Physical therapy for central vestibular dysfunction

Telerehabilitation: Vestibular Physiotherapy vs. Multicomponent Exercise for Functional Improvement in Older Adults: Randomized Clinical Trial

The loss of vestibular and motor function can occur naturally with aging. Vestibular physiotherapy exercises (VE) specifically address vestibular rehabilitation to reduce imbalances and improve physical condition, like therapeutic exercise (TE). During COVID-19, technology was used with the elderly for implementation. Objective: to determine if vestibular exercises are as effective as multicomponent exercises in improving functional capacity using technological tools. Methods: A randomized clinical trial compared two intervention groups of 21 subjects with functional limitations and frailty (average age 76.11 years). The intervention involved multicomponent exercise for the control group (Vivifrail protocol) and vestibular exercises for the experimental group (Cawthorne and Cooksey exercises) for 6 weeks with five sessions per week both groups. Two professionals implemented the exercises, and participants received tailored exercise videos. Primary outcomes were gait speed, dynamic balance, and physical capacity. Results: Both groups showed significant improvements. For physical function measured by SPPB (0-12 points), the multicomponent exercise group improved by 1.97 (0.91; 3.03), p < 0.001, and the vestibular exercise group improved by 1.63 (0.65; 2.60), p = 0.002. For dynamic balance measured by the Timed Up and Go (TUG) test, the multicomponent exercise group improved by -0.88 (-1.33; -0.42), p < 0.001, and the vestibular exercise group improved by -0.79 (-1.21; -0.37), p < 0.001. There were no significant differences between groups. Finally, regarding gait speed, there were no differences in either group between pretest and post-test (p > 0.05). Conclusions: Both multicomponent exercise and vestibular exercises improve functional capacities via telerehabilitation as measured by the SPPB, although vestibular physiotherapy does not show superior outcomes compared to the control group.

Remote Delivery of Vestibular Rehabilitation for Vestibular Dysfunction: A Systematic Review

BACKGROUND

People with vestibular dysfunction encounter many obstacles when seeking vestibular rehabilitation treatment. Remote delivery of vestibular rehabilitation may offer a promising avenue for overcoming these barriers, ensuring uninterrupted and cost-effective care.

OBJECTIVE

To evaluate clinical trials studying telerehabilitation and virtual reality devices as therapeutic interventions for individuals with vestibular dysfunction.

METHODS

A PRISMA systematic review of PubMed, EMBASE, Cochrane, Web of Science, and SCOPUS was conducted for randomized controlled trials describing the use of remote care delivery for vestibular rehabilitation. Bias of studies was assessed with the revised Cochrane risk-of-bias tool (RoB2).

RESULTS

The search identified 1,358 unique articles and 14 articles matched the search criteria. Study samples size ranged from 20 to 337, with mean ages ranging from 29.3 to 77.7 years. Interventions included telephone and online communication, exergaming devices, web-based applications, and head-mounted devices to deliver vestibular rehabilitation. Outcomes included validated questionnaires, objective clinical tests, and physical examinations.

CONCLUSIONS

The studies reviewed in this article reported greater or equivalent outcomes when incorporating remote care options as supplements or alternatives to standard care for patients with vestibular dysfunction. Further research is required to address limitations in these studies such as heterogeneity of control groups and cost-effectiveness of these interventions.

Physical Therapy and Aminopyridine for Downbeat Nystagmus Syndrome: A Case Report

BACKGROUND AND PURPOSE

Individuals with downbeat nystagmus (DBN) syndrome present with DBN, dizziness, blurred vision, and unsteady gait. Pharmacological intervention with 4-aminopyridine (4-AP) may be effective in improving oculomotor function, but there is minimal evidence to date that it improves gait. This suggests the possible benefit of combining pharmacotherapy with physical therapy to maximize outcomes. This case report documents improvements in gait and balance after physical therapy and aminopyridine (AP) in an individual with DBN syndrome.

CASE DESCRIPTION

The patient was a 70-year-old man with a 4-year history of worsening dizziness and imbalance, diagnosed with DBN syndrome. He demonstrated impaired oculomotor function, dizziness, and imbalance, which resulted in falls and limited community ambulation.

INTERVENTION

The patient completed a customized, tapered course of physical therapy over 6 months. Outcome measures included the 10-meter walk test, the Timed Up and Go (TUG), the Dynamic Gait Index (DGI), and the modified clinical test of sensory integration and balance.

OUTCOMES

Improvements exceeding minimal detectable change were demonstrated on the TUG and the DGI. Gait speed on the 10-meter walk test did not change significantly, but the patient was able to use a cane to ambulate in the community and reported no further falls.

DISCUSSION

Controlled studies are needed to explore the potential for AP to augment physical therapy in people with DBN syndrome. Physical therapists are encouraged to communicate with referring medical providers about the use of AP as pharmacotherapy along with physical therapy for individuals with DBN syndrome.

Short-term learning of the vestibulo-ocular reflex induced by a custom interactive computer game

Retinal image slip during head rotation drives motor learning in the rotational vestibulo-ocular reflex (VOR) and forms the basis of gaze-stability exercises that treat vestibular dysfunction. Clinical exercises, however, are unengaging, cannot easily be titrated to the level of impairment, and provide neither direct feedback nor tracking of the patient's adherence, performance, and progress. To address this, we have developed a custom application for VOR training based on an interactive computer game. In this study, we tested the ability of this game to induce VOR learning in individuals with normal vestibular function, and we compared the efficacy of single-step and incremental learning protocols. Eighteen participants played the game twice on different days. All participants tolerated the game and were able to complete both sessions. The game scenario incorporated a series of brief head rotations, similar to active head impulses, that were paired with a dynamic acuity task and with a visual-vestibular mismatch (VVM) intended to increase VOR gain (single-step: 300 successful trials at ×1.5 viewing; incremental: 100 trials each of ×1.13, ×1.33, and ×1.5 viewing). Overall, VOR gain increased by 15 ± 4.7% (mean ± 95% CI, P < 0.001). Gains increased similarly for active and passive head rotations, and, contrary to our hypothesis, there was little effect of the learning strategy. This study shows that an interactive computer game provides robust VOR training and has the potential to deliver effective, engaging, and trackable gaze-stability exercises to patients with a range of vestibular dysfunctions.NEW & NOTEWORTHY This study demonstrates the feasibility and efficacy of a customized computer game to induce motor learning in the high-frequency rotational vestibulo-ocular reflex. It provides a physiological basis for the deployment of this technology to clinical vestibular rehabilitation.

Effectiveness of Vestibular Rehabilitation for Patients with Degenerative Cerebellar Ataxia: A Retrospective Cohort Study

Many patients with cerebellar ataxia have dizziness caused by oculomotor or peripheral vestibular deficits; however, there is little evidence supporting the use of vestibular rehabilitation for this population. The purpose of this study was to determine whether patients with degenerative cerebellar diseases improve following rehabilitation including vestibular exercises. A secondary aim was to identify variables associated with the outcomes. A retrospective chart review identified 42 ambulatory patients (23 men and 19 women; mean age = 54.5 ± 14.4 years) with cerebellar degeneration. Fourteen patients had ataxia only, twenty had ataxia and oculomotor abnormalities, and eight had ataxia with oculomotor and peripheral vestibular deficits. Patients received customized physical therapy including balance and gait training, as well as gaze stabilization and habituation exercises for vestibular hypofunction and motion-provoked dizziness. Primary outcome measures (Activities-specific Balance Confidence Scale, Tinetti Performance Oriented Mobility Assessment, Dynamic Gait index, and Sensory Organization Test) were evaluated at baseline and discharge. Patients improved (p < 0.05) on all outcome measures. Patients with vestibular deficits were seen for more visits compared to those with gait ataxia only (7.1 vs. 4.8 visits). This study provides evidence that patients with degenerative cerebellar disease improve in balance confidence, fall risk and sensory integration with therapy that includes vestibular rehabilitation.

