Vestibular rehabilitation: useful but not universally so

Electrical stimulation of the vestibular nerve: evaluating effects and potential starting points for optimization in vestibular implants

PURPOSE OF REVIEW

Oscillopsia and unsteadiness are common and highly debilitating symptoms in individuals with bilateral vestibulopathy. A lack of adequate treatment options encouraged the investigation of vestibular implants, which aim to restore vestibular function with motion-modulated electrical stimulation. This review aims to outline the ocular and postural responses that can be evoked with electrical prosthetic stimulation of the semicircular canals and discuss potential approaches to further optimize evoked responses. Particular focus is given to the stimulation paradigm.

RECENT FINDINGS

Feasibility studies in animals paved the way for vestibular implantation in human patients with bilateral vestibulopathy. Recent human trials demonstrated prosthetic electrical stimulation to partially restore vestibular reflexes, enhance dynamic visual acuity, and generate controlled postural responses. To further optimize prosthetic performance, studies predominantly targeted eye responses elicited by the vestibulo-ocular reflex, aiming to minimize misalignments and asymmetries while maximizing the response. Changes of stimulation parameters are shown to hold promise to increase prosthetic efficacy, together with surgical refinements and neuroplastic effects.

SUMMARY

Optimization of the stimulation paradigm, in combination with a more precise electrode placement, holds great potential to enhance the clinical benefit of vestibular implants.

Patient-Reported Outcomes After Vestibular Implantation for Bilateral Vestibular Hypofunction

Importance

Standard-of-care treatment proves inadequate for many patients with bilateral vestibular hypofunction (BVH). Vestibular implantation is an emerging alternative.

Objective

To examine patient-reported outcomes from prosthetic vestibular stimulation.

Design, Setting, and Participants

The Multichannel Vestibular Implant (MVI) Early Feasibility Study is an ongoing prospective, nonrandomized, single-group, single-center cohort study conducted at Johns Hopkins Hospital that has been active since 2016 in which participants serve as their own controls. The study includes adults with severe or profound adult-onset BVH for at least 1 year and inadequate compensation despite standard-of-care treatment. As of March 2023, 12 candidates completed the eligibility screening process.

Intervention

The MVI system electrically stimulates semicircular canal branches of the vestibular nerve to convey head rotation.

Main Outcomes and Measures

Patient-reported outcome instruments assessing dizziness (Dizziness Handicap Inventory [DHI]) and vestibular-related disability (Vestibular Disorders-Activities of Daily Living [VADL]). Health-related quality of life (HRQOL) assessed using the Short Form-36 Utility (SF36U) and Health Utilities Index Mark 3 (HUI3), from which quality-adjusted life-years were computed.

Results

Ten individuals (5 female [50%]; mean [SD] age, 58.5 [5.0] years; range, 51-66 years) underwent unilateral implantation. A control group of 10 trial applicants (5 female [50%]; mean [SD] age, 55.1 [8.5] years; range, 42-73 years) completed 6-month follow-up surveys after the initial application. After 0.5 years of continuous MVI use, a pooled mean (95% CI) of within-participant changes showed improvements in dizziness (DHI, -36; 95% CI, -55 to -18), vestibular disability (VADL, -1.7; 95% CI, -2.6 to -0.7), and HRQOL by SF36U (0.12; 95% CI, 0.07-0.17) but not HUI3 (0.02; 95% CI, -0.22 to 0.27). Improvements exceeded minimally important differences in the direction of benefit (exceeding 18, 0.65, and 0.03, respectively, for DHI, VADL, and SF36U). The control group reported no mean change in dizziness (DHI, -4; 95% CI, -10 to 2), vestibular disability (VADL, 0.1; 95% CI, -0.9 to 1.1) or HRQOL per SF36U (0; 95% CI, -0.06 to 0.05) but an increase in HRQOL per HUI3 (0.10; 95% CI, 0.04-0.16). Lifetime HRQOL gain for MVI users was estimated to be 1.7 quality-adjusted life-years (95% CI, 0.6-2.8) using SF36U and 1.4 (95% CI, -1.2 to 4.0) using HUI3.

Conclusions and Relevance

This cohort study found that vestibular implant recipients report vestibular symptom improvements not reported by a control group. These patient-reported benefits support the use of vestibular implantation as a treatment for bilateral vestibular hypofunction.

Supervised multicomponent exercise as an adjuvant program for people with unilateral and/or bilateral chronic vestibular hypofunction: EXERVEST study protocol

Background

Unilateral and bilateral peripheral vestibular hypofunction (UVH and BVH) often complains of dizziness, gaze, and balance disturbances. There is a lack of evidence on exercise intervention in UVH and BVH patients. To investigate the effect of an eight-week supervised multicomponent exercise program in people suffering from UVH or BVH in comparison with a control group doing conventional vestibular rehabilitation at home.

Methods

This longitudinal, controlled, randomized, prospective, single-blinded, two-arm, parallel intervention study will include 66 adults (≥18 years old) with chronic UVH or BVH. Participants will be randomly assigned to an exercise intervention group or an attention control group. Participants will be assessed at baseline, after a two-month intervention period, and after a six-month follow-up. The primary variable will be the balance, measured by the dynamic posturography sensory organization test and the Modified Dynamic Gait Index test. Secondary outcome variables will include cardiorespiratory fitness (peak cardiopulmonary exercise test), body composition (bioimpedance and anthropometric variables), physical activity level and sleep quality (accelerometry), health-related quality of life (Dizziness Handicap Inventory questionnaire), emotional state (Beck Depression and Anxiety Inventory questionnaires), and blood pressure monitoring.

