Vestibular Rehabilitation for Children

Consequences of vestibular hypofunction in children with ADHD/DCD

BACKGROUND

Children with Attention Deficit Hyperactivity Disorder (ADHD) demonstrate a heterogeneous sensorimotor, emotional, and cognitive profile. Comorbid sensorimotor imbalance, anxiety, and spatial disorientation are particularly prevalent among their non-core symptoms. Studies in other populations presented these three comorbid dysfunctions in the context of vestibular hypofunction.

OBJECTIVE

To test whether there is a subgroup of children with ADHD who have vestibular hypofunction presenting with concomitant imbalance, anxiety, and spatial disorientation.

METHODS

Children with ADHD-only (n = 28), ADHD + Developmental Coordination Disorder (ADHD + DCD; n = 38), and Typical Development (TD; n = 19) were evaluated for vestibular function by the Dynamic Visual Acuity test (DVA-t), balance by the Bruininks-Oseretsky Test of motor proficiency (BOT-2), panic anxiety by the Screen for Child Anxiety Related Emotional Disorders questionnaire-Child version (SCARED-C), and spatial navigation by the Triangular Completion test (TC-t).

RESULTS

Children with ADHD vs. TD presented with a high rate of vestibular hypofunction (65 vs. 0 %), imbalance (42 vs. 0 %), panic anxiety (27 vs. 11 %), and spatial disorientation (30 vs. 5 %). Children with ADHD + DCD contributed more frequent and severe vestibular hypofunction and imbalance than children with ADHD-only (74 vs. 54 %; 58 vs. 21 %, respectively). A concomitant presence of imbalance, anxiety, and spatial disorientation was observed in 33 % of children with ADHD, all sharing vestibular hypofunction.

CONCLUSIONS

Vestibular hypofunction may be the common pathophysiology of imbalance, anxiety, and spatial disorientation in children. These comorbidities are preferentially present in children with ADHD + DCD rather than ADHD-only, thus likely related to DCD rather than to ADHD disorder. Children with this profile may benefit from a vestibular rehabilitation intervention.

The Technology to Enhance Patient Motivation in Virtual Reality Rehabilitation: A Review

Virtual reality (VR) technology has experienced a steady rise and has been widely applied in the field of rehabilitation. The integration of VR technology in rehabilitation has shown promising results in enhancing their motivation for treatment, thereby enabling patients to actively engage in rehab training. Despite the advancement, there is a dearth of comprehensive summary and analysis on the use of VR technology to enhance patient motivation in rehabilitation. Thus, this narrative review aims to evaluate the potential of VR technology in enhancing patient motivation during motor rehabilitation training. This review commences with an explanation of how enhancing motivation through the VR rehabilitation system could improve the efficiency and effectiveness of rehabilitation training. Then, the technology was analyzed to improve patient motivation in the present VR rehabilitation system in detail. Furthermore, these technologies are classified and summarized to provide a comprehensive overview of the state-of-the-art approaches for enhancing patient motivation in VR rehabilitation. Findings showed VR rehabilitation training utilizes game-like exercises to enhance the engagement and enjoyment of rehabilitation training. By immersing patients in a simulated environment with multisensory feedback, VR systems offer a unique approach to rehabilitation that can lead to improved patient motivation. Both ultimately lead to improved patient outcomes, which is not typically achievable with traditional rehabilitation methods. The review concludes that VR rehabilitation presents an opportunity to improve patient motivation and adherence to long-term rehabilitation training. However, to further enhance patient self-efficacy, VR rehabilitation should integrate psychology and incorporate methods. Moreover, it is necessary to build a game design theory for rehabilitation games, and the latest VR feedback technology should also be introduced.

Postural Sway Velocity of Deaf Children with and without Vestibular Dysfunction

BACKGROUND

Sensory information obtained from the visual, somatosensory, and vestibular systems is responsible for regulating postural control, and if damage occurs in one or more of these sensory systems, postural control may be altered.

OBJECTIVE

To evaluate and compare the postural sway velocity between children with normal hearing and with sensorineural hearing loss (SNHL), matched by sex and age group, and to compare the postural sway velocity between children with normal hearing and with SNHL, with and without vestibular dysfunction.

METHODS

Cross-sectional study that evaluated 130 children (65 with normal hearing and 65 with SNHL), of both sexes and aged between 7 and 11 years, from public schools of the city of Caruaru, Pernambuco state, Brazil. The postural sway velocity of the center of pressure (COP) was assessed by a force platform, in two directions, anteroposterior (AP) and mediolateral (ML)), in three positions, namely bipedal support with feet together and parallel (parallel feet (PF)), bipedal support with one foot in front of the other (tandem foot (TF)), and single-leg support (one foot (OF)), evaluated with the eyes open and closed.

RESULTS

Children with SNHL demonstrated greater postural sway velocity compared to children with normal hearing in all the positions evaluated, with significant differences in the AP direction, with the eyes open (PF: p = 0.001; TF: p = 0.000; OF: p = 0.003) and closed (PF: p = 0.050; TF: p = 0.005). The same occurred in the ML direction, with the eyes open (PF: p = 0.001; TF: p = 0.000; OF: p = 0.001) and closed (PF: p = 0.002; TF: p = 0.000). The same occurred in relation to vestibular function, where the children with SNHL with an associated vestibular dysfunction demonstrated greater postural sway velocity compared to children with normal hearing in all the positions evaluated, demonstrating significant differences in the AP direction, with the eyes open (TF: p = 0.001; OF: p = 0.029) and eyes closed (PF: p = 0.036; TF: p = 0.033). The same occurred in the ML direction, with the eyes open (TF: p = 0.000) and with the eyes closed (PF: p = 0.008; TF: p = 0.009).