Migraine management for the otolaryngologist

Objective

To characterize migraine pathophysiology, presentation, and current treatment strategies, specifically in regard to vestibulocochlear manifestations of migraine.

Methods

Narrative review of available literature.

Results

Migraine disorder can be described as a spectrum of otologic manifestations, with vestibular migraine now recognized with fully-fledged diagnostic criteria. Otologic manifestations are theorized to be due, in part, to trigeminal innervation of the inner ear structures and calcitonin gene-related peptide (CGRP) expression within the labyrinth. Patients can experience vertigo, aural fullness, enhanced tinnitus, and hearing loss without the characteristic migraine headache, leading to under recognition of these symptoms as migraine-related. Meniere's disease, mal de débarquement syndrome, persistent postural perceptual dizziness, and recurrent benign paroxysmal positional vertigo have close associations to migraine and may exist on the migraine spectrum. Migraine treatment consists of two goals: halting acute attacks (abortive therapy) and preventing attacks (prophylactic therapy). Abortive medications include triptans, corticosteroids, anti-histamines, and anti-emetics. Pharmacologic prophylaxis in conjunction with lifestyle modifications can decrease frequency and severity of symptoms and include tricyclic antidepressants, calcium channel blockers, anti-epileptic medications, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, beta-blockers, gepants, and monoclonal antibodies to CGRP. Promising evidence is emerging regarding the ability of migraine medications to positively treat the various otologic symptoms of migraine.

Conclusion

Migraine disorder manifesting with primarily cochleovestibular symptoms can be challenging to diagnose and manage for practicing clinicians. Patients with various vestibulopathies that are closely related to migraine may benefit from migraine treatment. Lifestyle choices and prophylactic medications are key to satisfactorily preventing acute migrainous attacks and improve function.

Close Your Eyes and See: Stroke Sequelae versus Functional Neurological Disorder in a Physician

The first author is a left-handed, 51-year-old nephrologist who experienced a neurologic event. She underwent neurosurgery complicated by hemorrhage. Postoperatively, she developed persistent vertigo and unilateral tongue pain which persisted for over 5 years. Early neuroimaging revealed expected encephalomalacia but no neuroanatomical basis for her symptoms. A functional neurological disorder was suspected, and she was seen by several psychiatrists and psychotherapists. However, she suspected a neuroanatomical lesion would better explain her unrelenting symptoms. After seeing many neurologists, a neuroanatomical diagnosis was finally made. The theory and practice of medicine mandate that subjective complaint guides the modality and interpretation of objective evidence. The final neurologist knew where on neuroimaging to look because she was guided by the patient's complaints - vertigo and unilateral tongue pain. In this case, detailed scrutiny of neuroimaging by a neurologist, after encephalomalacia and gliosis were fully completed, gave a more accurate neuroanatomical diagnosis and a more realistic prognosis.

Adults are not older adolescents: comparing physical therapy findings among adolescents, young adults and older adults with persistent post-concussive symptoms

OBJECTIVE

Individuals with persistent post-concussive symptoms (PPCS) may present with a myriad of physical symptoms. There is limited research available comparing the presence of examination findings among individuals with PPCS from different age groups.

METHODS

Retrospective case-control chart review of 481 patients with PPCS and 271 non-trauma controls. Physical assessments were categorized as ocular, cervical, and vestibular/balance. Differences in presentation were compared between PPCS and controls as well as between individuals with PPCS in three age groups: adolescents, young adults, and older adults.

RESULTS

All three PPCS groups had more abnormal oculomotor findings than their age-matched counterparts. When comparing PPCS patients from different age groups, no differences were seen in prevalence of abnormal smooth pursuits or saccades; however, adolescents with PPCS had more abnormal cervical findings and a lower prevalence of abnormal NPC, vestibular and balance findings.

CONCLUSION

Patients with PPCS presented with a different constellation of clinical findings based on their age. Adolescents were more likely to demonstrate evidence of cervical injury compared to younger and older adults, and adults were more likely to present with vestibular findings and impaired NPC. Adults with PPCS were more likely to present with abnormal oculomotor findings compared to adults with non-traumatic causes of dizziness.

Instrumental and Non-Instrumental Measurements in Patients with Peripheral Vestibular Dysfunctions

Vestibular dysfunction is a disturbance of the body's balance system. The control of balance and gait has a particular influence on the quality of life. Currently, assessing patients with these problems is mainly subjective. New assessment options using wearables may provide complementary and more objective information. Posturography makes it possible to determine the extent and type of posture dysfunction, which makes it possible to plan and monitor the effectiveness of physical rehabilitation therapy. This study evaluates the effectiveness of non-instrumental clinical tests and the instrumental mobile posturography MediPost device for patients with unilateral vestibular disorders. The study group included 40 patients. A subjective description of the symptoms was evaluated using a questionnaire about the intensity of dizziness using the Dizziness Handicap Inventory (DHI) and Vertigo Syndrome Scale-short form (VSS-sf). The clinical protocol contained clinical tests and MediPost measurements using a Modified Clinical Test of Sensory Interaction on Balance. All patients underwent vestibular rehabilitation therapy (VRT) for four weeks. The non-instrumental measurement results were statistically significant, and the best was in the Timed Up and Go test (TUG). In MediPost, condition 4 was the most valuable. This research demonstrated the possibilities of using an instrumental test (MediPost) as an alternative method to assess balance.

Migrainous Vertigo, Tinnitus, and Ear Symptoms and Alternatives

Migraine headaches frequently coexist with vestibular symptoms such as vertigo, motion sickness, and gait instability. Migraine-related vasospasm can also damage the inner ear, which results in symptoms such as sudden sensorineural hearing loss and resultant tinnitus. The pathophysiology of these symptoms is not yet fully understood, and despite their prevalence, there is no universally approved management. This review summarizes the data on complementary and integrative medicine in treating patients with migrainous ear disorders.

Vestibular Rehabilitation Therapy for the Treatment of Vestibular Migraine, and the Impact of Traumatic Brain Injury on Outcome: A Retrospective Study

INTRODUCTION

Vestibular migraine (VM) is a common condition; individuals experience dizziness with migraine symptoms. Vestibular rehabilitation therapy (VRT) has been reported as an effective treatment for VM, however, evidence is limited. VM and traumatic brain injury (TBI) can co-occur, and some suggest that TBI can induce VM. There is limited evidence on the effect a history of TBI has on VRT in patients with VM.