Discussion

This study will try to answer whether in people with UVH/BVH, an adjuvant program of multicomponent exercise will help the prognosis of this population.

Trial registration

ClinicalTrials.gov, identifier [NCT05192564]. Verification date: April 2023.

Individualized Vibrotactile Neurofeedback Training in Patients with Chronic Bilateral Vestibulopathy

Patients with bilateral vestibulopathy (BVP) suffer from postural imbalance during daily life conditions, which in turn leads to a high frequency of falls. Unfortunately, vestibular rehabilitation has only modest and somewhat inconsistent effects in this patient group. Approximately 50% of BVP patients show an improved postural control after conventional vestibular rehabilitation training. New and more promising approaches are required. The individualized vibrotactile neurofeedback training (IVNT) in stance and gait conditions has already been described as highly effective in patients with various vestibular disorders. The purpose of the present multicenter study was to determine the efficacy of the IVNT in improving balance, reducing self-perceived disability, and improving gait in patients with confirmed BVP. In total, 22 patients performed the IVNT with the Vertiguard® system for 10 daily sessions. The dizziness handicap inventory (DHI), the stance stability score of the sensory organization test (SOT) and the score for everyday life mobility in stance and gait tasks (SBDT) were obtained immediately before and after the rehabilitation training period, as well as 3 and 12 months later. All measures improved significantly after the IVNT. Between 77.3% and 94.4% of patients showed an individual benefit (depending on outcome measure). The effect was not significantly reduced within the follow-up period of 12 months. The results demonstrate a high efficacy of the IVNT for vestibular rehabilitation in BVP patients.

Durable improvement in participant-reported measures of disability and objective posturography after computerized vestibular retraining

BACKGROUND

Unilateral vestibular deficits are associated with postural instability and loss of quality of life. Common treatments frequently fail to achieve satisfactory outcomes.

OBJECTIVE

To assess the durability of changes in participant-reported disability and objective posturography after computerized vestibular retraining.

METHODS

This was a single-group study. Individuals with persistent symptoms of an objectively determined unilateral vestibular deficit completed questionnaires and posturography assessments before and after twelve sessions of computerized retraining, and 4-6 months and 10-12 months after treatment.

RESULTS

13 participants completed the post-treatment assessments; 9 completed the follow up. Mean improvements in perceived disability at 4-6 months after retraining were: DHI 14.3 points (95% confidence interval 4.0 to 24.5), ABC scale 14.9 points (4.3 to 25.6), FES-I 11.6 points (-3.2 to 26.5).The SOT composite score increased by 11.4 points (95% CI 1.9 to 20.9; p = 0.0175) immediately after treatment, 8.9 points (-2.9 to 20.7; p = 0.1528) at 4-6 months, and 10.6 points (2.2 to 19.0; p = 0.0162) after 10-12 months. At the 10-12 month time point, the areas of the functional stability region increased significantly for both endpoint excursion (p = 0.0086) and maximum excursion (p = 0.0025).

CONCLUSION

Computerized vestibular retraining was associated with improved participant reported disability and objective measures of postural stability.

Combining vestibular rehabilitation with noisy galvanic vestibular stimulation for treatment of bilateral vestibulopathy

OBJECTIVE

Noisy galvanic vestibular stimulation (nGVS) has been shown to partly restore vestibular function and to stabilize stance and gait in patients with incomplete bilateral vestibulopathy (BVP). Here, we examined potential synergistic effects of nGVS when combined with standardized vestibular rehabilitation training (VRT).

METHODS

23 patients with confirmed BVP received a 30-min vestibular rehabilitation training (VRT) program three times a week for 2 weeks. The intervention group (n = 12) was stimulated with nGVS (at individually determined optimal amplitudes) during training, whereas the control group (n = 11) received zero-amplitude nGVS (sham stimulation) during training. Outcome measurements assessed at baseline, after 2 weeks of training, and at 2-week follow-up included quantitative posturography, instrumented gait analysis, Timed Up and Go Test (TUG), Functional Gait Assessment (FGA), and clinical scores related to quality of life and balance confidence.

RESULTS

After 2 weeks of VRT, all patients showed moderate improvement in balance. Irrespective of nGVS treatment, performance improved in the TUG (p < 0.013), and in the FGA (p < 0.040). Furthermore, base of support when walking with closed eyes was reduced after 2-week training (p < 0.003). Postural sway did not change. There was no difference between groups and thereby no evidence for an additional influence of nGVS on the VRT treatment effects.

CONCLUSION

nGVS does not induce synergistic treatment effects in combination with VRT in patients with BVP when applied during treatment sessions. Hence, rather than being applied in parallel, nGVS and VRT might be complementary therapeutic options with nGVS being used during postural activities in daily life, e.g., walking.

Vestibular therapy to reduce falls in people with Alzheimer's disease: study protocol for a pilot randomized controlled trial

BACKGROUND

Falls are highly common in patients with Alzheimer's disease (AD); around two-thirds of AD patients fall annually. Fall events are major drivers of injury, early institutionalization, and shorter survival. Balance and mobility impairment are among the most important fall risk factors in AD patients. Vestibular therapy (VT) is an effective rehabilitation intervention in improving balance and fall risk through vestibular function, but not often used in AD. We want to evaluate the feasibility of using VT to reduce falls and improve balance function in patients with AD and drive use of an existing, potentially beneficial therapy in a patient population whose high level of vestibular deficits is currently unaddressed.

