Increased independence and decreased vertigo after vestibular rehabilitation

Effects of Cawthorne-Cooksey exercises on vestibular symptoms: A systematic review of randomized controlled trials

OBJECTIVES

To examine the effects of Cawthorne-Cooksey exercises on individuals with vestibular dysfunction symptoms.

METHODS

Systematic search was conducted using PubMed, EBSCO SCOPUS, Web of Science, and Google Scholar from inception to March 2023. The Physiotherapy Evidence Database (PEDro) scale was employed to evaluate the risk of bias in the included studies.

RESULTS

Ten randomized controlled trials met the eligibility criteria. In total, 610 participants, 41.31 % of whom were men were included in this review. The PEDro scale scores ranged from 6 to 8 with a median of 6.5/10. Our findings revealed improvements in patients' vestibular dysfunction symptoms after Cawthorne-Cooksey exercises and other conventional interventions.

CONCLUSIONS

The initial findings showed that Cawthorne-Cooksey exercises are not superior to other concurrent vestibular rehabilitation interventions in improving vestibular dysfunction symptoms. Additional trials with long-term follow-ups are strongly recommended to understand the impacts of Cawthorne-Cooksey exercises on vestibular dysfunction symptoms.

Comparison of the effects of mechanical hippotherapy and Cawthorne-Cooksey exercises in patients with multiple sclerosis: Randomized trial

BACKGROUND

Patients diagnosed with multiple sclerosis (MS) commonly encounter heightened postural instability and challenges in aligning their eyes, head, and bodily motions while engaging in specific tasks. This study aims to compare the effects of Cawthorne-Cooksey and mechanical hippotherapy exercises on fatigue, balance, gait, dizziness, and life quality in patients with MS.

METHODS

The MS patients were randomly divided into Cawthorne-Cooksey (n:25) and mechanical hippotherapy exercise (n:25) groups. In addition to the traditional physical therapy program, Cawthorne-Cooksey and hippotherapy exercises were applied to the groups 3 days a week, for 8 weeks. The trial's clinical number is NCT06005909. The Fatigue Severity Scale (FSS), Fatigue Impact Scale (FIS), Dizziness Handicap Inventory, Tinetti Balance and Gait Assessment Scale, and Ferrans&Powers Quality-of-Life Index were used for pre-and post-treatment assessment.

RESULTS

Both groups exhibited a significant decrease in FSS, FIS, and Dizziness Handicap Inventory scores, as well as an increase in Tinetti Balance and Gait Assessment Scale and Ferrans&Powers Quality-of-Life Index scores following treatment. In the inter-group comparison, the Tinetti balance and gait assessment and the Ferrans&Powers quality of life index scores were higher in the hippotherapy group compared to the Cooksey group.

CONCLUSIONS

Although both forms of physical activity have demonstrated effectiveness in reducing fatigue among individuals with MS, hippotherapy shows superior efficacy in enhancing balance, gait, and overall quality of life.

Vestibular dysfunction and its association with cognitive impairment and dementia

The vestibular system plays an important role in maintaining balance and posture. It also contributes to vertical perception, body awareness and spatial navigation. In addition to its sensory function, the vestibular system has direct connections to key areas responsible for higher cognitive functions, such as the prefrontal cortex, insula and hippocampus. Several studies have reported that vestibular dysfunction, in particular bilateral vestibulopathy, is associated with an increased risk of cognitive impairment and the development of dementias such as Alzheimer's disease. However, it is still controversial whether there is a causal relationship between vestibular damage and cognitive dysfunction. In this mini-review, we will explore the relationship between the vestibular system, cognitive dysfunction and dementia, hypotheses about the hypothesis and causes that may explain this phenomenon and also some potential confounders that may also lead to cognitive impairment. We will also review multimodal neuroimaging approaches that have investigated structural and functional effects on the cortico-vestibular network and finally, describe some approaches to the management of patients with vestibular damage who have shown some cognitive impairment.

[Vestibular rehabilitation for peripheral vestibular hypofunction: an interdisciplinary consensus]

The literature review presents approaches to the management of patients with vestibular disorders. The principles of organization of vestibular rehabilitation in peripheral vestibular hypofunction, indications for appointment, factors influencing its implementation, technique, methods of evaluating effectiveness are considered in detail. Attention is drawn to the fact that the selection of exercises and the duration of vestibular rehabilitation is carried out individually and depends on many factors, including the nature of vestibular deficiency and the specific characteristics of the patient. The possibilities of using additional pharmacological therapy with histamine preparations, which can accelerate the onset of vestibular compensation, are shown. It is noted that vestibular rehabilitation is a safe and effective method of treating peripheral vestibular hypofunction and should be recommended to patients of all ages with vestibular disorders leading to limited social and physical activity.

Item Level Psychometrics of the Dizziness Handicap Inventory in Vestibular Migraine and Meniere's Disease

OBJECTIVES

Evaluate the measurement properties of the Dizziness Handicap Inventory (DHI) using item response theory in patients diagnosed with vestibular migraine (VM) and Meniere's disease (MD).

DESIGN

One hundred twenty-five patients diagnosed with VM and 169 patients diagnosed with MD by a vestibular neurotologist according to the Bárány Society criteria in two tertiary multidisciplinary vestibular clinics and who completed the DHI at their initial visit, were included in the study. The DHI (total score and individual items) was analyzed using the Rasch Rating Scale model for patients in each subgroup, VM and MD, and as a whole group. The following categories were assessed: rating-scale structure, unidimensionality, item and person fit, item difficulty hierarchy, person-item match, and separation index, standard error of measurement, and minimal detectable change (MDC).

RESULTS

Patients were predominantly female (80% of the VM subgroup and 68% of the MD subgroup) with a mean age of 49.9 ± 16.5 years and 54.1 ± 14.2 years, respectively. The mean total DHI score for the VM group was 51.9 ± 22.3 and for the MD group was 48.5 ± 26.6 ( p > 0.05). While neither all items nor the separate constructs met all criteria for unidimensionality (i.e., items measuring a single construct), post hoc analysis showed that the all-item analysis supported a single construct. All analyses met the criterion for showing a sound rating scale and acceptable Cronbach's alpha (≥0.69). The all-item analysis showed the most precision, separating the samples into three to four significant strata. The separate-construct analyses (physical, emotional, and functional) showed the least precision, separated the samples into less than three significant strata. Regarding MDC, the MDC remained consistent across the analyses of the different samples; approximately 18 points for the full analyses and approximately 10 points for the separate construct (physical, emotional, and functional).

CONCLUSIONS

Our evaluation of the DHI using item response theory shows that the instrument is psychometrically sound and reliable. The all-item instrument fulfills criteria for essential unidimensionality but does seem to measure multiple latent constructs in patients with VM and MD, which has been reported in other balance and mobility instruments. The current subscales did not show acceptable psychometrics, which is in line with multiple recent studies favoring the use of the total score. The study also shows that the DHI is adaptable to episodic recurrent vestibulopathies. The total score shows better precision and separation of subjects in up to four strata compared to the separate construct that separate subjects into less than three strata. The measurement error smallest detectable change was found in our analysis to be 18 points, which means any change in the DHI of less than 18 points is not likely to be clinically significant. The minimal clinically important difference remains indeterminate.

Type, dose, and outcomes of physical therapy interventions for unilateral peripheral vestibular hypofunction: protocol for a systematic review

BACKGROUND

Unilateral peripheral vestibular hypofunction can result in symptoms of dizziness, gaze and gait instability, and impaired navigation and spatial orientation. These impairments and activity limitations may negatively impact an individual's quality of life, ability to perform activities of daily living, drive, and work. There is strong evidence supporting vestibular physical therapy for reducing symptoms, improving gaze and postural stability, and improving function in individuals with vestibular hypofunction. However, there is great variability in clinical practice with regard to the type of interventions and only weak evidence to guide optimal exercise dosage. It is important to identify the most appropriate interventions and exercise dosage to optimize and accelerate recovery of function and to decrease distress. The objective of this systematic review is to determine which interventions and which doses are most effective in decreasing dizziness or vertigo, improving postural control, and improving quality of life in adults with unilateral peripheral vestibular hypofunction.