METHODS

Retrospective case series of 93 (f = 63, m = 30) participants with VM and underwent VRT (mean age 48.62; SD 15.92). Pre- and post-treatment self-reported outcome measures and functional gait assessment were extracted from the participants health records and evaluated. The impact of TBI on VRT outcome in participants with VM was analyzed. Individuals with TBI and no history of migraine (n = 40) were also extracted to act as a control.

RESULTS

VRT significantly improved self-reported dizziness on the Dizziness Handicap Inventory (DHI), with a mean change of -18 points (p < 0.000) and +5 points on the functional gait assessment (FGA) (p < 0.000) in patients with VM. A history of TBI significantly impacted outcome on the DHI (p = 0.018) in patients with VM.VRT significantly improved all outcome measures for individuals with TBI, with a mean change of -16 points on the DHI (p = 0.001) and +5 points on the FGA (p < 0.000). VM presence significantly impacted outcome.

CONCLUSION

VRT should be considered as a treatment option to reduce dizziness and the risk of falls in individuals with VM. TBI may negatively impact VRT outcomes in individuals with VM.

Feasibility and safety of an immersive virtual reality-based vestibular rehabilitation programme in people with multiple sclerosis experiencing vestibular impairment: a protocol for a pilot randomised controlled trial

INTRODUCTION

Vestibular system damage in patients with multiple sclerosis (MS) may have a central and/or peripheral origin. Subsequent vestibular impairments may contribute to dizziness, balance disorders and fatigue in this population. Vestibular rehabilitation targeting vestibular impairments may improve these symptoms. Furthermore, as a successful tool in neurological rehabilitation, immersive virtual reality (VRi) could also be implemented within a vestibular rehabilitation intervention.

METHODS AND ANALYSIS

This protocol describes a parallel-arm, pilot randomised controlled trial, with blinded assessments, in 30 patients with MS with vestibular impairment (Dizziness Handicap Inventory ≥16). The experimental group will receive a VRi vestibular rehabilitation intervention based on the conventional Cawthorne-Cooksey protocol; the control group will perform the conventional protocol. The duration of the intervention in both groups will be 7 weeks (20 sessions, 3 sessions/week). The primary outcomes are the feasibility and safety of the vestibular VRi intervention in patients with MS. Secondary outcome measures are dizziness symptoms, balance performance, fatigue and quality of life. Quantitative assessment will be carried out at baseline (T0), immediately after intervention (T1), and after a follow-up period of 3 and 6 months (T2 and T3). Additionally, in order to further examine the feasibility of the intervention, a qualitative assessment will be performed at T1.

ETHICS AND DISSEMINATION

The study was approved by the Andalusian Review Board and Ethics Committee, Virgen Macarena-Virgen del Rocio Hospitals (ID 2148-N-19, 25 March 2020). Informed consent will be collected from participants who wish to participate in the research. The results of this research will be disseminated by publication in peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT04497025.

Effects of vestibular rehabilitation in the management of patients with and without vestibular migraine

OBJECTIVE

Vestibular Migraine (VM) is the second most common cause in patients with vertigo. Patients with VM complain about vestibular symptoms during a headache attack or during the period between attacks. Vestibular Rehabilitation (VR), an exercised based therapy to treat dizziness and balance dysfunction has been shown to be effective in vestibular diseases. In this study, we aimed to assess the effect of VR for vestibular symptoms and quality of life in VM patients, and to compare the results with patients with vestibular disorders without migraine.

METHODS

Sixty (60) patients who received VR treatment were divided into two groups: vestibular migraine group (30 patients) and non-migraine vestibular dysfunction group (30 patients). All patients received VR for 18 sessions and the program was completed in 1.5 months. Pre- and post-treatment Dizziness Handicap Inventory (DHI) scores, Vestibular Disorders Activities of Daily Living Scale (VADL) scores, the frequency of dizziness and headache, and Computerized Dynamic Posturography (CDP) scores were assessed and compared retrospectively.

RESULTS

With VR in both the vestibular migraine group and vestibular dysfunction group, DHI score, VADL score, the frequency of dizziness and headache scores significantly impaired. Post-treatment CDP results were higher than pre- treatment results for both patient groups.

CONCLUSION

With VR, a significant improvement was observed in subjective and objective balance assessment measurement. Vestibular Rehabilitation must be considered in patients who do not benefit from medical therapy or have limited benefit.

LEVEL OF EVIDENCE

Level III (evidence obtained from well-designed controlled trials without randomization).

Characterizing gaze and postural stability deficits in people with multiple sclerosis

BACKGROUND

People with Multiple Sclerosis (PwMS) experience a wide range of symptoms that can alter function and limit activity and community participation. Symptoms including sensory changes, weakness, fatigue and others have been well documented. However, symptoms related to changes in vestibular related function, including gaze and postural stability have not been fully explored. While some recent studies have begun to provide insight into these deficits in PwMS and have explored the use of rehabilitation paradigms for their management, much remains unknown about the full extent of these deficits. Therefore, this study aimed to characterize the presence of gaze and postural stability deficits in measures across the World Health Organization International Classification of Functioning, Disability, and Health (WHO ICF) and to examine how deficits in domains of body structure and function and activity contribute to participation level limitations.

METHODS

Baseline data from 41 PwMS (mean(SD) age = 53.9(11.2), 78% female) enrolled as part of a randomized clinical trial were used in this analysis. Measures of gaze and postural stability from the ICF domains of body structure and function (Vestibular ocular reflex [VOR] gain and postural sway area), activity (computerized dynamic visual acuity [cDVA] and MiniBEST test), and participation (Dizziness handicap inventory [DHI] and Activities Balance Confidence [ABC] scale) along with demographic data were used to characterize the sample. To explore relationships between ICF domains for gaze and postural stability, univariate correlations were performed between measures from each domain using Pearson's correlations. Separate multivariate regression models examined how measures from the body structure and function and activity domains contributed to the variance in the participation level outcomes. Variance explained by the models was quantified using R-squared statistic and contribution of the independent variables were quantified using the beta coefficient (p < 0.05).

RESULTS

Correlation analysis demonstrated significant relationships in the postural stability measures across domains. Specifically, between postural sway area on a firm surface and MiniBEST test score (r = -.48;p < 0.01) and MiniBEST test score and ABC score (r = 0.5;p < 0.01). Significant correlations were also found between the gaze stability measures of horizontal and vertical VOR gain (r = .68;p < 0.001), horizontal VOR gain and dynamic visual acuity (r = .38;p = 0.02), and vertical VOR gain and dynamic visual acuity (r = .54;p < 0.001). Regression models assessing postural stability, found that only the MiniBEST score significantly contributed to the variance in ABC score (p = 0.01) and the full model explained 34% of the variance in ABC score. Regression modeling of gaze stability outcomes did not produce any variable that significantly contributed to the variance in DHI score and the full model explained 18% of the variance in DHI score.

CONCLUSIONS

PwMS in this sample demonstrated deficits in gaze and postural stability across the domains of the WHO ICF compared to past samples of PwMS and healthy cohorts. Correlation between measures in the different domains were present, but no strong relationship between measures of body structure and function, activity and participation level outcomes were observed. This lack of relationship across the domains is likely contributed to the relatively small sample size, the high level of variability observed in the outcomes, and the diverse presentation often seen in PwMS.