METHODS

The proposed pilot clinical trial will be a parallel-group randomized controlled trial. Patients with a diagnosis of mild-moderate AD, age ≥ 60, and the presence of a caregiver will be recruited from the Johns Hopkins Memory and Alzheimer's Treatment Center. Eligible patients will be offered vestibular testing. Patients with vestibular loss will be offered participation in the VT trial. One-hundred AD patients with vestibular loss will be enrolled and randomized 1:1 into the control and intervention arms of the trial. All patients will undergo baseline balance and cognitive assessment, followed by 8 weeks of active control therapy or VT, consisting of ~25-min office sessions with a vestibular therapist. Patients will be tracked for falls and undergo follow-up balance and cognitive assessment at 8 and 52 weeks (1 year) to assess the potential short-term and longer-term effects, respectively, of VT on balance and cognition. The main outcomes of this trial are falls, balance (using the Berg Balance Scale and the Timed Up and Go test), and cognition (using the clock drawing test, the Card Rotations test, the Money Road Map test, and the triangle completion task).

DISCUSSION

As the population ages and the number of individuals with AD in the US grows to a projected 14 million in 2050, managing falls in AD will continue to grow as a critical public health concern; this trial assesses feasibility of a potential solution.

TRIAL REGISTRATION

ClinicalTrial.Gov identifier - NCT03799991 . Registered 01 August 2019.

Home-based Vestibular Rehabilitation: A Feasible and Effective Therapy for Persistent Postural Perceptual Dizziness (A Pilot Study)

INTRODUCTION

Persistent postural-perceptual dizziness (PPPD) is a chronic functional vestibular disorder where there is persistent dizziness or unsteadiness occurring on most days for more than 3 months duration. Treatment recommendations for PPPD include vestibular rehabilitation therapy (VRT) with or without medications and/or cognitive behavioral therapy.

OBJECTIVES

This paper is a pilot study designed to compare the effects of Bal Ex as a home-based VRT on the quality of life (EQ-5D), dizziness handicap (DHI) and mental health (DASS-21) against hospital-based VRT.

DESIGN

This was an assessor-blinded, randomized controlled pilot study where PPPD patients were randomly selected to undergo Bal Ex, the home-based VRT (intervention group) or hospital-based (control group) VRT. The participants were reviewed at 4 weeks and 12 weeks after the start of therapy to assess the primary endpoints using the subjective improvement in symptoms as reported by patients, changes in DHI scores, DASS-21 scores and EQ5D VAS scores.

RESULTS

Thirty PPPD patients successfully completed the study with 15 in each study group. Within 4 weeks, there were significant improvements in the total DHI scores as well as anxiety levels. By the end of 12 weeks, there were significant improvements in the DHI, DASS-21 and EQ5D. The degree of improvement between Bal Ex and the control was comparable.

CONCLUSION

VRT is an effective modality in significantly improving quality of life, dizziness handicap, depression, and anxiety levels within 3 months in PPPD. Preliminary results show Bal Ex is as effective as hospital-based VRT and should be considered as a treatment option for PPPD.

Advocacy for Change: An Osteopathic Review of Traumatic Brain Injury Among Combat Veterans

As a "signature injury" of the Iraq and Afghanistan wars, traumatic brain injury (TBI) remains a major health concern among military service members. Traumatic brain injury is associated with a wide range of symptoms which may be cognitive, emotional, psychological, biochemical, and social in nature. Mild TBI (mTBI) ranks as the most common traumatic brain injury among veterans. Due to the absence of specific symptoms, mTBI diagnosis may be challenging in acute settings. Repetitive traumatic brain injury during combat deployments can lead to devastating chronic neurodegenerative diseases and other major life disruptions. Many cases of TBI remain undetected in veterans and may lead to long-term adverse comorbidities such as post-traumatic stress disorder (PTSD), suicide, alcohol disorders, psychiatric diagnoses, and service-related somatic dysfunctions. Veterans with TBI are almost twice as likely to die from suicide in comparison to veterans without a history of TBI. Veterans diagnosed with TBI experience significant comorbid conditions and thus advocacy for improved care is justified and necessary. Given the complexity and variation in the symptomatology of TBI, a personalized, multimodal approach is warranted in the evaluation and treatment of veterans with TBI and other associated conditions. As such, this review provides a broad overview of treatment options, with an emphasis on advocacy and osteopathic integration in the standard of care for veterans.

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.

Dizziness and physical health are associated with pain in dizzy patients-A cross-sectional study

BACKGROUND AND PURPOSE

Associations between dizziness, health-related quality of life, and musculoskeletal pain have not been systematically explored in patients with vestibular disorders. Such knowledge may be important for choice of treatments. The study objectives were to examine the extent and localization of musculoskeletal pain and explore whether pain was associated with dizziness and health-related quality of life.

METHODS

The cross-sectional study investigated anonymized data from an earlier survey on patients with long-lasting dizziness (>3 months) examined in an oto-rhino-laryngological department. The sample includes patient between 18 and 70 years with Ménière's disease, vestibular schwannoma, benign positional paroxysmal vertigo, vestibular neuritis, non-otogenic dizziness, and cervicogenic dizziness. General musculoskeletal, that is, pain in muscles, tendons, and joints was registered by a yes/no question. A pain drawing registered localization of pain. Multiple binary logistic regression models were used to determine the association between pain and vertigo-balance and autonomic-anxiety related dizziness by the short Vertigo Symptom Scale (VSS) and sub-scales (VSS-V, VSS-A), and between pain and health-related quality of life by the SF-36, mental and physical component summary scale (SF-36 MCS, SF-36 PCS).