METHODS

The literature will be systematically searched using the following online databases: PubMed/MEDLINE, EMBASE, Web of Science (Science and Social Science Citation Index), Cumulative Index for Nursing and Allied Health Literature (CINAHL), and The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials [CENTRAL], Cochrane Methodology Register). The review will include randomized controlled trials (RCTs), including cluster RCTs, to assess the beneficial effects of the interventions. Assessment of methodological quality and risk of bias will be performed by two independent, blinded reviewers using the PEDro scale and Cochrane Risk of Bias version 2, respectively. The primary outcome measure will be change in self-perceived handicap related to dizziness from baseline to the end of the study, measured using the Dizziness Handicap Inventory. Other relevant outcome measures will include self-reported change in symptoms (to include severity, frequency, and duration) such as verbal or visual analog scales for dizziness. Tertiary outcome measures will include questionnaires related to disability and/or quality of life.

DISCUSSION

This systematic review will identify, evaluate, and integrate the evidence on the effectiveness of physical therapy interventions for unilateral peripheral vestibular hypofunction in an adult population. We anticipate our findings may inform individualized treatment and future research. Clinical recommendations generated from this systematic review may inform vestibular physical therapy treatment of individuals with unilateral peripheral vestibular hypofunction.

TRIAL REGISTRATION

In accordance with the guidelines, our systematic review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 06 August 2021 (registration number CRD42021266163 ). In the event of protocol amendments, the date of each amendment will be accompanied by a description of the change and the rationale.

Different Vestibular Rehabilitation Modalities in Unilateral Vestibular Hypofunction: A Prospective Study

OBJECTIVE

To assess the effectiveness of three vestibular rehabilitation protocols in patients with chronic unilateral vestibular hypofunction.

STUDY DESIGN

Prospective randomized trial.

SETTING

Audiology-neurootology laboratory in a general public hospital.

PATIENTS

Eighty-one patients were randomly allocated into three groups: adaptation exercises (AEs), habituation exercises (HEs), and combined exercises (AE-HEs).

INTERVENTIONS

Each patient completed an 8-week vestibular rehabilitation program with exercise, depending on their allocation group.

MAIN OUTCOME MEASURES

Evaluations performed at baseline, 4 weeks, and 8 weeks with (a) Functional Gait Assessment (FGA), (b) Mini-BESTest, (c) Vestibular Rehabilitation Benefit Questionnaire, and (d) Dizziness Handicap Inventory.

RESULTS

FGA and Mini-BESTest scores showed significant improvement between the baseline and 8-week scores in all groups (p < 0.001), except for the FGA score in the HE group. The AE-HE group showed better scores for all measurements at 4 weeks and had significantly better FGA and Mini-BESTest scores than the AE group and better FGA scores than the HE group. The Vestibular Rehabilitation Benefit Questionnaire and Dizziness Handicap Inventory scores in the AE-HE group were significantly better (p ≤ 0.001) than those in the HE group at 8 weeks.

CONCLUSIONS

The AE-HE group showed faster improvement and significantly better outcomes for static balance, dynamic postural stability, and self-perceived disability than the single-exercise protocols in chronic unilateral vestibular hypofunction.

Specific and individualized instructions improve the efficacy of booklet-based vestibular rehabilitation at home - a randomized controlled trial (RCT)

BACKGROUND

Vestibular rehabilitation therapy (VRT) is effective for most patients with dizziness and imbalance. Home exercise programs are widely used. It is unknown, however, how specific the instructions for exercises have to be.

OBJECTIVE

To evaluate the effects of expert assessment and instructions in a booklet-based home VRT program for patients with chronic dizziness.

METHODS

Randomized controlled study on 74 participants with disabling dizziness for >3 months. All study participants received a booklet-based VRT for training at home. Participants were prescribed 20 minutes of exercise, twice a day. The intervention group (n = 37) received specific instructions (expert physiotherapist). The control group (n = 37) practiced without specific instructions. Primary outcome was the total score of the Dizziness Handicap Inventory (DHI-G). All outcomes were assessed at baseline, after 4 weeks, and at follow up 4 weeks later.

RESULTS

Both groups improved (DHI-G 43.94±18.89 at inclusion to 33.06±19.67 at follow-up in controls and 42.82±16.60 to 22.65±19.12 in the intervention group). The intervention group, however, improved more (p = 0.014).

CONCLUSIONS

We show a significant effect of expert physiotherapy guidance in home-based VRT. This strengthens the role of the physiotherapist in VRT: Tailored, personalized instructions are needed to get the best effect of VRT.

The minimal clinically important difference for gait speed in significant unilateral vestibular hypofunction after vestibular rehabilitation

Gait speed is a valid measure of both physical function and vestibular health. Vestibular rehabilitation is useful to improve gait speed for patients with vestibular hypofunction, yet there is little data to indicate how changes in gait speed reflect changes in patient-reported health outcomes. We determined the minimal clinically important difference in the gait speed of patients with unilateral vestibular hypofunction, mostly due to deafferentation surgery, as anchored to the Dizziness Handicap Index and the Activities Balance Confidence scale, validated using regression analysis, change difference, receiver-operator characteristic curve, and average change methods. After six weeks of vestibular rehabilitation, a change in gait speed from 0.20 to 0.34 m/s with 95% confidence was required for the patients to perceive a significant reduction in perception of dizziness and improved balance confidence.

Determinants of functioning and health-related quality of life after vestibular stroke

Background

Stroke accounts for 5–10% of all presentations with acute vertigo and dizziness. The objective of the current study was to examine determinants of long-term functioning and health-related quality of life (HRQoL) in a patient cohort with vestibular stroke.

Methods

Thirty-six patients (mean age: 66.1 years, 39% female) with an MRI-proven vestibular stroke were followed prospectively (mean time: 30.2 months) in the context of the EMVERT (EMergency VERTigo) cohort study at the Ludwig-Maximilians Universität, Munich. The following scores were obtained once in the acute stage (<24 h of symptom onset) and once during long-term follow-up (preferably >1 year after stroke): European Quality of Life Scale-five dimensions-five levels questionnaire (EQ-5D-5L) and Visual Analog Scale (EQ-VAS) for HRQoL, Dizziness Handicap Inventory (DHI) for symptom severity, and modified Rankin Scale (mRS) for general functioning and disability. Anxiety state and trait were evaluated by STAI-S/STAI-T, and depression was evaluated by the Patient Health Questionnaire-9 (PHQ-9). Voxel-based lesion mapping was applied in normalized MRIs to analyze stroke volume and localization. Multiple linear regression models were calculated to determine predictors of functional outcome (DHI, EQ-VAS at follow-up).

Results

Mean DHI scores improved significantly from 45.0 in the acute stage to 18.1 at follow-up (p < 0.001), and mean mRS improved from 2.1 to 1.1 (p < 0.001). Mean HRQoL (EQ-5D-5L index/EQ-VAS) changed from 0.69/58.8 to 0.83/65.2 (p = 0.01/p = 0.11). Multiple linear regression models identified higher scores of STAI-T and DHI at the time of acute vestibular stroke and larger stroke volume as significant predictors for higher DHI at follow-up assessment. The effect of STAI-T was additionally enhanced in women. There was a significant effect of patient age on EQ-VAS, but not DHI during follow-up.

Conclusion

The average functional outcome of strokes with the chief complaint of vertigo and dizziness is favorable. The most relevant predictors for individual outcomes are the personal anxiety trait (especially in combination with the female sex), the initial symptom intensity, and lesion volume. These factors should be considered for therapeutic decisions both in the acute stage of stroke and during subsequent rehabilitation.