Effect of Repetitive Administration of a Next-generation Sensory Organization Test in Adults With and Without Vestibular Dysfunction

HYPOTHESIS

The overall aim was to assess the effects of repetitive testing on performance on a next-generation Sensory Organization Test (NG-SOT).

BACKGROUND

The psychometric properties of sensory organization assessment with a next-generation posturography device are not fully characterized. Thus, a better understanding of the reliability of the NG-SOT is required to support its use as an outcome measure.

METHODS

Forty adults (20 vestibular-impaired) participated. Test-retest reliability was determined using the interclass correlation coefficient [ICC (3,1)] for the composite, somatosensory, vision, vestibular, and visual preference scores. Learning effects were assessed by analyzing the change in the composite score over time.

RESULTS

Analyzing the NG-SOT scores across all participants produced the following interclass correlation coefficients [95% confidence interval (CI)]: composite = 0.95 (0.92, 0.97), somatosensory = 0.20 (-0.06, 0.44), vision = 0.93 (0.88, 0.96), vestibular = 0.91 (0.85, 0.94), and visual preference = 0.19 (-0.07, 0.43). The mean differences (95% CI; p value) for the composite score between administrations were: 2.7 (1.0, 4.4; 0.002) for visits 1 and 2; 1.4 (-0.3, 3.1; 0.099) for visits 2 and 3; 0.7 (-1.0, 2.4; 0.403) for visits 3 and 4; and 0.4 (-1.3, 2.1; 0.653) for visits 4 and 5.

CONCLUSIONS

Test-retest reliability was excellent for the composite, vision, and vestibular scores, but it was poor for the somatosensory and visual preference scores. A learning effect for the composite score was identified, but performance was stable after two administrations. Changes in the composite score that are greater than 6.5 points exceed the measurement error for the test.

Locked-In Syndrome: Practical Rehabilitation Management

Locked-in syndrome is a rare and devastating condition that results in tetraplegia, lower cranial nerve paralysis, and anarthria with preserved cognition, vertical gaze, and upper eyelid movements. Although acute management is much like that of any severe stroke, rehabilitation and recovery of these patients have not been previously described. Challenges relevant to this population include blood pressure management and orthostasis, timing and appropriateness of reinstating oral feeding, ventilatory support, decannulation after tracheostomy, bowel and bladder management, vestibular dysfunction, and eye care. Targeted rehabilitation of head, neck, and trunk stability to improve function, and proper fit in an appropriate wheelchair are essential to assist with mobility. Rehabilitation interventions should include a focus on distal motor control and upright tolerance training followed by balance and mobility exercises. In addition, special considerations must be given to developing early methods of communication through use of augmentative systems to call for help and express needs. These systems along with additional technology provide the basis to promote connectivity to family and friends through the use of social media and the internet. Establishment of communication, mobility, and connectivity is essential in promoting independence, autonomy, and improving quality of life. Overall, with specialized rehabilitative care and access to the proper equipment, long-term outcomes and quality of life in these patients can be favorable.

Case Report: Auditory Neuropathy and Central Auditory Processing Deficits in a Neuro-Otological Case-Study of Infratentorial Superficial Siderosis

Hearing and balance impairment are the most frequently reported features of infratentorial (classical) superficial siderosis (iSS). There are few comprehensive descriptions of audiovestibular function in iSS and therefore limited understanding of the affected segment(s) of the audiovestibular pathway. In addition, monitoring disease progression and response to treatment is challenging and currently mainly guided by subjective patient reports and magnetic resonance imaging. To the best of our knowledge, there have been no previous reports assessing central auditory function in iSS. We describe such findings in a patient with iSS in an attempt to precisely localize the site of the audiovestibular dysfunction, determine its severity and functional impact. We confirm the presence of (asymmetrical) auditory neuropathy and identify central auditory processing deficits, suggesting involvement of the central auditory pathway beyond the brainstem. We correlate the audiological and vestibular findings with self-report measures and the siderosis appearances on brain magnetic resonance images.

Efficacy of Vestibular Rehabilitation in Patients With Neurologic Disorders: A Systematic Review

OBJECTIVE

The aim of this systematic review is to critically assess the effectiveness of vestibular rehabilitation (VR) administered either alone or in combination with other neurorehabilitation strategies in patients with neurologic disorders.

DATA SOURCES

An electronic search was conducted by 2 independent reviewers in the following databases: MEDLINE (PubMed), the Physiotherapy Evidence Database, and the Cochrane Database of Systematic Reviews.

STUDY SELECTION

All clinical studies carried out on adult patients with a diagnosis of neurologic disorders who performed VR provided alone or in combination with other therapies were included.

DATA EXTRACTION

Screening of titles, abstracts, and full texts and data extraction were undertaken independently by pairs of reviewers. Included studies were quality appraised using a modified version of the Newcastle-Ottawa Scale.

DATA SYNTHESIS

The summary of results was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Twelve studies were included in the review. All the included studies, with 1 exception, report that improvements provided by customized VR in subject affected by a central nervous system diseases are greater than traditional rehabilitation programs alone.

CONCLUSIONS

Because of the lack of high-quality studies and heterogeneity of treatments protocols, clinical practice recommendations on the efficacy of VR cannot be made. Results show that VR programs are safe and could easily be implemented with standard neurorehabilitation protocols in patients affected by neurologic disorders. Hence, more high-quality randomized controlled trials of VR in patients with neurologic disorders are needed.

Vestibular rehabilitation in multiple sclerosis: study protocol for a randomised controlled trial and cost-effectiveness analysis comparing customised with booklet based vestibular rehabilitation for vestibulopathy and a 12 month observational cohort study of the symptom reduction and recurrence rate following treatment for benign paroxysmal positional vertigo

Background

Symptoms arising from vestibular system dysfunction are observed in 49–59% of people with Multiple Sclerosis (MS). Symptoms may include vertigo, dizziness and/or imbalance. These impact on functional ability, contribute to falls and significant health and social care costs. In people with MS, vestibular dysfunction can be due to peripheral pathology that may include Benign Paroxysmal Positional Vertigo (BPPV), as well as central or combined pathology. Vestibular symptoms may be treated with vestibular rehabilitation (VR), and with repositioning manoeuvres in the case of BPPV. However, there is a paucity of evidence about the rate and degree of symptom recovery with VR for people with MS and vestibulopathy. In addition, given the multiplicity of symptoms and underpinning vestibular pathologies often seen in people with MS, a customised VR approach may be more clinically appropriate and cost effective than generic booklet-based approaches. Likewise, BPPV should be identified and treated appropriately.

Methods/ design

People with MS and symptoms of vertigo, dizziness and/or imbalance will be screened for central and/or peripheral vestibulopathy and/or BPPV. Following consent, people with BPPV will be treated with re-positioning manoeuvres over 1–3 sessions and followed up at 6 and 12 months to assess for any re-occurrence of BPPV. People with central and/or peripheral vestibulopathy will be entered into a randomised controlled trial (RCT). Trial participants will be randomly allocated (1:1) to either a 12-week generic booklet-based home programme with telephone support or a 12-week VR programme consisting of customised treatment including 12 face-to-face sessions and a home exercise programme. Customised or booklet-based interventions will start 2 weeks after randomisation and all trial participants will be followed up 14 and 26 weeks from randomisation. The primary clinical outcome is the Dizziness Handicap Inventory at 26 weeks and the primary economic endpoint is quality-adjusted life-years. A range of secondary outcomes associated with vestibular function will be used.