CONCLUSIONS

Children with SNHL demonstrated greater instability of postural control than children with normal hearing in all the directions assessed. Children with SNHL and an associated vestibular dysfunction demonstrated the greatest instability of postural control in this study.

Vestibular Impairment and Postural Development in Children With Bilateral Profound Hearing Loss

Importance

Children with profound hearing loss (HL) and vestibular impairment have worse cochlear implant outcomes compared with those without vestibular impairment. However, the decision for cochlear implantation is rarely based on vestibular function assessment as a complement to audiologic testing.

Objectives

To identify the prevalence of vestibular impairment according to HL origin and to assess the association between vestibular impairment and delayed posturomotor development in children with profound HL.

Design, Setting, and Participants

This cohort study was conducted in a pediatric referral center for cochlear implantation in Paris, France, using medical records data on HL origin, vestibular assessment, and ages of developmental milestone achievement. The cohort included children with profound HL (loss >90 dB HL) who completed vestibular assessment prior to cochlear implantation between January 1, 2009, and December 31, 2019. Data analyses were conducted between January and June 2023.

Main Outcomes and Measures

The primary outcome was prevalence of vestibular impairment according to HL origin. Children were classified into 3 groups according to their responses to vestibular testing: normal vestibular function (NVF), partially impaired vestibular function (PVF), and complete bilateral vestibular loss (CBVL). Generalized logit models were performed to evaluate the association between vestibular impairment and causes of HL as well as posturomotor development delay.

Results

A total of 592 children were included (308 males [52.0%]; mean [SD] age, 38 [34] months). In children with documented HL origin (n = 266), 45.1% (120) had HL with genetic origin, 50.0% of which were syndromic (mainly Usher and Waardenburg syndromes) and 50.0% were nonsyndromic (mainly associated with connexin 26). Among patients with infectious HL origin (n = 74), 70.3% (52) had cytomegalovirus (CMV) infection. Vestibular impairment was found in 44.4% (263 of 592) of the children; it was mostly symmetrical in 88.9% (526) and was CBVL in 5.7% (34) of the cases. Vestibular impairment was present in 78.3% (47) of children with genetic syndromic HL (56.7% [34] with PVF; 21.7% [13] with CBVL) and in 69.2% (36) of children with CMV infection (57.7% [30] with PVF; 11.5% [6] with CBVL). Genetic syndromic HL origin was found to be more often associated with both PVF and CBVL than other HL causes. The odds of having delays in 4 developmental milestones (head holding, sitting, standing with support, and independent walking) were higher in both PVF and CBVL (eg, head-holding odds ratios: 2.55 and 4.79) compared with NVF, and the age of achieving these milestones was higher in CBVL than PVF (eg, head holding: 7.33 vs 4.03 years; P < .001). All 4 developmental milestones were associated with the degree of vestibular impairment.

Conclusions and Relevance

This cohort study found that among children with profound HL, vestibular impairment was prevalent, varied according to HL origin, and associated with posturomotor development; while all developmental milestones were associated with vestibular impairment severity, not all HL causes were associated with vestibular impairment severity. Children with profound HL may benefit from complete vestibular assessment before cochlear implantation, which would support early and adapted management, such as physical therapy for CBVL and cochlear implantation strategy.

Guidelines of the French Society of Otorhinolaryngology and Head and Neck Surgery (SFORL) for vestibular rehabilitation in children with vestibular dysfunction. A systematic review

INTRODUCTION

The consequence of complete or partial uncompensated vestibular dysfunction in children is usually balance disorders, with the risk of falls and increased fatigue, particularly during tasks requiring postural control. The aim of these recommendations is to establish guidelines for vestibular rehabilitation (VR) in children with vestibular impairment.

MATERIAL AND METHODS

The guidelines were developed based on a systematic review of the international literature, validated by a multidisciplinary group of French-speaking otorhinolaryngologists, scientists, and physiotherapists. They are classified as grade A, B, C, or expert opinion according to a decreasing level of scientific evidence.

RESULTS

A PubMed search of studies published between January 1990 and December 2021 was carried out using the keywords "vestibular," "rehabilitation," and "children". After filtering and reviewing the articles, a total of 10 publications were included to establish the recommendations.

CONCLUSION

It is recommended that a vestibular assessment be carried out before VR, including a study of vestibulo-ocular reflex, otolithic function, and postural control. In cases of vestibular dysfunction, physiotherapy treatment is recommended from an early age to train different aspects of postural control, including anticipatory and reactive postural adjustments. VR adapted to the pediatric population is recommended for children whose vestibular dysfunction leads to functional disorders or symptoms of vertigo for those who have suffered head trauma. It is recommended that children with bilateral vestibular impairment be treated using gaze stabilization exercises for adaptation and substitution. Optokinetic stimulation and virtual reality are not recommended for children and young adolescents.

Developing a serious game for gaze stability rehabilitation in children with vestibular hypofunction

BACKGROUND

Children with vestibular hypofunction (VH) may have gaze instability, balance disorders, and delayed postural-motor development. Gaze stabilization exercises (GSE) are designed to improve dynamic visual acuity (DVA). We aimed to assess the acceptability of a serious game prototype called Kid Gaze Rehab (KGR) designed to implement GSE training in children with VH, combined with traditional vestibular rehabilitation. Effects on DVA and motor performance were also analyzed.