Fall risk in older adults mediates the association between depression, executive dysfunction and daily life

Introduction

The present study aimed to identify signs of frequent fall-related body dysfunction (depression/cognition) as exhibited in daily activities among older adults. The role of fall risk in mediating body dysfunction and daily activities was also explored.

Method

Participants included 123 non-institutionalised older adults. Depression and cognitive status were measured by the Geriatric Depression Scale (GDS-15) and the Montreal Cognitive Assessment (MoCA). Fall risk was determined by a questionnaire, supported by the Time Up and Go test (TUG). Executive functions (EF) were assessed by the Behavior Rating Inventory of Executive Function-Adult Version (BRIEF-A) and the Alternate Executive Function Performance Test medication management performance-based assessment. Daily life measures included the Barthel and Instrumental scale of activities of daily living, and World Health Organization Quality of Life questionnaire.

Results

Based on a falls risk score, 39 out of 123 participants (32%) were high-risk fallers. High-risk fallers showed greater body dysfunction, as recognised in daily activities. Structural equation modelling (SEM) revealed that fall risk mediated the associations among depression, executive dysfunction and daily activities.

Conclusion

Emotional and cognitive dysfunctions that affect people with high fall risk may manifest while older people perform daily activities. Community fall prevention programmes should screen for such fall-related dysfunction and provide strategies to minimise falls and enhance daily function.

Development and cross-cultural adaptation of the vestibular disorders activities of daily living scale in the kannada language and testing its psychometric properties

Background

Vestibular Disorders Activities of Daily Living Scale (VADL) is a self-reported survey for assessing functions of individuals affected by vestibular disorders, and this survey has been translated and cross-culturally adapted into many languages.

Objective

: Kannada is one of the most-spoken languages in India, with approximately 64 million speakers. We aimed to develop the Kannada version of VADL and to assess its psychometric properties.

Materials and Methods

The translation and adaptation of the English version of VADL into Kannada were accomplished with the input of medical professional language experts. Pretesting of the Kannada VADL (VADL-K) was conducted on 30 patients with vestibular disorders. Six professional experts with medical background provided their opinion during the content validation process of VADL-K, and 50 subjects aged between 30 and 70 years with variant vestibular disorders were administered VADL-K and the Dizziness Handicap Inventory to determine the internal consistency, test-retest reliability, and concurrent validity of this assessment.

Results

This study effectively translated, adapted, and pretested VADL-K. The scale's content validity was 0.95, its internal consistency (Cronbach's alpha = α) was 0.94, its test-retest reliability with Intra Class- Correlation Coefficient was 0.97, and its concurrent validity in comparison with DHI was significant, with a moderate correlation r-value of 0.58.

Conclusion

The English version of VADL was successfully translated and adapted into the Kannada language. VADL-K is a valid and reliable measure for patients with vestibular disorders in the state of Karnataka to report their functional performance.

Patient-Reported Disability After Computerized Posturographic Vestibular Retraining for Stable Unilateral Vestibular Deficit

Importance

Individuals with persistent unilateral vestibular deficits experience loss of quality of life and increased risk of falling, and they have few well-supported options for effective treatment.

Objectives

To evaluate whether vestibular retraining using computerized dynamic posturography is associated with reduced participant-reported disability for patients with an objectively assessed unilateral peripheral vestibular deficit and to assess the feasibility of conducting a randomized clinical trial of vestibular retraining using computerized dynamic posturography.

Design, Setting, and Participants

This single-group cohort study was conducted from April 29 to July 23, 2021, in a tertiary neurotology clinic among 13 individuals with a stable unilateral vestibular deficit present for more than 6 months, confirmed with videonystagmography and vestibular evoked myogenic potential testing. Statistical analysis was performed from July 7, 2021, to January 25, 2022.

Interventions

Twelve twice-weekly sessions of posturography-assisted vestibular retraining with prescribed weight shifting tasks guided by an interactive display.

Main Outcomes and Measures

Change in scores on the Dizziness Handicap Inventory (DHI), the Activities-Specific Balance Confidence (ABC) Scale, and the Falls Efficacy Scale-International (FES-I), which participants completed before and after retraining to measure their perception of their disability. They also completed posturography measurements. Secondary outcomes included tolerability of the intervention and rate of completion of the full protocol.

Results

A total of 13 participants (8 men [62%]; median age, 51 years [range, 18-67 years]) were enrolled. All 13 participants completed the intervention and all follow-up. After treatment, the median changes in scores were -16 points (95% CI, -20 to 2) for the DHI, -9 (95% CI, -14 to 1) for the FES-I, and 11.9 (95% CI, 0-17.3) for the ABC Scale. Eight participants (62%) improved by greater than the minimum clinically important difference (MCID) for the DHI, whereas 4 (31%) exceeded the MCID for the ABC Scale, and 3 (23%) exceeded the MCID for the FES-I. Participants with moderate to severe disability at baseline (n = 7) had a larger magnitude of improvement in DHI scores than those with mild disability (n = 6) (-18 [95% CI, -78 to 2] vs -1 [95% CI, -8 to 16]). Six of the 7 patients (86%) with moderate to severe disability improved by greater than the MCID for DHI, wherease 4 of 7 patients (57%) improved by greater than the MCID for the ABC Scale, and 3 of 7 patients (43%) improved by greater than the MCID for the FES-I.

Conclusions and Relevance

This cohort study suggests that computerized, dynamic posturography-assisted retraining was associated with clinically meaningful improvements in participant-reported disability among those with stable unilateral vestibular deficit and moderate to severe disability. Further studies should compare posturography-assisted vestibular retraining with conventional physical therapy rehabilitation techniques.

Trial Registration

ClinicalTrials.gov Identifier: NCT04875013.

Reporting of exercise dose and dosage and outcome measures for gaze stabilisation in the literature: a scoping review

OBJECTIVES

The concept of this review is to examine and quantify the reporting of parameters of dose (duration, speed, head excursion) and dosage (daily and weekly frequency, duration) for gaze stabilisation exercises and to report on outcome measures used to assess change in gaze stabilisation following intervention. This review includes any population completing gaze stabilisation exercises.

DESIGN

Scoping review.

METHODS

We searched key terms in the following databases: PubMed, CINAHL, Scopus and Cochrane. Two researchers reviewed titles, abstracts and full-text articles for inclusion. Data retrieved included: patient diagnosis, specific interventions provided, dose and dosage of gaze stabilisation interventions and outcome measures.

RESULTS

From the initial 1609 results, 138 studies were included. Data extraction revealed that only 13 studies (9.4%) reported all parameters of dose and dosage. Most studies used other interventions in addition to gaze stabilisation exercises. Half of the studies did not use a clinical or instrumented outcome measure of gaze stability, using only patient-reported outcome measures. Clinical tests of gaze stability were used in 21.1% of studies, and instrumented measures of gaze stability were used in 14.7% of studies.

CONCLUSIONS

Full reporting of the dose and dosage of gaze stabilisation interventions is infrequent, impairing the ability to translate current evidence into clinical care. Most studies did not use a clinical or instrumented measure of gaze stabilisation as outcome measures, questioning the validity of intervention effects. Improved reporting and use of outcome measures are necessary to establish optimal intervention parameters for those with gaze stability impairments.

Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Updated Clinical Practice Guideline From the Academy of Neurologic Physical Therapy of the American Physical Therapy Association

Background:

Uncompensated vestibular hypofunction can result in symptoms of dizziness, imbalance, and/or oscillopsia, gaze and gait instability, and impaired navigation and spatial orientation; thus, may negatively impact an individual's quality of life, ability to perform activities of daily living, drive, and work. It is estimated that one-third of adults in the United States have vestibular dysfunction and the incidence increases with age. There is strong evidence supporting vestibular physical therapy for reducing symptoms, improving gaze and postural stability, and improving function in individuals with vestibular hypofunction. The purpose of this revised clinical practice guideline is to improve quality of care and outcomes for individuals with acute, subacute, and chronic unilateral and bilateral vestibular hypofunction by providing evidence-based recommendations regarding appropriate exercises.