Discussion

If customised VR is demonstrated to be clinically and cost-effective compared to generic booklet-based VR this will inform practice guidelines and the development of training packages for therapists in the diagnosis and treatment of vestibulopathy in people with MS.

Trial registration

ISRCTN Number: 27374299

Date of Registration 24/09/2018

Protocol Version 15 25/09/2019

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-020-01983-y.

Vestibular rehabilitation for persons with stroke and concomitant dizziness-a pilot study

BACKGROUND

Dizziness is common among patients with first time stroke. It affects self-perceived health and is a risk factor for falls. Vestibular rehabilitation (VR) is effective for treating dizziness among various conditions, but the effect of dizziness with origin in the central nervous system is poorly studied.This pilot study of a randomized controlled trial aimed at investigating a vestibular rehabilitation programme among patients with first time stroke and concomitant dizziness. A second aim was to study the feasibility of performing the randomized controlled trial.

METHODS

The participants were computer generated randomized to either an intervention or a control group. The intervention comprised of four different vestibular rehabilitation exercises, adapted for each patient and usual rehabilitation. The control group received usual rehabilitation without the vestibular rehabilitation exercises. Outcome measures used were The Activities-specific Balance Confidence Scale, the Berg Balance Scale, the Functional Gait Assessment Scale and the EuroQol-5D. Feasibility was studied in terms of recruitment, adherence and retention rates, also as the ability to collect primary and secondary outcomes as well as to find indications of treatment differences.

RESULTS

Self-rated health improved for all participants. No other differences between baseline and follow-up were detected neither within nor between groups. Recruitment rate was 23%, adherence to the intervention 90%, retention rate 69% and ability to collect outcome measures 90%. No adverse events occurred.

CONCLUSION

Both the intervention and the control groups improved in self-perceived health. The measures of feasibility were satisfactory in this study, apart from a low recruitment rate.

Role of Long-Term Vestibular Rehabilitation in a Patient with Posterior Fossa Tumor: A Case Report with 2 Years of Follow-Up

Patient: Male, 36-year-old

Final Diagnosis: Central vestibular disorders • lhermitte duclos • posterior fossa tumor

Symptoms: Blurred vision • dizziness • Headache • nausea • nystagmus • postural dizziness • tinnitus • vertigo

Medication: —

Clinical Procedure: Bedside test • Cawthorne-Cooksey exercises • magnetic resonance imaging • physical examination • vestibular rehabilitation • Video Head Impulse Test • videonystagmography

Specialty: Otolaryngology • Rehabilitation

Effectiveness of Vestibular Training for Balance and Dizziness Rehabilitation in People with Multiple Sclerosis: A Systematic Review and Meta-Analysis

Postural instability and dizziness are commonly observed in people with multiple sclerosis (PwMS). The aim of this systematic review was to evaluate the evidence for the use of vestibular rehabilitation, in comparison with other exercise interventions or no intervention, to treat balance impairments and dizziness in PwMS. An electronic search was conducted by two independent reviewers in the following databases: MEDLINE (Pubmed), Scopus, the Physiotherapy Evidence Database (PEDro), Web of Science (WOS), Lilacs, CINHAL and the Cochrane Database of Systematic Reviews (CDSR). A quality assessment was performed using the PEDro scale and the Cochrane Risk of Bias Tool. When possible, the data were pooled in a meta-analysis (95%CI). This systematic review followed the PRISMA guideline statement and was registered in the PROSPERO database (CRD42019134230). Seven studies were included, with a total of 321 participants analysed. Compared with no intervention, vestibular rehabilitation was more effective for balance development (SMD = 2.12; 95% CI = 0.49, 3.75; p = 0.01; I² = 89%) and dizziness symptoms improvement (SMD = −17.43; 95% CI = −29.99, −4.87; p= 0.007; I²= 66%). Compared with other exercise interventions, improvements in favour of the experimental group were observed, but statistical significance for the differences between groups was not reached.

Vestibular Rehabilitation Is Associated With Visuovestibular Improvement in Pediatric Concussion

BACKGROUND AND PURPOSE

Vision and vestibular-related deficits are common after concussion and are associated with prolonged recovery times, substantially impacting the quality of life for children. The utility of targeted vestibular rehabilitation for these deficits in children after concussion is unknown. The purpose of this study was to determine whether active vestibular rehabilitation is associated with an improvement in visuovestibular signs and symptoms in children with concussion.

METHODS

A retrospective cohort study of children diagnosed with concussion and referred to vestibular rehabilitation between 2012 and 2014 was conducted. Patient-reported symptoms and visuovestibular performance measures were assessed in the medical practice and physical therapy settings.

RESULTS

One hundred nine children were included in the study with a mean age of 11.8 (3.4) years. Among this group, 59 (54%) were male and 48 (44%) had a sports-related concussion. Children presented to a pediatric sports medicine office and physical therapy a median of 24 (interquartile range [IQR], 14-42) and 55 (IQR, 39-94) days after injury, respectively. Concussion symptoms decreased from a median of 9 (IQR, 5-13) symptoms at initial evaluation to a median of 0 (IQR, 0-2) symptoms at final assessment. Performance on all visuovestibular tasks improved significantly over the course of therapy except for near point of convergence. For the 45 children who completed the Balance Error Scoring System at both initial and final therapy visits, there was a significant improvement in mean level of performance (P < 0.0001). Characteristics between those who completed a full versus partial course of physical therapy were similar.

DISCUSSION AND CONCLUSIONS

Vestibular rehabilitation in children with concussion is associated with improvement in symptoms as well as visuovestibular performance. This active intervention may benefit children with persistent symptoms after concussion. Future prospective studies are needed to determine the efficacy and optimal postinjury timing of vestibular rehabilitation.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A208).

Vestibular rehabilitation has positive effects on balance, fatigue and activities of daily living in highly disabled multiple sclerosis people: A preliminary randomized controlled trial

BACKGROUND

Balance disorders are present in patients with Multiple Sclerosis and part of these disorders could be of vestibular origin. Vestibular Rehabilitation was found to be effective in improving balance in patients with central vestibular dysfunction.

OBJECTIVE

To investigate the clinical effects of vestibular rehabilitation on balance skills and secondly on fatigue and activity of daily living in highly disabled multiple sclerosis people.

METHODS

Thirty hospitalized participants with severe multiple sclerosis (EDSS 6-7) were randomly assigned to the experimental group (15 patients -9F-; mean age 50.64±11.73) and the control group (15 patients -8F-; mean age 45.77±10.91). All patients were evaluated before and after treatment with the Expanded Disability Status Scale, Barthel Index Tinetti Balance and Gait scale, Berg Balance Scale, Fatigue Severity Scale, Two Minute Walking Test and Timed 25-foot walk test. Two follow-ups (i.e., at 30 and 60 days after treatment) were carried out with Barthel Index.

RESULTS

Significant improvement was found in the experimental group with respect to the control group (p <  0,05) in balance, fatigue perception, activities of daily living and short distance gait. No significant improvements were found for gait endurance as measured by Two Minute Walking Test.