METHODS

Twelve children (6 to 9 years old) were included. Sessions were held at the hospital twice a week, for 5 weeks. An adapted French version of The Child Simulator Sickness Questionnaire (SSQ) and the Face Scale Pain-Revised (FPS-R) were used to assess pain in the cervical region and undesirable side effects after each session. Vestibular and motor function parameters (active and passive DVA and Movement Assessment Battery for Children-Second Edition, MABC-2) were assessed before and after the training.

RESULTS

All children included completed the 10 sessions. The FPS-R visual analog scale and SSQ showed good cervical tolerance and no oculomotor or vegetative adverse effects nor spatial disorientation. After training, active DVA scores were significantly improved for the right, left, and up directions (p < 0.05). Passive DVA scores were significantly improved for the left and down directions (p < 0.01 and p < 0.05, respectively). MABC-2 scores were improved in the balance and ball skill sections (p < 0.05).

CONCLUSION

An innovative pediatric training method, the use of a dedicated serious game for gaze stabilization was well-tolerated as a complement to conventional vestibular rehabilitation in children with VH. Moreover, both DVA and motor performance were found to improve in the study sample. Although replication studies are still needed, serious game-based training in children with VH could represent a promising rehabilitation approach for years to come.

TRIAL REGISTRATION

The study was conducted in accordance with the Declaration of Helsinki and approved by an Institutional Review Board (local ethics committee, CPP Sud-Est IV, ID 2013-799). The study protocol was registered on ClinicalTrials.gov (NCT04353115).

Does the Dizziness Handicap Inventory-Children and Adolescents (DHI-CA) Demonstrate Properties to Support Clinical Application in the Post-Concussion Population: A Rasch Analysis

The purpose of this cross-sectional validation study was to evaluate the clinical utility of the DHI-CA by (1) examining its dimensionality using exploratory factor analysis (EFA) and (2) calibrating DHI-CA items (using the multidimensional Rasch model) to obtain item difficulty levels. A retrospective chart review was conducted for 132 patients between the ages of 8 and 18 years (mean age = 15.3 ± 2.1 years) from a multidisciplinary post-concussion management tertiary center. Data were extracted on age, sex, and DHI-CA. EFA revealed that 12 out of 25 items did not fit in the subscale that they were originally described under, indicating poor dimensionality. Calibration of items on the Wright Maps revealed that 50% of the items pooled in the lower difficulty level, indicating a potential ceiling effect. Corrected item-rest correlations for the physical, emotional, walking/mobility, and community participation ranged from 0.44-0.66, 0.27-0.61, 0.54-0.57, and 0.32-0.69 (p < 0.001), respectively. The clinical utility of the DHI-CA was found to be questionable due to the presence of double-barreled items and the ceiling effect. Clinicians must supplement data from the DHI-CA with other measures and patient interviews to make informed clinical decisions specific to the post-concussion population until new, robust, and valid measures are developed.

Pediatric Vestibular Assessment: Clinical Framework

OBJECTIVES

Although vestibular deficits can have severe repercussions on the early motor development in children, vestibular assessment in young children has not yet been routinely integrated in clinical practice and clear diagnostic criteria to detect early vestibular deficits are lacking. In young children, specific adjustments of the test protocol are needed, and normative data are age-dependent as the vestibular pathways mature through childhood. Therefore, this study aims to demonstrate the feasibility of an extensive age-dependent vestibular test battery, to provide pediatric normative data with the concurrent age trends, and to offer a clinical framework for pediatric vestibular testing.

DESIGN

This normative study included 133 healthy children below the age of 4 years (mean: 22 mo, standard deviation: 12.3 mo, range: 5-47 mo) without history of hearing loss or vestibular symptoms. Children were divided into four age categories: 38 children younger than 1 year old, 37 one-year olds, 33 two-year olds, and 25 three-year olds. Children younger than 3 years of age were examined with the video Head Impulse Test (vHIT) of the horizontal semicircular canals, cervical vestibular evoked myogenic potentials (cVEMP) with bone conduction stimuli, and the rotatory test at 0.16, 0.04, and 0.01 Hz. In 3-year old children, the vHIT of the vertical semicircular canals and ocular vestibular evoked myogenic potentials (oVEMP) using a minishaker were added to the protocol.

RESULTS

The horizontal vHIT appeared to be the most feasible test across age categories, except for children younger than 1-year old in which the success rate was the highest for the cVEMP. Success rates of the rotatory test varied the most across age categories. Age trends were found for the vHIT as the mean vestibulo-ocular reflex (VOR) gain increased significantly with age (r = 0.446, p < 0.001). Concerning the cVEMP, a significant increase with age was found for latency P1 (r = 0.420, p < 0.001), rectified interpeak amplitude P1-N1 (r = 0.574, p < 0.001), and averaged electromyographic (EMG) activity (r = 0.430, p < 0.001), whereas age trends for the latency N1 were less pronounced (r = 0.264, p = 0.004). Overall, the response parameters of the rotatory test did not show significant age effects ( p > 0.01), except for the phase at 0.01 Hz (r = 0.578, p < 0.001). Based on the reported success rates and age-dependent normative vestibular data, straightforward cutoff criteria were proposed (vHIT VOR gain < 0.7, cVEMP rectified interpeak amplitude < 1.3, oVEMP interpeak amplitude < 10 µV) with accompanying clinical recommendations to diagnose early vestibular impairment.