Methods:

These guidelines are a revision of the 2016 guidelines and involved a systematic review of the literature published since 2015 through June 2020 across 6 databases. Article types included meta-analyses, systematic reviews, randomized controlled trials, cohort studies, case-control series, and case series for human subjects, published in English. Sixty-seven articles were identified as relevant to this clinical practice guideline and critically appraised for level of evidence.

Results:

Based on strong evidence, clinicians should offer vestibular rehabilitation to adults with unilateral and bilateral vestibular hypofunction who present with impairments, activity limitations, and participation restrictions related to the vestibular deficit. Based on strong evidence and a preponderance of harm over benefit, clinicians should not include voluntary saccadic or smooth-pursuit eye movements in isolation (ie, without head movement) to promote gaze stability. Based on moderate to strong evidence, clinicians may offer specific exercise techniques to target identified activity limitations and participation restrictions, including virtual reality or augmented sensory feedback. Based on strong evidence and in consideration of patient preference, clinicians should offer supervised vestibular rehabilitation. Based on moderate to weak evidence, clinicians may prescribe weekly clinic visits plus a home exercise program of gaze stabilization exercises consisting of a minimum of: (1) 3 times per day for a total of at least 12 minutes daily for individuals with acute/subacute unilateral vestibular hypofunction; (2) 3 to 5 times per day for a total of at least 20 minutes daily for 4 to 6 weeks for individuals with chronic unilateral vestibular hypofunction; (3) 3 to 5 times per day for a total of 20 to 40 minutes daily for approximately 5 to 7 weeks for individuals with bilateral vestibular hypofunction. Based on moderate evidence, clinicians may prescribe static and dynamic balance exercises for a minimum of 20 minutes daily for at least 4 to 6 weeks for individuals with chronic unilateral vestibular hypofunction and, based on expert opinion, for a minimum of 6 to 9 weeks for individuals with bilateral vestibular hypofunction. Based on moderate evidence, clinicians may use achievement of primary goals, resolution of symptoms, normalized balance and vestibular function, or plateau in progress as reasons for stopping therapy. Based on moderate to strong evidence, clinicians may evaluate factors, including time from onset of symptoms, comorbidities, cognitive function, and use of medication that could modify rehabilitation outcomes.

Discussion:

Recent evidence supports the original recommendations from the 2016 guidelines. There is strong evidence that vestibular physical therapy provides a clear and substantial benefit to individuals with unilateral and bilateral vestibular hypofunction.

Limitations:

The focus of the guideline was on peripheral vestibular hypofunction; thus, the recommendations of the guideline may not apply to individuals with central vestibular disorders. One criterion for study inclusion was that vestibular hypofunction was determined based on objective vestibular function tests. This guideline may not apply to individuals who report symptoms of dizziness, imbalance, and/or oscillopsia without a diagnosis of vestibular hypofunction.

Disclaimer:

These recommendations are intended as a guide to optimize rehabilitation outcomes for individuals undergoing vestibular physical therapy. The contents of this guideline were developed with support from the American Physical Therapy Association and the Academy of Neurologic Physical Therapy using a rigorous review process. The authors declared no conflict of interest and maintained editorial independence.

Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A369).

The Effect of Supervision in Vestibular Rehabilitation in Patients with Acute or Chronic Unilateral Vestibular Dysfunction: A Systematic Review

OBJECTIVE

The investigation of supervised vestibular rehabilitation treatment role for individuals with dizziness and imbalance due to peripheral, unilateral vestibular disorders.

DATABASES REVIEWED

Cochrane, PubMed, and Physiotherapy Evidence Database (PEDro) were utilized to identify relevant studies.

METHODS

The key search terms used were "Vestibular Rehabilitation and Unilateral Vestibular Hypofunction," "Vestibular Rehabilitation and Unilateral Vestibular Loss," and "Vestibular Rehabilitation and Supervision." A manual search was performed by exploring the references of included articles to identify studies not captured through the computer-based searches. The quality of the studies was assessed according to the PEDro scale. Inclusion criteria were: 1) studies with patients, aged from 18 to 80 years, with acute or chronic dizziness and disequilibrium due to unilateral vestibular dysfunction, 2) randomized control trials (RCTs), 3) studies comparing supervised vestibular rehabilitation program with an unsupervised vestibular rehabilitation program or home-based training or standard care or placebo, and 4) articles written in the English language. Studies reporting cases of vertigo and imbalance due to possible recurrent pathologies, acute benign paroxysmal positional vertigo, or central neurological/orthopedic deficits, were excluded.

RESULTS

A total of 448 articles were retrieved from the systematic database search strategy. Five of them were included in the systematic review after full-text analysis, plus one more after manual searching of their references. All studies involved supervised vestibular rehabilitation treatment programs compared with unsupervised home training, the performance of daily activities and, standard care. Based on PEDro's scoring system, one study rated as high-quality RCT, three studies were considered of fair quality and one scored as low-quality RCT.

CONCLUSIONS

Although most RCTs report better outcomes with a supervised vestibular rehabilitation treatment program regarding the emotional status, dizziness, and balance improvement, this systematic review failed to provide a strong evidence that supervision is superior to unsupervised protocols in patients with UNH. The self-reported subjective measures used by the included RCTs represent a serious limitation of their results.

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).

Automatically evaluating balance using machine learning and data from a single inertial measurement unit

Background

Recently, machine learning techniques have been applied to data collected from inertial measurement units to automatically assess balance, but rely on hand-engineered features. We explore the utility of machine learning to automatically extract important features from inertial measurement unit data for balance assessment.

Findings

Ten participants with balance concerns performed multiple balance exercises in a laboratory setting while wearing an inertial measurement unit on their lower back. Physical therapists watched video recordings of participants performing the exercises and rated balance on a 5-point scale. We trained machine learning models using different representations of the unprocessed inertial measurement unit data to estimate physical therapist ratings. On a held-out test set, we compared these learned models to one another, to participants’ self-assessments of balance, and to models trained using hand-engineered features. Utilizing the unprocessed kinematic data from the inertial measurement unit provided significant improvements over both self-assessments and models using hand-engineered features (AUROC of 0.806 vs. 0.768, 0.665).

Conclusions

Unprocessed data from an inertial measurement unit used as input to a machine learning model produced accurate estimates of balance performance. The ability to learn from unprocessed data presents a potentially generalizable approach for assessing balance without the need for labor-intensive feature engineering, while maintaining comparable model performance.

Development of Arabic Version of Vestibular Disorders Activities of Daily Living Scale: Cross-Cultural Adaptation and Assessment of Psychometric Properties

Background

The vestibular disorders activities of daily living (VADL) scale is a valid and reliable scale created 2 decades ago to specifically test the functional problems of patients with vestibular disorders. Since its development, the VADL has been cross-culturally validated and adapted in Spanish, Portuguese, Persian, and Turkish languages. A version is not yet available in Arabic, the primary language of more than 400 million people worldwide. This study aimed to translate the patient-reported VADL into Arabic and test its psychometric properties such as content validity, internal consistency, and test-retest reliability.

Material/Methods

Our study was conducted in 2 parts. In the first part, we translated and adapted the VADL from English into Arabic with expert input. In the second part, we tested the translated scale content validity by consulting 6 experts in the field. We assessed the scale’s internal consistency and test-retest reliability by administering it twice to 31 subjects with vestibular disorders with a 1-week interval between the 2 measurements.

Results

Translation, adaptation, and pretesting were successful, and we were able to create the VADL-A, an Arabic version of the VADL. The content validity of the VADL-A was 0.96, internal consistency was 0.96, and the test-retest reliability was 0.93.

Conclusions

We successfully translated, adapted, and created the VADL-A. Our preliminary testing of basic psychometric properties indicated that the scale has excellent content validity, internal consistency, and test-retest reliability.