CONCLUSIONS

Four weeks of Vestibular Rehabilitation training results in less fatigue, improved balance and performance of the activities of daily living in patients with severe Multiple Sclerosis.

Clinical Evaluation of Patients with Vestibular Dysfunction

Dizziness is a common reason for outpatient neurology consultation. Oftentimes, a complete workup by general practitioner, including MRI brain fails to reveal a cause. Some patients would have also undergone an ENT evaluation before approaching neurology for an answer. Such scenarios provide a challenge as well as opportunity for the neurologist to exercise their knowledge and clinical skills in arriving at a diagnosis. Conditions like ‘Unspecified Vestibular Dysfunction' and ‘Presbyvertigo' are often the underlying causes, which are either not recognized or misdiagnosed as BPPV, psychogenic or perceptive dizziness. This article's goal is to help understand vestibular system and diagnose vestibular dysfunction in clinical practice.

Considerations for Testing and Treating Children with Central Vestibular Impairments

This perspective explores common pediatric diagnoses that could present with central vestibular pathway dysfunction, leading to delays in motor development and postural control, and gaze instability. Specifically, the following diagnoses are considered: cerebral palsy, myelomeningocele, vestibular migraine, attention-deficit hyperactivity disorder, developmental coordination disorder, concussion, childhood cancer, congenital muscular torticollis, adolescent idiopathic scoliosis, and autism. Suggestions for clinical screening, vestibular function testing, and vestibular rehabilitation for children with these diagnoses are based on evidence for the efficacy of testing and interventions for children with peripheral vestibular hypofunction. More research is needed to explore peripheral and central vestibular function in children with these diagnoses. Testing and intervention methods may need to be modified to accommodate for the specific behavior and motor challenges that some children might present. Researchers should develop technology so that gaze stabilization exercises can be delivered in a fun, functional, and effective way.

Effects of Vestibular Rehabilitation in the Management of a Vestibular Migraine: A Review

Vestibular rehabilitation (VR) has been shown to be effective for many vestibular disorders. This review focuses on the current evidence on the effects of physical therapy in the management of vestibular symptoms in individuals with a vestibular migraine (VM). The individuals with a history of a migraine tend to have a high incidence of vestibular symptoms with some or all of their headaches. A total of six included studies investigated the effects of VR in the management of VM. The critical review form for quantitative studies was used to appraise quality assessment and risk of bias in the selected studies. Previous studies validated the use of VR in the treatment of vestibular symptoms for individuals with a VM to include improved headache and migraine-related disability in patients with a VM. From the current evidence, it is difficult to provide conclusive evidence regarding the efficacy of VR to minimize vestibular symptoms in patients with VM. Therefore, more randomized controlled studies are required to make firm evidence on the effect of VR in reducing vestibular symptoms in patients with VM. The future prospective, blinded, randomized controlled studies may help to isolate possible therapeutic effects of VR and other general effects.

Can pre-screening vestibulocerebellar involvement followed by targeted training improve the outcomes of balance in cerebellar ataxia?

Balance problems and frequent falls are common among clients with Cerebellar Ataxia (CA). CA is not a disease by itself but a collection of symptoms due to the involvement of cerebellum or its pathways. Presently the treatment for balance problems for CA is not standardized. Interventions available to improve balance are not specific to symptoms presentation. Functionally the cerebellum is divided into the spinocerebellum, vestibulocerebellum and corticocerebellum. Each functional zone has a distinct role in maintaining balance. Therefore, the presentation of symptoms will vary according to the functional zone involved. Pre-screening clients with CA for identifying the part of cerebellum involved will facilitate clinicians to provide tailor-made interventions for targeting specific symptoms for better outcomes. Pre-screening clients with CA according to the part of cerebellum involved is not in practice and our study will introduce this concept. We hypothesize pre-screening participants with spinocerebellar ataxia (SCA) for the involvement vestibulocerebellum followed by prescribing vestibulocerebellum targeted exercises will have better outcomes when compared to conventional balance training. We plan to conduct two related studies. In study 1 we will screen participants with CA for the involvement of vestibulocerebellum. In study 2, the effects of vestibulocerebellum targeted balance exercises on balance will be studied. We will assess the Subjective Visual Vertical (SVV) deviation and postural sway pattern to screen participants into people with and without vestibulocerebellar involvement. SVV deviation will be estimated using a computerized Subjective Visual Vertical (cSVV) device and postural sway pattern will be assessed using the limits of stability program of the Bertec© Balance system. The obtained SVV deviation scores will be used to derive at cut-off scores to discriminate clients with and without vestibulocerebellar involvement. The second study will test the treatment effects of conventional exercises plus vestibulocerebellum targeted exercises to improve balance by correcting SVV deviation in SCA with vestibulocerebellar involvement. The intervention is planned as 12 one-to-one sessions over three months period. Participants will be reassessed after the intervention and 3 months post-intervention. The findings of this cutting-edge research are extremely important to the clinicians, researchers and clients with SCA.

The Dizziness Handicap Inventory does not correlate with vestibular function tests: a prospective study

The Dizziness Handicap Inventory (DHI) is believed to quantitate the handicap related to the presence or severity of underlying vestibular dysfunction. However, patients with chronic vestibular diseases may manifest various degrees of behavioural and physiological adaptation resulting in variances of the DHI. Our primary study objective is to evaluate the correlation between the DHI and measurable vestibular parameters. Secondarily, we compared DHI among different vestibular disorders (central, peripheral and functional), and different types of anatomic deficits (semicircular canal vs otolithic). We also correlated the DHI and posturography. We prospectively evaluated 799 patients with precise vestibular diagnoses using video head impulse testing (vHIT), caloric irrigation, and cervical/ocular vestibular-evoked myogenic potentials (c/oVEMP). Posturography was done for 84 patients. All participants completed the DHI. No significant correlation was found between DHI and (1) vestibulo-ocular reflex parameters: unilateral weakness r = - 0.018, total calorics r = 0.055, vHIT right r = 0.007, vHIT left r = - 0.091, vHIT asymmetry r = 0.013; (2) otolith parameters: cVEMP amplitude right r = - 0.034, amplitude left r = - 0.004, asymmetry r = 0.016; oVEMP amplitude right r = 0.044, amplitude left r = - 0.007, asymmetry r = - 0.008. Patients with central vestibular disorders had higher DHI than those with peripheral (z = - 4.743, p = 0.001) or functional disorders (z = - 2.902, p = 0.004). DHI of patients with deficits of canal or otolith function did not differ significantly from those with no deficits (z = 2.153, p = 0.541). There was no significant correlation between DHI and postural sway on posturography. Therefore, the DHI does not correlate with vestibular tests, and neither reflects the presence nor severity of peripheral vestibular deficits.