CONCLUSIONS

In this large cohort of typically developing children below the age of 4 years, the vHIT and cVEMP were the most feasible vestibular tests. Moreover, the age-dependent normative vestibular data could specify age trends in this group of young children. Finally, based on the current results and clinical experience of more than ten years at the Ghent University Hospital (Belgium), a clinical framework to diagnose early vestibular deficits in young patients is proposed.

Vestibular Infant Screening-Flanders: What is the Most Appropriate Vestibular Screening Tool in Hearing-Impaired Children?

OBJECTIVES

As children with sensorineural hearing loss have an increased risk for vestibular impairment, the Vestibular Infant Screening-Flanders project implemented a vestibular screening by means of cervical vestibular evoked myogenic potentials (cVEMP) at the age of 6 months for each child with hearing loss in Flanders (Belgium). Given that vestibular deficits can affect the child's development, this vestibular screening should allow early detection and intervention. However, less is currently known about which screening tool would be the most ideal and how vestibular impairment can evolve. Therefore, this study aimed to determine the most appropriate tool to screen for vestibular deficits, to assess the necessity of vestibular follow-up, and to set clinical guidelines for vestibular screening in children with hearing loss.

DESIGN

In total, 71 children with congenital or early-onset sensorineural hearing loss were enrolled (mean age at first appointment = 6.7 months). Follow-up was provided at 6 months, 1, 2, and 3 years of age. Below three years of age, the video Head Impulse Test (vHIT) of the horizontal semicircular canals (SCC), the cVEMP, and the rotatory test at 0.16, 0.04, and 0.01 Hz were applied. At 3 years of age, the vHIT of the vertical SCC and ocular vestibular evoked myogenic potentials (oVEMP) were added. To evaluate early motor development, the Alberta Infant Motor Scale (AIMS) results at 6 months and 1-year old were included.

RESULTS

At 6 months of age, the highest success rate was obtained with the cVEMP (90.0%) compared to the vHIT (70.0%) and the rotatory test (34.3-72.9%). Overall, vestibular deficits were found in 20.0% of the children, consisting of 13.9% with both SCC and otolith deficits (bilateral: 9.3%, unilateral: 4.6%), and 6.1% with unilateral isolated SCC (4.6%) or otolith (1.5%) deficits. Thus, vestibular deficits would not have been detected in 4.6% of the children by only using the cVEMP, whereas 1.5% would have been missed when only using the vHIT. Although vestibular deficits were more frequently found in severe to profound hearing loss (28.6%), characteristics of vestibular function were highly dependent on the underlying etiology. The AIMS results showed significantly weaker early motor development in children with bilateral vestibular deficits ( p = 0.001), but could not differentiate children with bilateral normal vestibular function from those with unilateral vestibular deficits ( p > 0.05). Progressive or delayed-onset vestibular dysfunction was only found in a few cases (age range: 12-36 months), in which the hearing loss was mainly caused by congenital cytomegalovirus (cCMV).

CONCLUSIONS

The cVEMP is the most feasible screening tool to assess vestibular function in 6-months-old children with hearing loss. Although the majority of children with vestibular deficits are detected with the cVEMP, the vHIT seems even more sensitive as isolated SCC deficits are associated with specific etiologies of hearing loss. As a result, the cVEMP is an appropriate vestibular screening tool, which is advised at least in severe to profound hearing loss, but certain etiologies require the addition of the vHIT (i.e., cCMV, meningitis, cochleovestibular anomalies with or without syndromic hearing loss).

Effectiveness and acceptance of Vestibulo-Ocular Reflex adaptation training in children with recurrent vertigo with unilateral vestibular dysfunction and normal balance function

Objective

This was a block randomized controlled study to evaluate the effectiveness and acceptance of Vestibulo-Ocular Reflex (VOR) adaptation training in children with recurrent vertigo with unilateral vestibular dysfunction (UVD) and normal balance function.

Methods

Thirty children, aged 4-13 years, diagnosed with recurrent vertigo of childhood (RVC) with UVD (according to a caloric test) and normal balance function were analyzed. These 30 children were divided into 10 blocks based on similar age and severity of vertigo. Three children in each block were randomly assigned to one of three groups to receive 1 month of treatment. Group A received vestibular-ocular reflex (VOR) adaptation training, Group B received Cawthorne-Cooksey training, and a control group received no training. All children were administered pharmacotherapy [Ginkgo biloba leaf extract (drops)]. The Dizziness Handicap Inventory (DHI), Visual Analog Scale of Quality of Life with Vertigo (VAS-QLV), and canal paralysis (CP) on the caloric test were recorded before and after treatment, and the effectiveness of treatment was evaluated. The Visual Analog Scale of Acceptance (VAS-A) was used to evaluate the acceptance of the training in the two groups that received training.