Benefits of vestibular rehabilitation on patient-reported outcomes in older adults with vestibular disorders: a randomized clinical trial

BACKGROUND

Chronic dizziness has a negative impact on emotional aspects, functional capacity, and quality of life of older people.

OBJECTIVE

To compare the effects of the conventional Cawthorne & Cooksey and the multimodal Cawthorne & Cooksey protocols on patient-reported outcomes in older adults with vestibular disorders.

METHODS

This is a single-blind, randomized controlled trial with three-months' follow-up. Older adults with chronic dizziness were randomly assigned to conventional or multimodal protocols. The protocols were performed in individual 50-minute sessions, twice weekly, for two months. The primary outcome was the Dizziness Handicap Inventory (DHI) and the secondary outcomes were the Visual Analogue Scale, the Vestibular Disorders Activities of Daily Living Scale, the Geriatric Depression Scale, and the Activities-specific Balance Confidence Scale. Outcomes were collected at baseline, post-treatment and three-month follow-up; and analyzed on an intention-to-treat approach.

RESULTS

Eighty-two patients were randomized into the conventional (n = 40) or multimodal (n = 42) protocols. There was no between-group difference on DHI at post-treatment (Mean Difference (MD): -0.7; 95% CI: -9.2, 7.8) and at three-month follow-up (MD: -1.6; 95% CI: -9.5, 6.2). No between-group difference was found for the secondary outcomes. All patient-reported outcomes in the within-group analysis showed significant improvement between baseline and post-treatment, and changes were maintained between post-treatment and follow-up. Following treatment, 55% of patients in the conventional and 57% in the multimodal protocol reached DHI clinical improvement (decrease ≥18).

CONCLUSIONS

The addition of multimodal exercises to the conventional Cawthorne & Cooksey protocol did not promote extra benefits on patient-reported outcomes in older adults with chronic dizziness.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry-ANZCTR (ACTRN12610000018011), the trial was registered January 7, 2010 and the first participant was enrolled April 15, 2010. URL of the registry: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=334985.

Does vestibular rehabilitation improve postural control of subjects with chronic subjective dizziness?

Postural control is the ability to maintain equilibrium and orientation in a gravitational environment. Patients with chronic subjective dizziness have some troubles with their postural stability. The present study aimed to assess the benefit of home-based vestibular rehabilitation in patients with chronic subjective dizziness using computerized dynamic posturography. Therefore, 100 subjects, between 19 to 86 years, diagnosed with dizziness were included in the study. Computerized dynamic posturography was performed to assess postural stability. Vestibular rehabilitation programs included exercises tailored to the particular needs of each patient. After vestibular rehabilitation, patients were re-examined using the same tests. Posturographic data were analyzed and compared for before and after vestibular rehabilitation findings. The mean composite scores before the intervention (58,92 ±11,64) was significantly (p<0.01) lower than the mean composite scores after vestibular rehabilitation (73,83 ± 8,26). This result is found to be statistically significant. In conclusion it could be suggested that the effectiveness of vestibular rehabilitation could be verified by means of computerized dynamic posturography as a concrete method.

Effect of Vestibular Rehabilitation on Spontaneous Brain Activity in Patients With Vestibular Migraine: A Resting-State Functional Magnetic Resonance Imaging Study

Previous studies have shown that vestibular migraine (VM) is a cerebral disease with recurrent vertigo. Vestibular rehabilitation (VR) is an effective type of physical therapy for minimizing vestibular symptoms, as it improves vestibular compensation in patients with VM. Currently, the cerebral regions that are associated with the pathogenesis of VM are largely unknown. To further understand the underlying mechanisms of VM, we performed resting-state functional magnetic resonance imaging (fMRI) before and after 1 month of VR in 14 patients with VM. The Dizziness Handicap Inventory (DHI), the 36-Item Short-Form Health Survey (SF-36), the Hamilton Depression Scale (HAMD) and the Hamilton Anxiety Scale (HAMA) scores were included as clinical outcomes. The amplitude of low-frequency fluctuation (ALFF) was assessed to characterize spontaneous brain activity. The correlations between the clinical characteristics and ALFF values were assessed. After 1 month of VR training, the DHI scores in patients with VM were significantly lower than those at baseline (p = 0.03), as were the HAMA scores (p = 0.02). We also found that the ALFF values in the left posterior cerebellum of VM patients increased significantly after 1 month of VR training. Moreover, the ALFF values in the left cerebellum were inversely correlated with the patients’ DHI scores. Overall, this study showed that VR exercise for 1 month has a positive effect on vestibular symptoms in patients with VM. Asymmetric cerebellar hyperactivity might be a functional compensation for vestibular dysfunction in patients with VM.

Using Unidirectional Rotations to Improve Vestibular System Asymmetry in Patients with Vestibular Dysfunction

The vestibular system provides information about head movement and mediates reflexes that contribute to balance control and gaze stabilization during daily activities. Vestibular sensors are located in the inner ear on both sides of the head and project to the vestibular nuclei in the brainstem. Vestibular dysfunction is often due to an asymmetry between input from the two sides. This results in asymmetrical neural inputs from the two ears, which can produce an illusion of rotation, manifested as vertigo. The vestibular system has an impressive capacity for compensation, which serves to rebalance how asymmetrical information from the sensory end organs on both sides is processed at the central level. To promote compensation, various rehabilitation programs are used in the clinic; however, they primarily use exercises that improve multisensory integration. Recently, visual-vestibular training has also been used to improve the vestibulo-ocular reflex (VOR) in animals with compensated unilateral lesions. Here, a new method is introduced for rebalancing the vestibular activity on both sides in human subjects. This method consists of five unidirectional rotations in the dark (peak velocity of 320°/s) toward the weaker side. The efficacy of this method was shown in a sequential, double-blinded clinical trial in 16 patients with VOR asymmetry (measured by the directional preponderance in response to sinusoidal rotations). In most cases, VOR asymmetry decreased after a single session, reached normal values within the first two sessions in one week, and the effects lasted up to 6 weeks. The rebalancing effect is due to both an increase in VOR response from the weaker side and a decrease in response from the stronger side. The findings suggest that unidirectional rotation can be used as a supervised rehabilitation method to reduce VOR asymmetry in patients with longstanding vestibular dysfunction.

Virtual reality in vestibular rehabilitation: a pilot study

Background/Aims

We evaluated the efficacy of using virtual reality with specific games for vestibular rehabilitation to treat patients with benign paroxysmal positional vertigo.

Methods

The Activity-Specific Balance Confidence Scale (ABC Scale), Dizziness Handicap Inventory, Tinnitus Handicap Inventory, Berg Balance Scale, Balancim, Romberg and Dix-Hallpike tests were used to evaluate 10 participants (5 males and 5 females; mean age 38.5 ± 14.7 years) with benign paroxysmal positional vertigo, who played 3 specific games of Nintendo Wii console (Snowboard Slalom, Tightrope Walk, Rhythm Parade) for 10 minutes twice a week for 4 weeks.

Results

The intervention resulted in significant increases in Activity-Specific Balance Confidence Scale score (d de Cohen >0.50), decreases in Dizziness Handicap Inventory (P<0.05 in t test for all dimensions and total score) and Tinnitus Handicap Inventory (P<0.05 in Wilcoxon test for all dimensions and total score), and improvement in balance shown on Romberg test, Berg Balance Scale (P<0.05 in t test for all dimensions and total score) and Balancim (d de Cohen >0.80).

Conclusions

Virtual reality with the selected games seemed to be effective on benign paroxysmal positional vertigo treatment, improving scores of tests and scales used in the assessment.