RESULTS

The sample consisted of 503 patients, 60.2% were women, the median age was 50 years. General musculoskeletal pain was reported by 72.8% of patients, neck pain by 59.2% and widespread pain by 21.9%. Multiple binary logistic regression models demonstrated that all the pain measures were significantly associated with VSS-V and VSS-A and SF-36 PCS, but not SF-36 MCS.

DISCUSSIONS

Musculoskeletal pain is prevalent in patients with long-lasting dizziness. The strong associations between pain, VSS, and SF-36 PCS could result in a self-sustaining complex condition. The findings imply that in addition to assessing and treating the vestibular symptoms, musculoskeletal symptoms and physical health should be addressed.

Effects of customized vestibular rehabilitation plus canalith repositioning maneuver on gait and balance in adults with Benign Paroxysmal Positional Vertigo: A Randomized Controlled Trial

BACKGROUND

Adults with unilateral posterior canal benign paroxysmal positional vertigo (BPPV) may continue to present with residual dizziness and balance impairments after the canalith repositioning maneuver (CRM). Customized Vestibular rehabilitation (VR) in addition to the standard CRM may improve postural control in adults with BPPV. However, the effectiveness of this intervention for improving dyanmic gait measures in adults with BPPV is unknown.

OBJECTIVE

We aimed to determine the effectiveness of customized VR in addition to the standard CRM on dynamic gait measures among adults with unilateral posterior canal BPPV.

METHODS

In this double blind, randomized controlled trial, 28 adults with BPPV were randomized to either control (n = 14, age: 54.36±8.55) or experimental (n = 14, age: 50.71±9.88) groups. The experimental and control groups received customized VR plus standard CRM for six weeks and standard CRM for two weeks respectively. Dynamic gait measures (duration of a complete gait cycle, stride velocity, turning duration and number of steps while turning) were recorded using a portable mobility sensor (iTUG) at baseline, week 4 and 6. A mixed model ANOVA was used to estimate the main effects of the interventions.

RESULTS

During walking, a group effect was demonstrated on gait duration, stride velocity, turning duration and number of steps while turning (p <  0.05).

CONCLUSIONS

Six weeks of customized VR performed in addition to the standard CRM was more effective than the standard CRM alone in improving balance and gait in adults with posterior canal BPPV. (252 words).

Differences in Vestibular-Evoked Myogenic Potential Responses by Using Cochlear Implant and Otolith Organ Direct Stimulation

Objective: Several studies have demonstrated the possibility to obtain vestibular potentials elicited with electrical stimulation from cochlear and vestibular implants. The objective of this study is to analyze the vestibular-evoked myogenic potentials (VEMPs) obtained from patients implanted with cochlear and vestibulo-cochlear implant. Material and Methods: We compared two groups: in the first group, four cochlear implant (CI) recipients with present acoustic cVEMPs before CI surgery were included. In the second group, three patients with bilaterally absent cVEMPs and bilateral vestibular dysfunction were selected. The latter group received a unilateral cochleo-vestibular implant. We analyze the electrically elicited cVEMPs in all patients after stimulation with cochlear and vestibular electrode array stimulation. Results: We present the results obtained post-operatively in both groups. All patients (100%) with direct electrical vestibular stimulation via the vestibular electrode array had present cVEMPs. The P1 and N1 latencies were 11.33-13.6 ms and 18.3-21 ms, respectively. In CI patients, electrical cVEMPs were present only in one of the four subjects (25%) with cochlear implant ("cross") stimulation, and P1 and N1 latencies were 9.67 and 16.33, respectively. In these patients, the responses present shorter latencies than those observed acoustically. Conclusions: Electrically evoked cVEMPs can be present after cochlear and vestibular stimulation and suggest stimulation of vestibular elements, although clinical effect must be further studied.

Once-Daily Incremental Vestibular-Ocular Reflex Adaptation Training in Patients With Chronic Peripheral Vestibular Hypofunction: A 1-Week Randomized Controlled Study

BACKGROUND AND PURPOSE

This was a double-blinded randomized controlled study to investigate the effects of once-daily incremental vestibulo-ocular reflex (VOR) training over 1 week in people with chronic peripheral vestibular hypofunction.

METHODS

A total of 24 patients with peripheral vestibular hypofunction were randomly assigned to intervention (n = 13) or control (n = 11) groups. Training consisted of either x1 (control) or incremental VOR adaptation exercises, delivered once daily for 15 minutes over 4 days in 1 week. Primary outcome: VOR gain with video-oculography. Secondary outcomes: Compensatory saccades measured using scleral search coils, dynamic visual acuity, static balance, gait, and subjective symptoms. Between-group differences were analyzed with a linear mixed-model with repeated measures.

RESULTS

There was a difference in the VOR gain increase between groups (P < 0.05). The incremental training group gain increased during active (13.4% ± 16.3%) and passive (12.1% ± 19.9%) head impulse testing (P < 0.02), whereas it did not for the control group (P = 0.59). The control group had reduced compensatory saccade latency (P < 0.02). Both groups had similarly improved dynamic visual acuity scores (P < 0.05). Both groups had improved dynamic gait index scores (P < 0.002); however, only the incremental group had improved scores for the 2 walks involving head oscillations at approximately 2 Hz (horizontal: P < 0.05; vertical: P < 0.02), increased gait speed (P < 0.02), and step length (P < 0.01) during normal gait, and improved total Dizziness Handicap Inventory (P < 0.05).