Results

There were 10 children each in Group A, Group B, and the control group; the male to female ratio was 1, and the average age in each group was 9.0 ± 3.2, 8.4 ± 3.0, and 8.3 ± 2.6 years, respectively. The effective rate was 100% in Group A, 65% in Group B, and 60% in Group C. The recovery rate on caloric testing after treatment was 100, 70, and 50%, respectively. DHI scores before and after training were 56.8 ± 12.4 and 8.8 ± 6.1 in Group A, 57.8 ± 12.6 and 18.8 ± 9.7 in Group B, and 56.8 ± 12.4 and 24.0 ± 15.3 in Group C (all P = 0.000). VAS-QLV scores before and after training were 7.5 ± 1.0 and 0.9 ± 0.9 in Group A, 6.4 ± 2.2 and 2.7 ± 1.1 in Group B, and 6.6 ± 1.6 and 2.6 ± 1.4 in Group C (all P < 0.05). The CP values before and after training were 35.7 ± 15.1 and 12.9 ± 8.7 in Group A, 33.6 ± 20.1 and 23.6 ± 19.3 in Group B, and 38.6 ± 21.1 and 24.8 ± 17.9 in Group C (P = 0.001, P = 0.015, and P = 0.050, respectively). Between-group comparisons showed that the decreases in DHI and VAS-QLV scores after training were significantly different (P = 0.015, P = 0.02), while CP values were not (P = 0.139). After training, the DHI value had decreased significantly more in Group A compared with Group C (P < 0.05), but there were no other differences. After training, VAS-QLV scores in Group A had decreased significantly more compared with Group B and C (P < 0.05). In terms of acceptance, the VAS-A score was 7.6 ± 2.2 in Group A and 3.1 ± 2.8 in Group B (P =0.004), The acceptance rate was 70% in group A and 10% in group B. there was no significant correlation between age and VAS-A in either group A or group B (P > 0.05).

Conclusion

This study strongly suggests that vestibular rehabilitation training should be performed in children with vertigo to improve symptoms. For children with RVC with UVD but normal balance function, a single VOR adaptation program can effectively improve vertigo symptoms, and given its simplicity, time-effectiveness, and excellent outcomes, it is associated with better acceptance in children compared to classic Cawthorne-Cooksey training.

The Effects of Vestibular Rehabilitation on Kinesiophobia and Balance with Individuals Who has Vestibular Hypofunction

 The study aimed to examine the effects of vestibular rehabilitation on kinesiophobia, quality of life, dynamic visual acuity, and balance. Thirty vestibular hypofunction patients aged 18-65 years who were diagnosed by videonystagmography (VNG) voluntarily participated in the study. Before and after treatment Tampa Kinesiophobia Scale, World Health Organization Quality of Life Scale-Turkish Short Form, Tandem Stance Test, Dynamic Visual Acuity, Visual Analog Scale to measure dizziness, Subjective Visual Vertical and Subjective for verticality and horizontality perception Visual Horizontal tests were applied. The exercise program was applied for 8 weeks. Patients were observed in the hospital every two weeks. The exercises given in the session were given as home exercises, 3 times a day, for 10 repetitions. As a result of the study, statistical correlations were found tandem stance test, subjective visual vertical and subjective visual horizontal tests for the perception of verticality and horizontality, visual analog scale to measure the severity of dizziness, dynamic visual acuity, quality of life and tampa kinesiophobia scales (p < 0.05). It can be said that vestibular rehabilitation improves the quality of life, balance, dynamic visual acuity, and overcomes kinesiophobia in patients. Trial registration number: NCT05070936, Date of registration:10/06/2021 (Retrospectively registered).

Evaluation and management of paediatric vertigo

PURPOSE OF REVIEW

This review summarizes the most current information on cause, evaluation and treatment of dizziness in children.

RECENT FINDINGS

There has been an increased understanding of the multifactorial cause of dizziness in the paediatric population. Quantitative vestibular testing is increasingly used and valuable as a diagnostic adjunct. Vestibular rehabilitation, migraine hygiene, psychological therapies, pharmaceuticals and/or surgery can be used as well tolerated and effective treatments for vertigo in children and adolescents when tailored to cause.

SUMMARY

Paediatric vertigo can be effectively evaluated through careful history taking and physical examination along with adjunctive tests, such as vestibular testing and audiometry, when appropriate. Options for treatment of vestibular disorders in children and adolescents have greatly expanded in recent years allowing for the effective management of nearly all cases of paediatric vertigo, though a multimodal and/or multidisciplinary approach is often needed.

[To address on the refined and individualized comprehensive evaluation of inner ear function]

Auditory and vestibular function detection technology is the premise and key to the diagnosis and management for inner ear diseases. Concurrent damage to the auditory and vestibular system occurs in many inner ear diseases. The general points and issues on hearing and vestibular function tests, as well as the clinical significance of refined and individualized comprehensive evaluation of inner ear function are described in this paper.

Pediatric Sports-Related Concussion: An Approach to Care

Sports-related concussion (SRC) is a common sports injury in children and adolescents. With the vast amount of youth sports participation, an increase in awareness of concussion and evidence that the injury can lead to consequences for school, sports and overall quality of life, it has become increasingly important to properly diagnose and manage concussion. SRC in the student athlete is a unique and complex injury, and it is important to highlight the differences in the management of child and adolescent concussion compared with adults. This review focuses on the importance of developing a multimodal systematic approach to diagnosing and managing pediatric sports-related concussion, from the sidelines through recovery.

Vestibular and balance dysfunction in children with congenital CMV: a systematic review

OBJECTIVE

This systematic review evaluates vestibular and balance dysfunction in children with congenital cytomegalovirus (cCMV), makes recommendations for clinical practice and informs future research priorities.

DESIGN

MEDLINE, Embase, EMCARE, BMJ Best Practice, Cochrane Library, DynaMed Plus and UpToDate were searched from inception to 20 March 2021 and graded according to Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) criteria.

PATIENTS

Children with cCMV diagnosed within 3 weeks of life from either blood, saliva and/or urine (using either PCR or culture).

INTERVENTION

Studies of vestibular function and/or balance assessments.

MAIN OUTCOME MEASURES

Vestibular function and balance.