Automatically Evaluating Balance: A Machine Learning Approach

Compared to in-clinic balance training, in-home training is not as effective. This is, in part, due to the lack of feedback from physical therapists (PTs). In this paper, we analyze the feasibility of using trunk sway data and machine learning (ML) techniques to automatically evaluate balance, providing accurate assessments outside of the clinic. We recruited sixteen participants to perform standing balance exercises. For each exercise, we recorded trunk sway data and had a PT rate balance performance on a scale of 1-5. The rating scale was adapted from the Functional Independence Measure. From the trunk sway data, we extracted a 61-dimensional feature vector representing the performance of each exercise. Given these labeled data, we trained a multi-class support vector machine (SVM) to map trunk sway features to PT ratings. Evaluated in a leave-one-participant-out scheme, the model achieved a classification accuracy of 82%. Compared to participant self-assessment ratings, the SVM outputs were significantly closer to PT ratings. The results of this pilot study suggest that in the absence of PTs, ML techniques can provide accurate assessments during standing balance exercises. Such automated assessments could reduce PT consultation time and increase user compliance outside of the clinic.

Rebalancing the Vestibular System by Unidirectional Rotations in Patients With Chronic Vestibular Dysfunction

Introduction: Vestibular dysfunction is a common disorder that results in debilitating symptoms. Even after full compensation, the vestibulo-ocular reflex (VOR) could be further improved by using rehabilitation exercises and visual-vestibular adaptation. We hypothesized that in patients with asymmetric vestibular function, the system could be rebalanced by unidirectional rotations toward the weaker side (i.e., a pure vestibular stimulation).

Methods: Sixteen subjects (5 female and 11 male, 43.2 ± 17.0 years old) with chronic vestibular dysfunction that was non-responsive to other types of medical treatment were recruited for the study (ClinicalTrials.gov Identifier: NCT01080430). Subjects had VOR asymmetry quantified by an abnormal directional preponderance (DP) with rotation test and no previous history of central vestibular problems or fluctuating peripheral vestibular disorders. They participated either in the short-term study (one session) or the long-term study (7 visits over 5 weeks). Rehabilitation consisted of five trapezoid unidirectional rotations (peak velocity of 320°/s) toward the weaker side. Care was taken to slowly stop the rotation in order to avoid stimulation in the opposite direction during deceleration. To study the short-term effect, VOR responses were measured before and 10, 40, and 70 min after a single unidirectional rotational rehabilitation session. For long-term effects, the VOR gain was measured before and 70min after rehabilitation in each session.

Results: We observed a significant decrease in VOR asymmetry even 10 min after one rehabilitation session (short-term study). With consecutive rehabilitation sessions in the long-term study, DP further decreased to reach normal values during the first 2 sessions and only one subjects required further rehabilitation after week 4. This change in DP was due to an increase in responses during rotations toward the weaker side and a decrease in VOR responses during rotations in the other direction.

Conclusion: Our results show that unidirectional rotation can reduce the VOR imbalance and asymmetry in patients with previously compensated vestibular dysfunction and could be used as an effective supervised method for vestibular rehabilitation even in patients with longstanding vestibular dysfunction.

Comparing the Effects of Epley Maneuver and Cinnarizine on Benign Positional Paroxysmal Vertigo; A Randomized Clinical Trial

Background:

The fastest and safest treatment method of BPPV is repositioning maneuvers. In Iran, this methods are not widely used, and many physicians use medical therapy, despite their side effects, for management of BPPV.

Materials and Methods:

In this randomized clinical trial patients with BPPV were randomly allocated to Epley repositioning maneuver or Cinnarizine (25mg every 8 hours) for two weeks. The patients were evaluated for symptoms using visual analogue scale (VAS) scoring system before intervention, first and second weeks after intervention. In the second and third visitd the results of hallpike test was recorded for both groups.

Results:

43 patients with a mean age of 46.88±11.08 years in two Epley and Cinnarizine group underwent analysis. The mean VAS score for improvement of symptoms after intervention was 1.66±1.06 in Epley and 1.50±0.91 in Cinnarizine group (P=0.57).

Conclusion:

we found that there is no significant difference between Epley maneuver and Cinnarizine for treatment and controlling symptoms of BPPV.

A speed-based approach to vestibular rehabilitation for peripheral vestibular hypofunction: A retrospective chart review

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSIONS:

Changes in cognitive function in patients with intractable dizziness following vestibular rehabilitation

The purpose of the present study was to investigate changes in cognitive functions, including visuospatial ability, attention, and executive function in patients with intractable dizziness following vestibular rehabilitation. The correlations between improvements in cognitive function and dizziness-related variables and emotional distress were also explored. During hospitalization for 5 days, participants were trained on a vestibular rehabilitation program. Participants completed questionnaires including the Dizziness Handicap Inventory (DHI), Hospital Anxiety and Depression Scale (HADS), and Trail Making Test (TMT), which were used to assess cognitive function. The center of gravity fluctuation measurement and timed up and go test (TUG), which were objective dizziness severity indexes, were performed before, 1 month after, and 4 months after hospitalization. Following vestibular rehabilitation, participants exhibited a significant improvement in the TMT, DHI, HADS, and TUG scores. Correlation analysis between the variables at each time point indicated that TMT scores positively correlated with TUG at baseline. The correlation between changes observed in the TUG and TMT scores was not significant. The degree of improvement of the TUG score did not bear a linear relationship with that of the TMT scores. However, these correlation results were not completely consistent with those in the multiply imputed dataset.

Using visual stimuli to enhance gait control

Gait control challenges commonly coincide with vestibular dysfunction and there is a long history in using balance and gait activities to enhance functional mobility in this population. While much has been learned using traditional rehabilitation exercises, there is a new line of research emerging that is using visual stimuli in a very specific way to enhance gait control. For example, avatars can be created in an individualized manner to incorporate specific gait characteristics. The avatar could then be used as a visual stimulus to which the patient can synchronize their own gait cycle. This line of research builds upon the rich history of sensorimotor control research in which augmented sensory information (visual, haptic, or auditory) is used to probe, and even enhance, human motor control. This review paper focuses on gait control challenges in patients with vestibular dysfunction, provides a brief historical perspective on how various visual displays have been used to probe sensorimotor and gait control, and offers some recommendations for future research.

An adaptive vestibular rehabilitation technique

OBJECTIVES/HYPOTHESIS

There is a large variation in vestibular rehabilitation (VR) results depending on type of therapy, adherence, and the appropriateness for the patient's level of function. A novel adaptive vestibular rehabilitation (AVR) program was developed and evaluated.

STUDY DESIGN

Technology and procedure development, and prospective multicenter trial.

METHODS

Those with complete unilateral vestibular hypofunction and symptomatic at least 3 months with a Dizziness Handicap Inventory (DHI) >30 were eligible. Patients were given a device to use with their own computer. They were instructed to use the program daily, with each session lasting about 10 minutes. The task consisted of reporting orientation of the letter C, which appeared when their angular head velocity exceeded a threshold. The letter size and head velocity required were adjusted based on prior performance. Performance on the task was remotely collected by the investigator as well as a weekly DHI score.

RESULTS

Four patients aged 31 to 74 years (mean = 51 years) were enrolled in this feasibility study to demonstrate efficacy. Two had treated vestibular schwannomas and two had vestibular neuritis. Starting DHI was 32 to 56 (mean = 42), which was reduced to 0 to 16 (mean = 11.5) after a month of therapy, a clinically and statistically significant (P < .05) improvement. The three who continued therapy an additional month improved to a DHI of 4.

CONCLUSIONS

This AVR method has advantages over traditional VR in terms of cost and customization for patient ability and obtained a major improvement in symptoms. This study demonstrated a clinically and statistically significant decrease in symptoms after 4 weeks of therapy.

LEVEL OF EVIDENCE

2b. Laryngoscope, 128:713-718, 2018.

Aging

This chapter reviews studies that have examined age-related anatomic and functional changes in sensory, neuromuscular, and cognitive systems that impair the control of balance and gait. Specifically, we examine age-related changes in peripheral systems: lower-limb sensation, visual functions such as contrast sensitivity and depth perception, vestibular sense, strength, and power in the lower-limb muscle groups, as well as central factors including processing speed and executive functioning. Significant impairments in any one of the above systems can predispose older people to falls, with the risk of falling increasing substantially with the number of impairments present. There is increasing evidence that interventions aimed at addressing specific sensory and neuromuscular impairments can improve balance control and reduce fall risk. In particular, task-specific exercise can improve muscle strength, balance, gait and mobility and prevent falls in older people.