Cerebellar ataxia

The cerebellum plays an integral role in the control of limb and ocular movements, balance, and walking. Cerebellar disorders may be classified as sporadic or hereditary with clinical presentation varying with the extent and site of cerebellar damage and extracerebellar signs. Deficits in balance and walking reflect the cerebellum's proposed role in coordination, sensory integration, coordinate transformation, motor learning, and adaptation. Cerebellar dysfunction results in increased postural sway, hypermetric postural responses to perturbations and optokinetic stimuli, and postural responses that are poorly coordinated with volitional movement. Gait variability is characteristic and may arise from a combination of balance impairments, interlimb incoordination, and incoordination between postural activity and leg movement. Intrinsic problems with balance lead to a high prevalence of injurious falls. Evidence for pharmacologic management is limited, although aminopyridines reduce attacks in episodic ataxias and may have a role in improving gait ataxia in other conditions. Intensive exercises targeting balance and coordination lead to improvements in balance and walking but require ongoing training to maintain/maximize any effects. Noninvasive brain stimulation of the cerebellum may become a useful adjunct to therapy in the future. Walking aids, orthoses, specialized footwear and seating may be required for more severe cases of cerebellar ataxia.

Vestibular dysfunction and concussion

The assessment and treatment of sport-related concussion (SRC) often requires a multifaceted approach. Vestibular dysfunction represents an important profile of symptoms and pathology following SRC, with high prevalence and association with prolonged recovery. Signs and symptoms of vestibular dysfunction may include dizziness, vertigo, disequilibrium, nausea, and visual impairment. Identifying the central and peripheral vestibular mechanisms responsible for pathology can aid in management of SRC. The most common vestibular disturbances after SRC include benign paroxysmal positional vertigo, vestibulo-ocular reflex impairment, visual motion sensitivity, and balance impairment. A variety of evidence-based screening and assessment tools can help to identify the various types of vestibular pathology in SRC. When vestibular dysfunction is identified, there is emerging support for applying targeted vestibular rehabilitation to manage this condition.

Central vestibular disorder due to ischemic injury on the parieto-insular vestibular cortex in patients with middle cerebral artery territory infarction: Observational study

Central vestibular disorder is common after middle cerebral artery (MCA) territory infarction. The MCA supplies blood to the parieto-insular vestibular cortex (PIVC), a core region of central vestibular symptoms. We report on patients that sustained injuries of the core vestibular pathway to the PIVC with central vestibular disorder following MCA territory infarction, demonstrated on diffusion tensor imaging (DTI). Nineteen patients with MCA territory infarction and 12 control subjects were recruited. To reconstruct the core vestibular pathway to the PIVC, we defined seed region of interest (ROI) as vestibular nuclei of pons and target ROI as the PIVC. Fractional anisotropy (FA), mean diffusivity, and tract volume were measured. In the affected hemisphere, FA value of the core vestibular pathway to the PIVC revealed significant difference between all patient groups and the control group (P < .05). In contrast, patients with symptoms of ataxia only revealed significant decrement of tract volume compared with the control group (P < .05). Additionally, subgroup B revealed significant decrement of tract volume compared with that of subgroup A and the control group (P < .05). In the unaffected hemisphere, there was no significant difference in all DTI parameters between all patient groups and the control group (P < .05). Injury to the core vestibular pathway to the PIVC was demonstrated in patients that revealed typical central vestibular disorder following MCA territory infarction. Analysis of the core vestibular pathway to the PIVC using DTI would be beneficial in clinical evaluation and management of patients with MCA territory infarction.

The relationship between ground reaction force in sit-to-stand movement and lower extremity function in community-dwelling Japanese older adults using long-term care insurance services

[Purpose] The purpose of this study was to investigate which of the four chair-rising methods has low-load and the highest success rate, and whether the GRF parameters in that method are useful for measuring lower extremity function among physically frail Japanese older adults. [Subjects and Methods] Fifty-two individuals participated in this study. The participants voluntarily attempted four types of Sit-to-stand test (one variation without and three variations with the use of their arms). The following parameters were measured: peak reaction force (F/w), two force development rate parameters (RFD1.25/w, RFD8.75/w) and two time-related parameters (T1, T2). Three additional commonly employed clinical tests (One-leg balance with eyes open, Timed up and go and 5-meter walk test) were also conducted. [Results] “Hands on a chair” chair-rising method produced the highest success rate among the four methods. All parameters were highly reliable between testing occasions. T2 showed strongly significant associations with Timed up and go and 5-meter walk test in males. RFD8.75/w showed significant associations with Timed up and go and 5-meter walk test in females. [Conclusion] Ground reaction force parameters in the Sit-to-stand test are a reliable and useful method for assessment of lower extremity function in physically frail Japanese older adults.

Translation and validation of the dizziness handicap inventory in Greek language

OBJECTIVE

The aim of the study was to test the reliability and validity of the Dizziness Handicap Inventory in the Greek language (DHI).

DESIGN

This study was performed in a university tertiary centre. Internal consistency was estimated using Cronbach's alpha for the DHI, physical (DHI-P), functional (DHI-F) and emotional (DHI-E) subscale scores. Correlation between DHI (total and subscales) and the SOT (sensory organisation test) as well as correlation between the DHI and FGA (functional gait assessment) was tested using Spearman's correlation coefficient. Test-retest reliability was tested using ICC (Intraclass Correlation Coefficient).

SAMPLE SIZE

Ninety (90) patients were included in the study.

RESULTS

Internal consistency was excellent for the total score and very good for the physical functional and emotional subscale scores. No statistically significant correlation was found between SOT and DHI. There was a moderate correlation between FGA and total DHI scores (r = -0.472; p < 0.0001) and poor to moderate between FGA and DHI subscale scores (DHI-E r₁ = -0.342; p₁ = 0.001, DHI-F r₂ = -0.448 p₂ < 0.0001, DHI-P r₃ = -0.472 p₃ < 0.0001). Test-retest reliability was excellent.

CONCLUSION

Greek version of DHI is recommended as a valid measure for patients with vestibular disorders.

Effects of Vestibular Rehabilitation on Balance Control in Older People with Chronic Dizziness: A Randomized Clinical Trial

OBJECTIVE

The aim of this study was to compare the effects of vestibular rehabilitation protocols on balance control in elderly with dizziness.

DESIGN

This is a randomized clinical trial with 3-mo follow-up period. The sample was composed of 82 older individuals with chronic dizziness from vestibular disorders. The control group was treated according to the Conventional Cawthorne & Cooksey protocol (n = 40), and the experimental group was submitted to a Multimodal Cawthorne & Cooksey protocol (n = 42). Measures included Dynamic Gait Index, fall history, hand grip strength, Time Up-and-Go Test, sit-to-stand test, multidirectional reach, and static balance tests.

RESULTS

With the exception of history of falls, Forward Functional Reach, Unipedal Right and Left Leg Eyes Closed, and Sensorial Romberg Eyes Open, all outcomes improved after treatments. Such results persisted at follow-up period, with the exception of the Tandem Eyes Open and the Timed Up-and-Go manual. The between-group differences for Sensorial Romberg Eyes Closed (4.27 secs) and Unipedal Left Leg Eyes Open (4.08 secs) were significant after treatment, favoring the Multimodal protocol.

CONCLUSIONS

Both protocols resulted in improvement on elderly's balance control, which was maintained during a short-term period. The multimodal protocol presented better performance on specific static balance tests.

Is customized vestibular rehabilitation effective in patients with Parkinson's?

BACKGROUND

Patients with Parkinson's disease complain about restrictions in their daily life activities and impairment in their mobility and balance.

OBJECTIVE

The aim of this study was to compare the effects of vestibular rehabilitation on functioning, quality of life, balance, and postural stability in patients with Parkinson's disease.