RESULTS

1371 studies were identified, and subsequently 16 observational studies were eligible for analysis, leading to an overall cohort of 600 children with cCMV. All studies were of low/moderate quality. In 12/16 studies, vestibular function tests were performed. 10/12 reported vestibular dysfunction in ≥40% of children with cCMV. Three studies compared outcomes for children with symptomatic or asymptomatic cCMV at birth; vestibular dysfunction was more frequently reported in children with symptomatic (22%-60%), than asymptomatic cCMV (0%-12.5%). Two studies found that vestibular function deteriorated over time: one in children (mean age 7.2 months) over 10 months and the other (mean age 34.7 months) over 26 months.

CONCLUSIONS

Vestibular dysfunction is found in children with symptomatic and asymptomatic cCMV and in those with and without hearing loss. Audiovestibular assessments should be performed as part of neurodevelopmental follow-up in children with cCMV. Case-controlled longitudinal studies are required to more precisely characterise vestibular dysfunction and help determine the efficacy of early supportive interventions.

PROSPERO REGISTRATION

CRD42019131656.

Feasibility and Preliminary Effects of a 1-Week Vestibular Rehabilitation Day Camp in Children with Developmental Coordination Disorder

AIM

This pilot study investigated the feasibility and preliminary effects of an intensive 1-week day camp program for children with Developmental Coordination Disorder (DCD) that focused on vestibular rehabilitation.

METHODS

Ten participants (6-10 years) were assessed twice pre-intervention, post intervention, and at 8-week follow-up. Videonystagmography, Video Head Impulse Tests (vHIT), and Modified Emory Clinical Vestibular Chair Test (m-ECVCT) test were assessed at baseline. Outcomes measures were gaze stability (Dynamic Visual Acuity; DVA), functional gait (Functional Gait Assessment; FGA), balance (Sensory Organization Test), motor function (Bruininks-Oseretsky Test), and participation (Miller Function and Participation).

RESULTS

No abnormal results were detected from the videonystagmography, vHIT and m-ECVCT. There was a 100% attendance rate at the camp and assessment sessions. FGA scores significantly improved following intervention and changes were maintained at follow-up. The number of children with abnormal DVA scores decreased from 3 to 1 to 0 between pre-intervention, post-intervention, and follow-up. There were no significant changes in any of the other outcomes following intervention.

CONCLUSIONS

Intensive vestibular rehabilitation delivered in a day camp format is feasible and show positive preliminary effects on functional gait and dynamic visual acuity in children with DCD.

Vestibular testing in children - The suppression head impulse (SHIMP) test

INTRODUCTION

The incidence of vestibular disorders and vertigo during childhood is increasing and pediatric clinicians have become more sensitive to children's balance disorders; thus, there is a need for appropriate detection test procedures for peripheral vestibular hypofunction. In order to ensure a reliable diagnosis and minimize misdiagnosis, a standardized clinical procedure via careful history and clinical examination is recommended. However, children, especially, are often unable to verbalize "vertigo" in a concrete manner, which often necessitates a consultation with a pediatrician holding nonspecific symptoms. The so-called suppression of the head impulse test (SHIMPs) represents a modification of the video head impulse test (HIMP) and is used for a more sensitive assessment of residual vestibular functions. In adults, SHIMPs are already an established diagnostic method. Nevertheless, to date, nothing is known about the applicability and standard values in childhood.

MATERIAL AND METHODS

In this monocentric, prospective study, we investigated whether SHIMPs enable a sensitive functional analysis of the vestibular system in healthy children of different ages. For this purpose, SHIMPs were performed in 40 children aged 3-18 years.

RESULTS

In this study, we demonstrated that SHIMPs can be easily performed in children (3-18 years). It is vital that the test be appropriately explained for children to ensure sufficient test tolerance and compliance.

CONCLUSION

SHIMPs are a helpful supplement to clinically established vestibular tests such as the HIMP in pediatric vestibular balance disorder diagnostics and can be integrated into the clinical routine, especially in children who have minimal verbal abilities or understanding of the instructions for HIMP. Similar to the HIMP, SHIMPs are characterized by a short test duration and a high tolerance.

Vestibular Dysfunction and Gross Motor Milestone Acquisition in Children With Hearing Loss: A Systematic Review

OBJECTIVE

To describe the impact of vestibular dysfunction on gross motor development in children with hearing loss.

DATA SOURCES

MEDLINE (PubMed), Embase (Elsevier), Web of Science (Clarivate), and the Cumulative Index of Nursing and Allied Health Literature (EBSCO).

REVIEW METHODS

A systematic review was reported in concordance with the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses). Articles on children with hearing loss who underwent at least 1 instrumented measure of vestibular function and had gross motor milestones assessed were included. The Downs and Black checklist was used to assess risk of bias and methodological quality.

RESULTS

Eleven articles were included in the systematic review. Three articles stratified quantitative results of gross motor milestone acquisition by severity of vestibular impairment. Over half of studies were case series published within the last 5 years. This systematic review showed that children with hearing loss and severe, bilateral vestibular dysfunction demonstrate delayed gross motor milestones. However, it was difficult to draw conclusions on whether milder forms of vestibular dysfunction significantly affect gross motor milestone acquisition in children with hearing loss. The reason is that most studies were of low to moderate quality, used different assessment methods, and contained results that were descriptive in nature.

CONCLUSIONS

This emerging area would benefit from future research, such as higher-quality studies to assess vestibular function and gross motor milestones. This would allow for better characterization of the impacts of vestibular impairment, especially milder forms, in children with hearing loss.