Analysis of Factors Affecting the Outcomes of In-hospitalized Vestibular Rehabilitation in Patients With Intractable Dizziness

OBJECTIVE

To analyze somatic and psychological factors affecting the outcomes of in-hospital vestibular rehabilitation in patients with intractable dizziness.

MATERIALS AND METHODS

The study involved 138 patients with persistent dizziness caused by peripheral vestibular dysfunction. They were hospitalized and taught to conduct a vestibular rehabilitation program for 30 minutes by themselves three times a day over 5 days. They were then instructed to continue performing the program every day after discharge. Several questionnaires were conducted immediately before, and 1 month after, the treatment. For example, the dizziness handicap inventory (DHI), the somatosensory catastrophizing scale (SSCS), and indexes of depression and anxiety. Posturography was also performed. The main outcome was the difference between the DHI scores before and after rehabilitation. Body sway was objectively evaluated using static posturography.

RESULTS

The vestibular rehabilitation significantly improved the DHI score, the SSCS score, depression, and anxiety. Multivariate analysis indicated that the improvement in the DHI score was poorer in patients who showed high SSCS score before intervention. A higher prevalue of the DHI was associated with greater improvements in this perceived handicap after the rehabilitation. Small body sway pre-rehabilitation was related to positive effects on the DHI score in patients with a high prevalue of the DHI.

CONCLUSION

The vestibular rehabilitation contributed to the improvement of perceived handicap due to dizziness, catastrophization of bodily sensation, and emotional distress. Patients who catastrophized their bodily sensations before vestibular rehabilitation saw smaller improvements in perceived handicap due to dizziness.

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.

Comparing the effect of Cawthorne-Cooksey and Frenkel exercises on balance in patients with multiple sclerosis: a randomized controlled trial

OBJECTIVE

To evaluate the effect of Cawthorne-Cooksey and Frenkel exercises on balance in patients with multiple sclerosis.

DESIGN

It was a three-arm parallel randomized controlled trial study.

SETTING

Outpatient clinic.

SUBJECTS

Patients with multiple sclerosis.

INTERVENTIONS

Subjects in the intervention groups completed a 12-week program consisted of Cawthorne-Cooksey or Frenkel exercises. The control group only received routine care.

MAIN MEASURES

The outcome measure was the Berg Balance Scale.

RESULTS

Seventy-two patients completed the study. At the end of the intervention, there was a statistically significant improvement in Berg Balance Scale in the Cawthorne-Cooksey group ( n = 24) in comparison with the other two groups ( P = 0.001). In the Frenkel group ( n = 23), the improvement was statistically greater than the changes in the control group ( n = 25), but it did not appear to be clinically significant. The Berg Balance Scale score increased to 8.9 in the Cawthorne-Cooksey group and 2.3 in the Frenkel group, while it decreased to 1.2 in the control group. When comparing inter-group changes, Berg Balance Scale showed significant improvements in favor of the Cawthorne-Cooksey group after the intervention ( P < 0.05).

CONCLUSION

This study demonstrated that in comparison with Frenkel and the control groups, a program of Cawthorne-Cooksey exercise is more effective in improving balance in patients with multiple sclerosis.

Is the Headache in Patients with Vestibular Migraine Attenuated by Vestibular Rehabilitation?

Background

Vestibular rehabilitation is the most effective treatment for dizziness due to vestibular dysfunction. Given the biological relationship between vestibular symptoms and headache, headache in patients with vestibular migraine (VM) could be improved by vestibular rehabilitation that leads to the improvement of dizziness. This study aimed to compare the effects of vestibular rehabilitation on headache and other outcomes relating to dizziness, and the psychological factors in patients with VM patients, patients with dizziness and tension-type headache, and patients without headache.

Methods

Our participants included 251 patients with dizziness comprising 28 patients with VM, 79 patients with tension-type headache, and 144 patients without headache. Participants were hospitalized for 5 days and taught to conduct a vestibular rehabilitation program. They were assessed using the Dizziness Handicap Inventory (DHI), Headache Impact Test (HIT-6), Hospital Anxiety and Depression Scale (HADS), and Somatosensory Catastrophizing Scale (SSCS) and underwent center of gravity fluctuation measurement as an objective dizziness severity index before, 1 month after, and 4 months after their hospitalization.

Results

The VM and tension-type headache groups demonstrated a significant improvement in the HIT-6 score with improvement of the DHI, HADS, SSCS, and a part of the objective dizziness index that also shown in patients without headache following vestibular rehabilitation. The change in HIT-6 during rehabilitation in the VM group was positively correlated with changes in the DHI and anxiety in the HADS. Changes in the HIT-6 in tension-type headache group positively correlated with changes in anxiety and SSCS.

Conclusion

Vestibular rehabilitation contributed to improvement of headache both in patients with VM and patients with dizziness and tension-type headache, in addition to improvement of dizziness and psychological factors. Improvement in dizziness following vestibular rehabilitation could be associated with the improvement of headache more prominently in VM compared with comorbid tension-type headache.

Adherence of older people with instability in vestibular rehabilitation programmes: prediction criteria

OBJECTIVE

To determine whether demographic characteristics or balance examination findings can predict the adherence of older people with instability to a vestibular rehabilitation programme.

METHODS

A prospective case-control study was conducted of 120 patients aged 65 years or more (mean age, 77.3 ± 6.33 years). Two groups were classified according to patients' adherence with the follow-up post-rehabilitation protocol. Analysed variables included: age, sex, body mass index, Timed Up and Go test findings, computerised dynamic posturography, Dizziness Handicap Inventory scores and Short Falls Efficacy Scale - International questionnaire results, number of falls, and type of vestibular rehabilitation.

RESULTS

Two groups were established: adherents (99 individuals) and non-adherents (21 individuals). There were differences between the groups regarding: sex (female-to-male ratio of 4.8:1 in adherents and 1.63:1 in non-adherents), age (higher in non-adherents) and voluntary movement posturographic test results (non-adherents had poorer scores).

CONCLUSION

The patients most likely to abandon a vestibular rehabilitation programme are very elderly males with low scores for centre of gravity balancing and limits of stability.

Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Evidence-Based Clinical Practice Guideline: FROM THE AMERICAN PHYSICAL THERAPY ASSOCIATION NEUROLOGY SECTION

BACKGROUND

Uncompensated vestibular hypofunction results in postural instability, visual blurring with head movement, and subjective complaints of dizziness and/or imbalance. We sought to answer the question, "Is vestibular exercise effective at enhancing recovery of function in people with peripheral (unilateral or bilateral) vestibular hypofunction?"

METHODS

A systematic review of the literature was performed in 5 databases published after 1985 and 5 additional sources for relevant publications were searched. Article types included meta-analyses, systematic reviews, randomized controlled trials, cohort studies, case control series, and case series for human subjects, published in English. One hundred thirty-five articles were identified as relevant to this clinical practice guideline.

RESULTS/DISCUSSION

Based on strong evidence and a preponderance of benefit over harm, clinicians should offer vestibular rehabilitation to persons with unilateral and bilateral vestibular hypofunction with impairments and functional limitations related to the vestibular deficit. Based on strong evidence and a preponderance of harm over benefit, clinicians should not include voluntary saccadic or smooth-pursuit eye movements in isolation (ie, without head movement) as specific exercises for gaze stability. Based on moderate evidence, clinicians may offer specific exercise techniques to target identified impairments or functional limitations. Based on moderate evidence and in consideration of patient preference, clinicians may provide supervised vestibular rehabilitation. Based on expert opinion extrapolated from the evidence, clinicians may prescribe a minimum of 3 times per day for the performance of gaze stability exercises as 1 component of a home exercise program. Based on expert opinion extrapolated from the evidence (range of supervised visits: 2-38 weeks, mean = 10 weeks), clinicians may consider providing adequate supervised vestibular rehabilitation sessions for the patient to understand the goals of the program and how to manage and progress themselves independently. As a general guide, persons without significant comorbidities that affect mobility and with acute or subacute unilateral vestibular hypofunction may need once a week supervised sessions for 2 to 3 weeks; persons with chronic unilateral vestibular hypofunction may need once a week sessions for 4 to 6 weeks; and persons with bilateral vestibular hypofunction may need once a week sessions for 8 to 12 weeks. In addition to supervised sessions, patients are provided a daily home exercise program.