CONCLUSIONS

Our results suggest incremental VOR adaptation significantly improves gain, gait with head rotation, balance during gait, and symptoms in patients with chronic peripheral vestibular hypofunction more so than conventional x1 gaze-stabilizing exercises.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A336).

Effectiveness of whole-body vibration or biofeedback postural training as an add-on to vestibular exercises rehabilitation therapy in chronic unilateral vestibular weakness: A randomized controlled study

BACKGROUND

The efforts to achieve better functional results in vestibular rehabilitation have been continued by using different visual and somatosensory stimuli for a long time. Whole-body vibration (WBV) is a mechanical vertical stimulation that provides high frequency vibration stimulus to the proprioceptive receptors. Biofeedback provides continuous information to the subject regarding postural changes. These techniques may aid to improve vestibular rehabilitation.

OBJECTIVE

We aimed to investigate the effect of adding WBV or biofeedback postural training (BPT) to standard rehabilitation exercises in patients with chronic unilateral vestibular weakness.

METHODS

Ninety patients were randomized into three groups. Group 1 had WBV and Group 2 BPT in addition to the standard rehabilitation exercises. Group 3 only carried out the home-based exercises and served as the control. Outcome measures such as static posturography, Berg Balance Scale, Timed Up-and-Go test, Visual Analog Scale, and Dizziness Handicap Inventory (DHI) were used for comparison.

RESULTS

Statistically significant gains were achieved in all groups with all parameters at the end of treatment when compared to baseline (p < 0.05). The patients in Group 1 (WBV), however, were significantly better than those in Groups 2 and 3 at the static posturographic stability score, Berg Balance Scale, and DHI (p < 0.05).

CONCLUSION

Adding WBV to a rehabilitation program may be an effective strategy to improve postural stability and achieve better physical, functional and emotional outcomes.

Factors Associated With Rehabilitation Outcomes in Patients With Unilateral Vestibular Hypofunction: A Prospective Cohort Study

OBJECTIVE

The purpose of this study was to determine factors associated with rehabilitation outcomes following vestibular rehabilitation (VR).

METHODS

In this prospective cohort study, 116 patients who completed at least 2 supervised sessions participated. Patient characteristics and comorbidities were recorded. Initial and discharge measures included symptom intensity, balance confidence, quality of life, percent of time symptoms interfere with life, perceived benefits of VR, gait speed, fall risk, visual acuity during head movement, and anxiety/depression. Intention-to-treat analyses were performed to determine outcomes at discharge. Bivariate correlations between independent (group characteristics and baseline measures) and dependent (discharge measures) variables were determined. Logistic regressions were performed to identify factors associated with whether a patient would have a normal score or meaningful change at discharge.

RESULTS

There was a large effect of VR with significant improvement for the group as a whole on each outcome measure. For each outcome measure, most patients improved. Based on preliminary logistic regression, 2 patient characteristics were associated with outcome: number of therapy visits predicted meaningful improvement in gait speed, and falls after the onset of the unilateral vestibular hypofunction (UVH) predicted meaningful change in the percent of time symptoms interfered with life. Initial Activities-Specific Balance Confidence Scale (ABC) and Dynamic Gait Index scores predicted normal ABC scores at discharge, and initial ABC scores predicted recovery of Dynamic Gait Index scores. Preliminary prediction models were generated for balance confidence, impact of dizziness on life, dynamic visual acuity, gait speed, and fall risk.

CONCLUSIONS

Therapists may use these findings for patient education or to determine the need for adjunct therapy, such as counseling.

IMPACT

Not all people with UVH improve following VR, but there is little research examining why. This study looked at multiple factors and identified number of visits and falls after onset of UVH as patient characteristics associated with outcomes following VR; these findings will help therapists create better predictive models.

Simultaneous activation of multiple vestibular pathways upon electrical stimulation of semicircular canal afferents

Background and purpose

Vestibular implants seem to be a promising treatment for patients suffering from severe bilateral vestibulopathy. To optimize outcomes, we need to investigate how, and to which extent, the different vestibular pathways are activated. Here we characterized the simultaneous responses to electrical stimuli of three different vestibular pathways.

Methods

Three vestibular implant recipients were included. First, activation thresholds and amplitude growth functions of electrically evoked vestibulo-ocular reflexes (eVOR), cervical myogenic potentials (ecVEMPs) and vestibular percepts (vestibulo-thalamo-cortical, VTC) were recorded upon stimulation with single, biphasic current pulses (200 µs/phase) delivered through five different vestibular electrodes. Latencies of eVOR and ecVEMPs were also characterized. Then we compared the amplitude growth functions of the three pathways using different stimulation profiles (1-pulse, 200 µs/phase; 1-pulse, 50 µs/phase; 4-pulses, 50 µs/phase, 1600 pulses-per-second) in one patient (two electrodes).

Results

The median latencies of the eVOR and ecVEMPs were 8 ms (8–9 ms) and 10.2 ms (9.6–11.8 ms), respectively. While the amplitude of eVOR and ecVEMP responses increased with increasing stimulation current, the VTC pathway showed a different, step-like behavior. In this study, the 200 µs/phase paradigm appeared to give the best balance to enhance responses at lower stimulation currents.

Conclusions

This study is a first attempt to evaluate the simultaneous activation of different vestibular pathways. However, this issue deserves further and more detailed investigation to determine the actual possibility of selective stimulation of a given pathway, as well as the functional impact of the contribution of each pathway to the overall rehabilitation process.