METHODS

The patients with Parkinson's disease divided into a rehabilitation group (Group 1, n: 29) and a control group(Group 2, n: 11). All patients were evaluated before and after eight weeks of customized vestibular rehabilitation for motor score (Unified Parkinson's Disease Rating Scale); quality of life (Parkinson's Disease Questionnaire-39); balance (Activities-Specific Balance Confidence Scale [ABC], Timed Up and Go Test, Dynamic Gait Index [DGI], and Berg Balance Scale [BBS]); and postural stability (Modified Clinical Test for Sensory Interaction on Balance [mCTSIB].

RESULTS

There were significant differences in the pre- and post-exercise ABC, BBS, and DGI scores in Group 1 (p <  0.05). A statistically significant impairment was observed in mCTSIB (firm and foam eyes closed [EC]) in the control group (p <  0.05). There were no significant intergroup differences in any of the parameters evaluated (p >  0.05).

CONCLUSION

In this study, vestibular rehabilitation was found to be effective for improving balance in patients with Parkinson's disease.

Relationship Between Cognitive Assessment and Balance Measures in Adolescents Referred for Vestibular Physical Therapy After Concussion

OBJECTIVE

To examine the relationship between cognitive and balance performance in adolescents with concussion.

DESIGN

Retrospective case series.

SETTING

Tertiary.

PATIENTS

Sixty patients.

INTERVENTIONS

Correlation analyses were performed to describe the relationship between symptoms, cognitive measure, and balance measure at the time of initiation of vestibular physical therapy.

MAIN OUTCOME MEASURES

Cognitive performance was assessed using the Immediate Post-concussion Assessment and Cognitive Testing (ImPACT). The dizziness and balance function measures included dizziness severity rating, Activities-specific Balance Confidence scale (ABC), Dizziness Handicap Inventory (DHI), Functional Gait Assessment, gait speed, Timed "UP and GO," Five Times Sit to Stand, and Sensory Organization Test (SOT). To account for multiple comparisons, the False Discovery Rate method was used.

RESULTS

Performance measures of balance were significantly correlated with cognitive measures. Greater total symptom scores were related to greater impairment in the ABC and DHI (r = 0.35-0.39, P ≤ 0.008) and worse performance in condition 2 of the SOT (r = -0.48, P = 0.004). Among the ImPACT composite scores, lower memory scores were correlated with impaired balance performance measures (r = 0.37-0.59, P ≤ 0.012). Lower visual memory was also correlated with worse ABC scores.

CONCLUSIONS

The significant relationships reported between the cognitive performance scores and balance measures may reflect that similar levels of functioning exist across domains in individuals with protracted recovery who receive vestibular physical therapy.

CLINICAL RELEVANCE

The weak-to-moderate relationships warrant the continuous use of multiple domains of assessment. A better understanding to the relationships between the domains of functioning after concussion may improve the overall management approach for adolescents with concussion.

An overview of vestibular rehabilitation

Data related to the efficacy of vestibular rehabilitation and its evolution as an intervention are provided. Concepts and various treatment strategies are described, with explanations of why people with uncompensated peripheral and central vestibular disorders might improve with rehabilitation. Various tests and measures are described that are commonly used to examine patients and determine their level of ability to participate in their environment. Factors that affect recovery, both positively and negatively, are described in order to better prognosticate recovery. A case utilizing many of the principles discussed is included to provide insight into how to utilize vestibular rehabilitation with a person with an uncompensated peripheral vestibular loss.

Cross-cultural adaptation and measurement properties of the Arabic version of the Fall Efficacy Scale International

OBJECTIVE

To translate the Falls Efficacy Scale International (FES-I) into Arabic according to the World Health Organization`s (WHO) criteria and to evaluate the concurrent validity of the FES-I in persons living with balance and vestibular disorders.

METHODS

This cross-sectional descriptive study included 43 persons with balance and vestibular disorders presenting to an outpatient dizziness center at King Abdulaziz University Hospital, Riyadh, Kingdom of Saudi Arabia between June 2012 and May 2013. All participants completed the Arabic version of the FES-I and the Dizziness Handicap Inventory (DHI) during their assessment with the clinical audiologist. In addition, subjects completed the Dynamic Gait Index 4-item (DGI-4) gait test. An additional 55 control participants also completed the Arabic FES-I, the DGI-4, and the Arabic DHI.

RESULTS

Forty-three participants with vestibular disorders (36 females, 7 males) with a mean age of 32 years (standard deviation (SD) 10 years, range 18-56 years) and 55 control participants (27 females, 28 males) with a mean age of 33, (SD-12), and age range of 18-78 participated. The correlation between the Arabic FES-I and the Arabic DHI was 0.75 in patients and 0.77 in control participants. The correlation between the Arabic FES-I and the DGI-4 was r=-0.30 (p=0.003).

CONCLUSION

The Arabic FES-I has established concurrent validity and may be helpful for measuring an individual`s concern of falling in people with vestibular and balance disorders.

Long-term outcome of vertigo and dizziness associated disorders following treatment in specialized tertiary care: the Dizziness and Vertigo Registry (DiVeR) Study

To investigate the long-term outcome of interdisciplinary treatment in a tertiary care neuro-otology institution after 2 years as part of the Dizziness and Vertigo Registry study. Risk factors associated with unfavourable outcome were assessed. 3113 consecutive patients with disorders of vertigo and dizziness were recruited prospectively between March 2010 and February 2012. Patients were clinically assessed and treated according to their diagnosis. Standardized instruments were used at baseline and at 2-year follow-up [Dizziness Handicap Inventory (DHI), Quality of Life Questionnaire, General Depression Scale, Stait-Trait Anxiety Index], as well as a custom health-related questionnaire. The primary outcome variable of this observational study was the change in DHI after 2 years. Patients suffered from phobic postural vertigo (23%), benign peripheral paroxysmal vertigo (14.4%), unilateral vestibulopathy (10.5%), central vestibular disorders (8%), Menière's disease (9.8%), vestibular migraine (6.9%), bilateral vestibulopathy (5.5%), and vestibular paroxysmia (3.1%). Mean disease duration was 4.6 ± 6.3 years. 1272 patients were available for follow-up, 1159 completed the DHI score. 72.1% of patients improved in DHI score from baseline to 2 years follow-up. Mean reduction in DHI score was 14 points (p = 0.02). Long-term outcome following diagnosis and treatment in a specialized tertiary care centre is good and persistent after 2 years. Risk factors for an unfavourable outcome were advanced age, severe disability, constant vertigo or dizziness, and concomitant back pain, while depression and anxiety did not contribute to this risk considerably.

Vestibular assessment: a practical approach

This paper presents an evidence-based introduction to assessing and managing the dizzy patient. It is based upon a literature review highlighting current best practice and the clinical experience of the author. Dizziness is common, often chronic and largely untreated, resulting in great personal and economic loss. Serious pathological causes of dizziness may be quickly and effectively screened by a simple ocular motor examination, differentiating these from peripheral vestibular lesions. A triage, differentiating dizziness into either acute onset, intermittent episodes or continuous symptoms is proposed, along with management strategies for the commonest causes of dizziness. Vestibular suppressant medication should be restricted to the acute phase of a vestibular episode. Vestibular rehabilitation therapy is the most effective treatment for continuous or chronic dizziness.