibited a higher population baseline prevalence of migraine (23% and 38%, respectively). Benzodiazepines and SSRI/SNRIs were helpful in both subtypes of MdDS (>50% individuals with a positive response). Physical therapy was modestly helpful in the MT (56%) subtype but not in non-MT (15%). Vestibular therapy made as many individuals worse as better in MT and none improved in the non-MT group. Conclusion General demographic characteristics and exacerbating factors are similar in MT and non-MT MdDS, but there are differences in the duration of illness, effect of motion on symptoms, and response to therapy. Recognizing clinical features of MdDS subtypes may allow for better tailoring of therapy and potentially serve as classification criteria for new clinical designations.
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Affiliation(s)
- Yoon-Hee Cha
- Laureate Institute for Brain Research, Tulsa, OK, United States.,School of Community Medicine, University of Tulsa, Tulsa, OK, United States
| | - Yong Yan Cui
- Department of Internal Medicine, Columbia Medical Center, New York, NY, United States
| | - Robert W Baloh
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
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98
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Lee JO, Lee ES, Kim JS, Lee YB, Jeong Y, Choi BS, Kim JH, Staab JP. Altered brain function in persistent postural perceptual dizziness: A study on resting state functional connectivity. Hum Brain Mapp 2018; 39:3340-3353. [PMID: 29656497 DOI: 10.1002/hbm.24080] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 03/29/2018] [Accepted: 04/03/2018] [Indexed: 11/09/2022] Open
Abstract
This study used resting state functional magnetic resonance imaging (rsfMRI) to investigate whole brain networks in patients with persistent postural perceptual dizziness (PPPD). We compared rsfMRI data from 38 patients with PPPD and 38 healthy controls using whole brain and region of interest analyses. We examined correlations among connectivity and clinical variables and tested the ability of a machine learning algorithm to classify subjects using rsfMRI results. Patients with PPPD showed: (a) increased connectivity of subcallosal cortex with left superior lateral occipital cortex and left middle frontal gyrus, (b) decreased connectivity of left hippocampus with bilateral central opercular cortices, left posterior opercular cortex, right insular cortex and cerebellum, and (c) decreased connectivity between right nucleus accumbens and anterior left temporal fusiform cortex. After controlling for anxiety and depression as covariates, patients with PPPD still showed decreased connectivity between left hippocampus and right inferior frontal gyrus, bilateral temporal lobes, bilateral insular cortices, bilateral central opercular cortex, left parietal opercular cortex, bilateral occipital lobes and cerebellum (bilateral lobules VI and V, and left I-IV). Dizziness handicap, anxiety, and depression correlated with connectivity in clinically meaningful brain regions. The machine learning algorithm correctly classified patients and controls with a sensitivity of 78.4%, specificity of 76.9%, and area under the curve = 0.88 using 11 connectivity parameters. Patients with PPPD showed reduced connectivity among the areas involved in multisensory vestibular processing and spatial cognition, but increased connectivity in networks linking visual and emotional processing. Connectivity patterns may become an imaging biomarker of PPPD.