Vestibular Infant Screening (VIS)-Flanders: results after 1.5 years of vestibular screening in hearing-impaired children

Due to the close anatomical relationship between the auditory and vestibular end organs, hearing-impaired children have a higher risk for vestibular dysfunction, which can affect their (motor) development. Unfortunately, vestibular dysfunction often goes unnoticed, as vestibular assessment in these children is not standard of care nowadays. To timely detect vestibular dysfunction, the Vestibular Infant Screening–Flanders (VIS–Flanders) project has implemented a basic vestibular screening test for hearing-impaired infants in Flanders (Belgium) with a participation rate of 86.7% during the first year and a half. The cervical Vestibular Evoked Myogenic Potentials (cVEMP) test was applied as vestibular screening tool to map the occurrence of vestibular (mainly saccular) dysfunction in this population. At the age of 6 months, 184 infants were screened. No refers on vestibular screening were observed in infants with permanent conductive hearing loss. In infants with permanent sensorineural hearing loss, a cVEMP refer rate of 9.5% was observed. Failure was significantly more common in infants with severe-profound compared to those with mild-moderate sensorineural hearing loss (risk ratio = 9.8). Since this is the first regional study with a large sample size and successful participation rate, the VIS–Flanders project aims to set an example for other regions worldwide.

Severe motion sickness in infants and children

INTRODUCTION

Susceptibility to severe motion sickness has not been well described in the pediatric population, particularly in very young children. This study aimed to describe and evaluate risk factors and treatment responses in a group of children with severe motion sickness, including infants and toddlers.

METHODS

We conducted a retrospective review of patients less than 18 years of age seen in our pediatric vestibular program for evaluation of motion sickness over a 6-year period.

RESULTS

A total of 23 patients with motion sickness were identified. Age of onset ranged from 0 to 15 years old, with a mean age of 6.6 ± 4.2 years. Eleven patients (47.8%) were diagnosed with a migraine variant. Vestibular deficits were identified in four out of 17 patients (23.5%) who underwent formal vestibular testing. Other frequent comorbid conditions included recurrent/chronic otitis media (n = 9; 39.1%) and a history of motor delay (n = 7; 30.4%). A high proportion of patients reported symptom improvement when treated with meclizine, ondansetron, cyproheptadine, or vestibular rehabilitation.

DISCUSSION

Motion sickness can impact children even in infancy. Common comorbid conditions that may contribute to pediatric motion sickness include migraine disorders, vestibular impairment, otitis media, and motor delay. Treatments such as cyproheptadine and vestibular rehabilitation may be helpful but require further study.

The feasibility, validity and reliability of a child friendly vestibular assessment in infants and children candidates to cochlear implant

OBJECTIVES

The pediatric vestibular assessment has developed significantly in the past two decades, especially in terms of assessment of cochlear implant (CI) candidates. Different methods and test protocols have been applied, however without a general consensus. We present here the feasibility, validity and reliability of a child friendly vestibular testing in use at our department for the assessment of pediatric CI candidates.

METHODS

The test battery consisted of head impulse test (HIT), video head impulse test (vHIT), cervical evoked myogenic potentials (cVEMP) and mini ice water caloric test (mIWC), all adapted from previous methods, mentioned in literature. We defined specific criteria for test feasibility, for test validity and test positivity (i.e. indicating vestibular insufficiency). The reliability of the whole protocol was assessed with test agreement analysis.

RESULTS

Complete data from 35 children, all CI candidates, age ranging 4-79 months (67% under 2 years) and recruited over two years, were obtained. All but one child could complete at least one test with valid responses bilaterally, with the best compliance for HIT (97,1%) and least for cVEMP (68,6%). Feasibility did not appear to be affected by age or hearing loss etiology. Among the valid responses there was a substantial test agreement between HIT and vHIT, moderate agreement between vHIT/HIT and mIWC and no apparent agreement between the canal tests and cVEMP. Simple clinical guidelines were introduced to solve the tests' disagreement and to improve the protocol reliability: a) a pathological response had to be confirmed in at least two different canal tests and in at least three cVEMP trials; b) a canal/otolith disagreement was interpreted as a partial vestibular loss to be opposed to a complete vestibular insufficiency.

CONCLUSIONS

The search for vestibular insufficiency in infants and young children can be attained with an opportunely adapted vestibular assessment, such the test battery proposed here. That assessment resulted easy to conduct and to interpret in a representative sample of CI candidates in preschool age, the most of whom were younger than 2 years. This method appears to particularly suit the demands of a vestibular assessment in young children CI candidates.

Vestibular rehabilitation exercises programs to improve the postural control, balance and gait of children with sensorineural hearing loss: A systematic review

BACKGROUND

Several studies have demonstrated that children with sensorineural hearing loss (SNHL) exhibit postural instabilities, as well as balance and gait disorders, due to the vestibular dysfunction that they are prone to display as a consequence of inner ear injury. Thus, some experiments have proposed vestibular rehabilitation exercises programs as a treatment to improve these motor skills in children with SNHL.

OBJECTIVE

Assess the evidence quality of the trials that used vestibular rehabilitation exercises programs to improve the postural control, balance and gait of children with SNHL.

METHODS

This is a systematic review that surveyed articles in nine databases, published up to July 4, 2019, in any language, using the following inclusion criteria: (1) Randomized or quasi-randomized controlled trials. (2) Participants of both groups with clinical diagnosis of SNHL, aged up to 12 years old, with no physical problems, cognitive or neurological impairments, except the vestibular dysfunction. (3) Using vestibular rehabilitation exercises programs to improve the following outcomes: postural control, balance and/or gait.

RESULTS

Six experiments, including 153 children, met the inclusion criteria of this systematic review. Two randomized controlled trials (45 children) on the postural control exhibited low evidence quality and four others; three randomized and controlled trials (90 children) on the balance and one quasi-randomized (18 children) on the gait demonstrated very low evidence quality, respectively.