Influence of vestibular rehabilitation on the recovery of all vestibular receptor organs in patients with unilateral vestibular hypofunction

BACKGROUND

Only a few studies in the literature demonstrate the effect of vestibular rehabilitation (VR) on all vestibular receptor organs. Furthermore, very little evidence of the effect of VR on isolated otolith dysfunction (IOD) is available.

OBJECTIVE

The study aimed to investigate the effect of VR on all vestibular receptor organs in patients with different types of unilateral vestibular hypofunction (UVH).

METHODS

We enrolled 80 patients with three different types of UVH; combined and isolated loss of semicircular canal and otolith organ function. All patients performed a 12-week customized program of VR and received a full battery of vestibular function tests, before and after the VR. The DHI and SF-36 were performed before, after 6 weeks, and 12 weeks of the VR.

RESULTS

Parameters of the caloric test, video head impulse test, ocular and cervical vestibular evoked myogenic potentials were significantly improved after VR. A total of 59 (74%) patients fully recovered, with no significant difference in recovery regarding the type (p = 0.13) and stage of UVH (p = 0.13). All patients reported significantly lower disability and a better quality of life after the VR based on the DHI and SF-36 score.

CONCLUSIONS

Vestibular rehabilitation has a positive effect on the recovery of all vestibular receptor organs and it should be used in patients with IOD.

Evaluation of vocal changes after vestibular rehabilitation in patients with balance disorders

BACKGROUND

Although there are articles and studies that associate postural changes with changes in vocal quality, to the best of our knowledge, this was the first study investigating the association between balance disorders and voice.

OBJECTIVE

This study aimed to determine whether patients with balance disorders present any clinical, acoustic, or endoscopic vocal changes, and if the correction of balance impairments, such as through vestibular rehabilitation, lead to improvement in vocal quality.

METHODS

This was a prospective cohort study that analyzed vocal differences (clinical, videoendostroboscopic, audio-perceptual, and acoustic vocal parameters) in a sample of 43 patients with vestibular dysfunction at three different time points (pre-treatment, post-treatment, and 3 months' post-treatment) diagnosed by videonystagmography with changes in computerized dynamic posturography who were treated with vestibular rehabilitation.

RESULTS

In pre-treatment, all of the patients presented supraglottic hyperfunction during videoendoscopic examination and abnormal values in the audio-perceptual scale. After treatment for balance disorders, there was a statistically significant improvement in some parameters of the videoendoscopic and audio-perceptual measures. These improvements were detected immediately after treatment and remained present until at least three months after treatment.

CONCLUSIONS

The results suggested that the treatment for balance disorders results in changes in posture and consequently in voice quality.

Cervical myogenic potentials and controlled postural responses elicited by a prototype vestibular implant

Gaze stabilization and postural control are two key functions of the vestibular system. In consequence, oscillopsia and chronic imbalance are the two main complaints of patients presenting with a severe bilateral vestibular function loss. The vestibular implant is emerging as a promising treatment for this group of patients whose quality of life is significantly impaired. Although the final aim of the vestibular implant should be to restore vestibular function as a whole, until now the research has focused mainly on the restoration of the vestibulo-ocular reflex to improve gaze stabilization. In this study, we aimed to explore whether the vestibulo-collic and vestibulo-spinal pathways could be activated and controlled with the electrical stimuli provided by our vestibular implant prototype. This was first explored and demonstrated with recordings of electrically elicited cervical vestibular evoked myogenic potentials (ecVEMPs). ecVEMPs with characteristics similar to the classical acoustically elicited cervical vestibular evoked myogenic potentials (cVEMPs) were successfully evoked in five out of the eight tested patients. Amplitudes of the electrically elicited N–P complex varied, ranging from 44 to 120 µV. Mean latencies of the N and P waves were of 9.71(± 1.17) ms and 17.24 ms (± 1.74), respectively. We also evaluated the possibility of generating controlled postural responses using a stepping test. Here, we showed that controlled and consistent whole-body postural responses can be effectively obtained with rapid changes in the “baseline” (constant rate and amplitude) electrical activity delivered by the vestibular implant in two out of the three tested subjects. Furthermore, obtained amplitude of body rotations was significantly correlated with the intensity of stimulation and direction of body rotations correlated with the side of the delivered stimulus (implanted side). Altogether, these data suggest that the vestibular implant could also be used to improve postural control in patients with bilateral vestibulopathy.

Chronic Progressive External Ophthalmoplegia and Bilateral Vestibular Hypofunction: Balance, Gait, and Eye Movement Before and After Multimodal Chiropractic Care: A Case Study

Objective

The purpose of this report is to describe care of a patient with chronic progressive external ophthalmoplegia and bilateral vestibular hypofunction.

Clinical Features

A 66-year-old patient presented with limited eye movement and mild ptosis, which led to a diagnosis of chronic progressive external ophthalmoplegia. Rotary chair testing suggested vestibular involvement. Other symptoms included dizziness, problems with balance, and chronic stiffness in his cervical and thoracic regions. He had anxiety about loss of function and limited exercise habits because of fear of falling. Examination methods included balance assessment, kinetic aspects of walking, and videonystagmography.

Intervention and Outcome

He had already begun regular practice of vestibular rehabilitation exercises before receiving 18 sessions of manual and instrument-assisted chiropractic manipulation, along with mobilization, stretching, and transverse massage, over 37 weeks. In addition to self-reported improvements, there was substantially decreased postural sway during balance assessment and there were small improvements in eye movement, ptosis, and walking.