DISCLAIMER

These recommendations are intended as a guide for physical therapists and clinicians to optimize rehabilitation outcomes for persons with peripheral vestibular hypofunction undergoing vestibular rehabilitation.Video Abstract available for more insights from the author (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A124).

The value of close monitoring in vestibular rehabilitation therapy

BACKGROUND

Vestibular rehabilitation therapy is a well-established treatment modality for patients with vestibular problems.

HYPOTHESIS

Performing vestibular rehabilitation therapy in a closely monitored setting may result in a better outcome than a home exercise programme.

METHODS

A retrospective study was conducted of patients undergoing vestibular rehabilitation therapy between June 2005 and November 2012 in a tertiary university hospital. The Dynamic Gait Index, the main outcome measure, was utilised before and after the rehabilitation programme. The magnitude of improvement for all patients was analysed, mainly to compare the home exercise group with the closely monitored therapy group.

RESULTS

Only 32 patients underwent the vestibular rehabilitation therapy programme. In all patients, there was significant improvement in the mean Dynamic Gait Index score (from 11.75 to 17.38; p < 0.01). Dynamic Gait Index improvement was significantly higher with closely monitored therapy (mean improvement of 7.83 vs 2.79; p < 0.01).

CONCLUSION

The small sample size is a major limitation; nevertheless, closely monitored vestibular rehabilitation therapy resulted in improved performance status. More studies are needed to establish the efficiency of vestibular rehabilitation therapy and compare closely monitored therapy with tailored home exercise rehabilitation.

Translation of the Dizziness Handicap Inventory into Chinese, Validation of it, and Evaluation of the Quality of Life of Patients with Chronic Dizziness

The aims of this study were 1) to translate the Dizziness Handicap Inventory (DHI) into Chinese and to validate it and 2) to use the Chinese DHI and the Chinese (Hong Kong) Short Form-36 Health Survey (Chinese [HK] SF-36) to evaluate the quality of life (QoL) of patients with chronic dizziness. Seventy-one patients with 6 months of dizziness due to vestibular dysfunction were evaluated initially, 7 days later (n = 49), and after 7 months of medical treatment (n = 17). The Chinese DHI has been shown to retain good test-retest reliability (intraclass correlation coefficient range, 0.64 to 0.87) and internal consistency (Cronbach alpha coefficient > 0.7) as compared to the original DHI and has a moderate responsiveness (0.54). We find the Chinese DHI to be a valid tool for evaluation of QoL of Chinese patients with dizziness. Low mean scores on the Chinese DHI and Chinese (HK) SF-36 signify that chronic dizziness has a considerable impact on the QoL of these patients.

The Use of Computer-Assisted Home Exercises to Preserve Physical Function after a Vestibular Rehabilitation Program: A Randomized Controlled Study

Objective. The purpose of this study was to evaluate whether elderly patients with vestibular dysfunction are able to preserve physical functional level, reduction in dizziness, and the patient's quality of life when assistive computer technology is used in comparison with printed instructions. Materials and Methods. Single-blind, randomized, controlled follow-up study. Fifty-seven elderly patients with chronic dizziness were randomly assigned to a computer-assisted home exercise program or to home exercises as described in printed instructions and followed for tree month after discharge from an outpatient clinic. Results. Both groups had maintained their high functional levels three months after finishing the outpatient rehabilitation. No statistically significant difference was found in outcome scores between the two groups. In spite of moderate compliance levels, the patients maintained their high functional level indicating that the elderly should not necessarily exercise for the first three months after termination of the training in the outpatient clinic. Conclusion. Elderly vestibular dysfunction patients exercising at home seem to maintain their functional level, level of dizziness, and quality of life three months following discharge from hospital. In this specific setup, no greater effect was found by introducing a computer-assisted training program, when compared to standard home training guided by printed instructions. This trial is registered with NCT01344408.

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.

Reduction of falls in older people by improving balance with vestibular rehabilitation (ReFOVeRe study): design and methods

MAIN OBJECTIVE

Evaluate the effectiveness of vestibular rehabilitation (VR) to improve the balance in older people, assessed immediately afterwards.

SECONDARY OBJECTIVES

(a) To verify the maintenance of improvement of the balance achieved in the medium term (6-12 months). (b) To consider whether this improvement results in a reduction in the number of falls. (c) To compare among themselves the effectiveness of three different methods of VR in improving balance and to explore whether there are differences to achieve a reduction in the number of falls.

METHODOLOGY

DESIGN

Experimental study, single-centre, open, randomised (balanced blocks of patients) in four branches in parallel, in 220 elderly patients (over 64 years) with high risk of falls and a follow-up period of 12 months.

SETTING

Department of Otolaryngology of the University Hospital of Santiago.

PARTICIPANTS

People over 64 years, fulfilling one of the following requirements: (a) At least one fall in the last year. (b) Take at least 16 s or require some support in perform the test "timed up and go". (c) A percentage of average balance in the sensory organisation test (SOT) in the dynamic posturography (CDP) <68%. (d) At least one fall in any of the conditions in the SOT of CDP.

INTERVENTION

Three different protocols of VR.

MAIN OUTCOME MEASURE

The percentage of average balance in the SOT in CDP. Secondary measures: time and supports in the test of "timed up and go", scores of the dynamic posturography and SwayStar system, and rate of falls.

A Career in Inquiry

This article, based on the 52nd Eleanor Clarke Slagle lecture given at the 95th American Occupational Therapy Association Annual Conference & Expo, explores the concept of inquiry as the basis for a career and as an activity of daily living. Using the heliocentric theory and the space program at NASA as examples, the broad concept of inquiry is discussed, because it has led to important changes in society over the course of history. The article describes how a career as a clinician-scientist can be grounded in the concept of inquiry and explains how all occupational therapists and occupational therapy assistants can base their own careers in inquiry, using examples from the early history of the profession of occupational therapy and from work by current investigators. Practical suggestions applicable to every clinician are provided.

Vestibular Function and Activities of Daily Living: Analysis of the 1999 to 2004 National Health and Nutrition Examination Surveys

OBJECTIVE

Vestibular dysfunction increases with age and is associated with mobility difficulties and fall risk in older individuals. We evaluated whether vestibular function influences the ability to perform activities of daily living (ADLs).

METHOD

We analyzed the 1999 to 2004 National Health and Nutrition Examination Survey of adults aged older than 40 years (N = 5,017). Vestibular function was assessed with the Modified Romberg test. We evaluated the association between vestibular function and difficulty level in performing specific basic and instrumental ADLs, and total number of ADL impairments.

RESULTS

Vestibular dysfunction was associated with significantly higher odds of difficulty with nine ADLs, most strongly with difficulty managing finances (odds ratio [OR] = 2.64, 95% confidence interval [CI] = [1.18, 5.90]). In addition, vestibular dysfunction was associated with a significantly greater number of ADL impairments (β = .21, 95% CI = [0.09, 0.33]). This effect size was comparable with the influence of heavy smoking (β = .21, 95% CI = [0.06, 0.36]) and hypertension (β = .10, 95% CI = [0.02, 0.18]) on the number of ADL impairments.

CONCLUSION

Vestibular dysfunction significantly influences ADL difficulty, most strongly with a cognitive rather than mobility-based task. These findings underscore the importance of vestibular inputs for both cognitive and physical daily activities.

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.