CONCLUSION

There is promising evidence that vestibular rehabilitation exercises programs improve the postural control, balance and gait of children with SNHL. However, due to the methodological limitations of the trials and low quality of current evidence on this topic, the trials results analyzed by this systematic review should be interpreted with caution. Due to the low quality of evidence observed in this review, we suggest that new trials be proposed on this topic, with better methodological quality, to prove the effectiveness of vestibular rehabilitation exercises programs to improve the postural control, balance and gait of children with SNHL.

Methodological aspects of testing vestibular evoked myogenic potentials in infants at universal hearing screening program

Motor development in infants is dependent upon the function of the inner ear balance organ (vestibular organ). Vestibular failure causes motor delays in early infancy and suboptimal motor skills later on. A vestibular test for newborns and infants that is applicable on a large scale, safe and cost effective is in demand in various contexts: in the differential diagnosis of early onset hearing loss to determine forms associated with vestibular failure; in early hearing habilitation with cochlear implant, indicating the vestibular predominant side; and in the habilitation of children affected by motor skill disorders, revealing the contribution of a vestibular failure. This work explored the feasibility of cervical vestibular evoked myogenic potentials (VEMP) in conjunction with newborn universal hearing screening program. VEMP was measured after the hearing tests and was evoked by bone-conducted stimuli. Moreover, stimulus delivery was regulated by neck muscle activity, with infants rested unconstrained in their parents´ arms and with the head supported by the operator´s hand. This VEMP protocol showed a high level of feasibility in terms of test viability and result reproducibility. VEMP integrated into the newborn hearing screening program may represent a practical method for large-scale assessment of balance function in infants.

Pediatric Vestibular Rehabilitation: A Case Study

BACKGROUND

A 9-year-old child with a 9-month history of complaints of dizziness, headache, and motion sensitivity came to physical therapy. The child complained of difficulties playing on a playground, running, riding in a car, watching "action movies," sitting under fluorescent lights, and making quick head movements.

METHODS

An initial evaluation included a clinical oculomotor examination, vergence testing, static and dynamic visual acuity testing, head impulse testing, subjective visual vertical, balance testing, the pediatric vestibular symptom questionnaire, the Dizziness Handicap Inventory-child caregivers version (DHI-PC) and a visual vertigo analog scale. Physical therapy included virtual reality with Xbox games plus adaptation, habituation, and balance exercises. She was seen once per week and given a home program of exercises 2 to 3 times a day.

RESULTS

After 10 treatment sessions, she reported that playing was easier, headaches had reduced, she could travel as a passenger in a car for long distances without complaints, and that she could watch 3-dimensional action movies without symptoms. Her pediatric vestibular symptom questionnaire scores had reduced from 0.7 to 0.1. The DHI-PC had decreased from 22 to 12 points and her visual vertigo analog scale scores were improved.

CONCLUSIONS

Vestibular rehabilitation improved this child's quality of life. She was able to return to her daily living activities with fewer symptoms.

Vestibular Infant Screening - Flanders: The implementation of a standard vestibular screening protocol for hearing-impaired children in Flanders

OBJECTIVES

The Vestibular Infant Screening - Flanders (VIS-Flanders) project aims to implement and refine a vestibular screening protocol for all children with neonatal hearing loss in Flanders (Belgium) to limit the impact of a vestibular dysfunction on the motor, cognitive and psychosocial development of hearing-impaired children.

METHODS

Each child with a confirmed neonatal hearing loss in Flanders will undergo a vestibular screening at the age of 6 months in the reference centers involved in the neonatal hearing screening program. The cervical Vestibular Evoked Myogenic Potential (cVEMP) test will be used as a screening tool. The test is short, child-friendly, feasible at a young age and highly correlated with motor and balance performance. The results of an extensive follow-up protocol at the Ghent University Hospital will enable further refinement of the screening protocol.

RESULTS

Data collection in all reference centers has started since June 2018. This paper outlines the rationale for the screening and the set-up of this four-year project.

CONCLUSIONS

Current available literature strongly favors vestibular assessment in congenitally hearing-impaired children. A standard vestibular screening for these children should lead to early identification of vestibular deficits and subsequent prompt referral for further motor assessment and rehabilitation, in order to limit the impact of a vestibular dysfunction in developing children and improve their quality of life.

Relationship between dizziness and learning difficulties in schoolchildren: an integrative review

ABSTRACT Purpose: this study aims to verify the level of scientific evidence on the relationship between dizziness and academic achievement in childhood. Methods: the study was performed using the following search terms: dizziness, vertigo, child, learning, spelling, learning skills, academic skills, reading, and their correspondents in Portuguese in the following databases: PubMed, Scielo, LILACS and PsycINFO. Observational studies that examined the relationship between dizziness and academic achievement in childhood, published between 2007 and 2017, were included. Articles that did not allow access to the full text, and studies based on samples with motor, hearing, and cognitive disorders were excluded. Results: we initially found 315 articles and three met the established inclusion and exclusion criteria. These were scored according to the Newcastle-Ottawa Modified Scale with scores between 2 and 3 and as IIb according to the American Speech-Language Hearing Association levels of evidence and quality indicators. Conclusion: the results of this integrative review showed a low level of scientific evidence on the relationship between dizziness and academic achievement in childhood. It is important to emphasize the importance of improving study design to better understand their relationship, to allow provision of the best preventive, assessment, and intervention methods.