Conclusion

This patient showed improvements in balance, eye movements, and walking while undergoing multimodal chiropractic care and practicing eye and balance exercises.

A pilot study investigating the association between chronic bilateral vestibulopathy and components of a clinical functional assessment tool

BACKGROUND

This study aimed to analyze the association between prospectively assessed falls and functional abilities in patients with bilateral vestibulopathy (BVP).

METHODS

Nineteen BVP patients had functional abilities assessed at baseline with the expanded timed get-up-and-go (ETGUG) test. Falls were prospectively recorded with a monthly "fall calendar" over a one-year period. Association between baseline functional abilities and falls was evaluated by Mann-Whitney U testing. Logistic regression was applied to describe the relationship between falls and functional abilities. Area under the receiver-operating characteristic curve (AUC) was used predicting falls based on gait speed.

RESULTS

Eight (45%) of 18 patients (61.11 ± 15.19 years, 12 male) reported 19 falls. Fallers had a significantly faster preferred gait speed (p = 0.03) in the fifth component of the ETGUG. Preferred gait speed was a significant factor in the prediction of falls model (odds ratio = 2.00, p = 0.05, CI = 1.00/4.00 per 10 cm/s). ACU was 0.80 and the cutoff score of 1.35m/s (sensitivity = 75%, specificity = 70%) in predicting falls.

DISCUSSION

BVP patients classified as fallers demonstrated significant faster gait speed after a turning maneuver. Future studies in larger BVP patient samples are needed to refute or confirm our findings.

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.

Patients with chronic peripheral vestibular hypofunction compared to healthy subjects exhibit differences in gaze and gait behaviour when walking on stairs and ramps

Objective

The aim of this study was to compare gaze behaviour during stair and ramp walking between patients with chronic peripheral vestibular hypofunction and healthy human subjects.

Methods

Twenty four (24) patients with chronic peripheral vestibular hypofunction (14 unilateral and 10 bilateral) and 24 healthy subjects performed stair and ramp up and down walks at self-selected speed. The walks were repeated five times. A mobile eye tracker was used to record gaze behaviour (defined as time directed to pre-defined areas) and an insole measurement device assessed gait (speed, step time, step length). During each walk gaze behaviour relative to i) detection of first transition area “First TA”, ii) detection of steps of the mid-staircase area and the handrail “Structure”, iii) detection of second transition area “Second TA”, and iv) looking elsewhere “Elsewhere” was assessed and expressed as a percentage of the walk duration. For all variables, a one-way ANOVA followed by contrast tests was conducted.

Results

Patients looked significantly longer at the “Structure” (p<0.001) and “Elsewhere” (p<0.001) while walking upstairs compared to walking downstairs (p<0.013). Patients looked significantly longer at the “Structure” (p<0.001) and “Elsewhere” (p<0.001) while walking upstairs compared to walking downstairs (p<0.013). No differences between groups were observed for the transition areas with exception of stair ascending. Patients were also slower going downstairs (p = 0.002) and presented with an increased step time (p = 0.003). Patients were walking faster up the ramp (p = 0.014) with longer step length (p = 0.008) compared to walking down the ramp (p = 0.050) with shorter step length (p = 0.024).

Conclusions

Patients with chronic peripheral vestibular hypofunction differed in time directed to pre-defined areas during stair and ramp walking and looked longer at stair and ramp areas of interest during walking compared to healthy subjects. Patients did not differ in time directed to pre-defined areas during the stair-floor transition area while going downstairs, an area where accidents may frequently occur.

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).

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.

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

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

Vestibular assessment: a practical approach

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

Vestibular rehabilitation for unilateral peripheral vestibular dysfunction

BACKGROUND

This is an update of a Cochrane review first published in The Cochrane Library in Issue 4, 2007 and previously updated in 2011.Unilateral peripheral vestibular dysfunction (UPVD) can occur as a result of disease, trauma or postoperatively. The dysfunction is characterised by complaints of dizziness, visual or gaze disturbances and balance impairment. Current management includes medication, physical manoeuvres and exercise regimes, the latter known collectively as vestibular rehabilitation.

OBJECTIVES

To assess the effectiveness of vestibular rehabilitation in the adult, community-dwelling population of people with symptomatic unilateral peripheral vestibular dysfunction.

SEARCH METHODS

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The most recent search was 18 January 2014.

SELECTION CRITERIA

Randomised controlled trials of adults living in the community, diagnosed with symptomatic unilateral peripheral vestibular dysfunction. We sought comparisons of vestibular rehabilitation versus control (e.g. placebo), other treatment (non-vestibular rehabilitation, e.g. pharmacological) or another form of vestibular rehabilitation. Our primary outcome measure was change in the specified symptomatology (for example, proportion with dizziness resolved, frequency or severity of dizziness). Secondary outcomes were measures of function, quality of life and/or measure(s) of physiological status, where reproducibility has been confirmed and shown to be relevant or related to health status (for example, posturography), and adverse effects

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We included 39 studies involving 2441 participants with unilateral peripheral vestibular disorders in the review. Trials addressed the effectiveness of vestibular rehabilitation against control/sham interventions, medical interventions or other forms of vestibular rehabilitation. Non-blinding of outcome assessors and selective reporting were threats that may have biased the results in 25% of studies, but otherwise there was a low risk of selection or attrition bias.Individual and pooled analyses of the primary outcome, frequency of dizziness, showed a statistically significant effect in favour of vestibular rehabilitation over control or no intervention (odds ratio (OR) 2.67, 95% confidence interval (CI) 1.85 to 3.86; four studies, 565 participants). Secondary outcomes measures related to levels of activity or participation measured, for example, with the Dizziness Handicap Inventory, which also showed a strong trend towards significant differences between the groups (standardised mean difference (SMD) -0.83, 95% CI -1.02 to -0.64). The exception to this was when movement-based vestibular rehabilitation was compared to physical manoeuvres for benign paroxysmal positional vertigo (BPPV), where the latter was shown to be superior in cure rate in the short term (OR 0.19, 95% CI 0.07 to 0.49). There were no reported adverse effects.