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Affiliation(s)
- Jin-Ok Lee
- Department of Neurology, Seoul National University of College of Medicine, Seoul National University Bundang Hospital, Republic of Korea
| | - Eek-Sung Lee
- Department of Neurology, Soonchunhyang University Bucheon Hospital, Republic of Korea
| | - Ji-Soo Kim
- Department of Neurology, Seoul National University of College of Medicine, Seoul National University Bundang Hospital, Republic of Korea
| | - Young-Beom Lee
- Department of Bio and Brain Engineering, Korea Advanced Institute of Science and Technology, Republic of Korea.,KI for Health Science and Technology, Korea Advanced Institute of Science and Technology, Republic of Korea
| | - Yong Jeong
- Department of Bio and Brain Engineering, Korea Advanced Institute of Science and Technology, Republic of Korea.,KI for Health Science and Technology, Korea Advanced Institute of Science and Technology, Republic of Korea
| | - Byung Se Choi
- Department of Radiology, Seoul National University Bundang Hospital, Republic of Korea
| | - Jae-Hyoung Kim
- Department of Radiology, Seoul National University Bundang Hospital, Republic of Korea
| | - Jeffrey P Staab
- Departments of Psychiatry and Psychology and Otorhinolaryngology - Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
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99
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Hirsch JA. Integrating Hypnosis with Other Therapies for Treating Specific Phobias: A Case Series. AMERICAN JOURNAL OF CLINICAL HYPNOSIS 2018; 60:367-377. [PMID: 29485374 DOI: 10.1080/00029157.2017.1326372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
There is a high prevalence of anxiety disorders including specific phobias and panic disorder in the United States and Europe. A variety of therapeutic modalities including pharmacotherapy, cognitive behavioral therapy, systematic desensitization, hypnosis, in vivo exposure, and virtual reality exposure therapy have been applied. No one modality has been entirely successful. There has been only a limited attempt to combine psychological therapies in the treatment of specific phobias and panic disorder and what has been done has been primarily with systematic desensitization or cognitive behavioral therapy along with hypnotherapy. I present two cases of multiple specific phobias that were successfully treated with hypnotherapy combined with virtual reality exposure therapy or in vivo exposure therapy. The rationale for this integrative therapy and the neurobiological constructs are considered.
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100
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Stephan AJ, Kovacs E, Phillips A, Schelling J, Ulrich SM, Grill E. Barriers and facilitators for the management of vertigo: a qualitative study with primary care providers. Implement Sci 2018; 13:25. [PMID: 29422076 PMCID: PMC5806383 DOI: 10.1186/s13012-018-0716-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 01/25/2018] [Indexed: 11/23/2022] Open
Abstract
Background Although the management of patients presenting with vertigo and dizziness in primary care has been reported to be inefficient, little is known about the primary care providers’ (PCPs) perspectives, needs, and attitudes regarding vertigo management. The objective of this study was to understand which challenges and barriers PCPs see when diagnosing and treating patients presenting with vertigo or dizziness. Specifically, we wanted to identify facilitators and barriers of successful guideline implementation in order to inform the development of targeted interventions. Methods A theory-based interview structure was developed based on the implementation theory of capability, opportunity, and motivation for behaviour change (COM-B) using questions based on constructs from the Theoretical Domains Framework (TDF) and the Consolidated Framework for Implementation Research (CFIR). Transcripts of the semi-structured interviews were analysed using directed content analysis. The pathways through which guideline characteristics and supportive interventions affect the relationship between the PCPs’ perceived capability, opportunity, and motivation as well as their practice of managing vertigo patients were graphically presented using the COM-B model structure. Results Twelve PCPs from Bavaria in Southern Germany participated in semi-structured interviews. Diagnostics posed the biggest challenge in vertigo management to the PCPs. Requirements for an acceptable guideline were stakeholder involvement in the development process, clarity of presentation, and high applicability. Guideline implementation might be effectively supported through educational meetings and sustained by organisational interventions. Conclusions From the PCPs’ perspective, both guideline characteristics and interventions supporting guideline implementation may help resolve challenges in vertigo management in primary care. These results should be used to guide future interventions in the primary care setting to ensure successful and targeted patient management. Electronic supplementary material The online version of this article (10.1186/s13012-018-0716-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anna-Janina Stephan
- Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-Universität München, Marchioninistraße 17, 81377, Munich, Germany.
| | - Eva Kovacs
- Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-Universität München, Marchioninistraße 17, 81377, Munich, Germany.,German Centre for Vertigo and Balance Disorders, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Amanda Phillips
- Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-Universität München, Marchioninistraße 17, 81377, Munich, Germany.,German Centre for Vertigo and Balance Disorders, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Jörg Schelling
- Institute for General Practice and Family Medicine, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Susanne Marlene Ulrich
- Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-Universität München, Marchioninistraße 17, 81377, Munich, Germany
| | - Eva Grill
- Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-Universität München, Marchioninistraße 17, 81377, Munich, Germany.,German Centre for Vertigo and Balance Disorders, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany.,Munich Centre of Health Sciences, Ludwig-Maximilians-Universität München, Munich, Germany
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