AUTHORS' CONCLUSIONS

There is moderate to strong evidence that vestibular rehabilitation is a safe, effective management for unilateral peripheral vestibular dysfunction, based on a number of high-quality randomised controlled trials. There is moderate evidence that vestibular rehabilitation resolves symptoms and improves functioning in the medium term. However, there is evidence that for the specific diagnostic group of BPPV, physical (repositioning) manoeuvres are more effective in the short term than exercise-based vestibular rehabilitation; although a combination of the two is effective for longer-term functional recovery. There is insufficient evidence to discriminate between differing forms of vestibular rehabilitation.

Computer-assisted training as a complement in rehabilitation of patients with chronic vestibular dizziness--a randomized controlled trial

OBJECTIVE

To compare a computer-assisted home exercise program with conservative home-training following printed instructions in the rehabilitation of elderly patients with vestibular dysfunction.

DESIGN

Single-blind, randomized, controlled trial.

SETTING

Geriatric department of a university hospital.

PARTICIPANTS

Patients with chronic dizziness due to vestibular dysfunction (N=63) were randomly assigned to either rehabilitation in the clinic followed by computer-assisted home exercises (intervention group: n=32) or rehabilitation in the clinic followed by home exercises according to printed instructions (control group: n=31).

INTERVENTIONS

Patients in the intervention group received assisted rehabilitation by a computer program.

MAIN OUTCOME MEASURES

Measurements at baseline and at 8 and 16 weeks were compared. These included the One Leg Stand Test, Dynamic Gait Index, Chair Stand Test, Motion Sensitivity Test, Short Form-12, Dizziness Handicap Inventory, and visual analog scale.

RESULTS

Both groups improved significantly during 16 weeks of rehabilitation. However, neither t tests nor repeated-measures analysis of variance demonstrated any significant differences between the 2 groups. The overall compliance rate to computer program exercises during 16 weeks was 57%.

CONCLUSIONS

A computer-assisted program to support the home training of elderly patients with vestibular dysfunction did not improve rehabilitation more than did printed instructions.

The Efficacy of Vestibular Rehabilitation in Patients with Benign Paroxysmal Positional Vertigo

Objective

To systematically review the evidence on the effectiveness of vestibular rehabilitation in addition to a canalith repositioning maneuver in patients with benign paroxysmal positional vertigo.

Data Sources

A literature search was performed in the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, and EMBASE databases.

Review Methods

A comprehensive search was performed up to July 2013. Two authors independently scanned the search results to identify randomized controlled trials of vestibular rehabilitation in addition to a canalith repositioning maneuver in patients with benign paroxysmal positional vertigo. We included trials that were available in the English language and did not apply publication year or publication status restrictions. Studies were methodologically assessed using the Cochrane risk of bias tool. Primary outcome was the effect on vertigo attacks and balance.

Results

Of 76 identified trials, only 2 trials fulfilled our inclusion criteria and were included in this review, involving 106 patients. One study was methodologically weak, the other strong. The studies differed in type of intervention, type of outcome, and follow-up time. Both studies reported no significant difference in the vertigo intensity between groups. A small effect was found on balance.

Conclusion

Two level II studies in benign paroxysmal positional vertigo showed no effect of vestibular rehabilitation in addition to a canalith repositioning maneuver on vertigo intensity and a small, beneficial effect on balance. We therefore conclude that there is no evidence for an effect of vestibular rehabilitation in addition to a canalith repositioning maneuver in patients with benign paroxysmal positional vertigo.

Examination and treatment of patients with unilateral vestibular damage, with focus on the musculoskeletal system: a case series

BACKGROUND AND PURPOSE

Persistent dizziness and balance problems have been reported in some patients with unilateral vestibular pathology. The purpose of this case series was to address the examination and treatment of musculoskeletal dysfunction in patients with unilateral vestibular hypofunction.

CASE DESCRIPTION

The musculoskeletal system was evaluated with the Global Physiotherapy Examination, dynamic balance was measured during walking with triaxial accelerometers positioned on the lower and upper trunk, and symptoms and functional limitations were assessed with standardized self-report measures. The 4 included patients had symptoms of severe dizziness that had lasted more than 1 year after the onset of vestibular dysfunction and a moderate level of perceived disability. Musculoskeletal abnormalities typically included postural misalignment, restricted abdominal respiration, restricted trunk movements, and tense muscles of the upper trunk and neck. The patients attended a modified vestibular rehabilitation program consisting of body awareness exercises addressing posture, movements, and respiration.

OUTCOMES

After the intervention, self-reported symptoms and perceived disability improved. Improvements in mobility and positive physical changes were found in the upper trunk and respiratory movements. The attenuation of mediolateral accelerations (ie, body oscillations) in the upper trunk changed; a relatively more stable upper trunk and a concomitantly more flexible lower trunk were identified during walking in 3 patients.

DISCUSSION

The recovery process may be influenced by self-inflicted rigid body movements and behavior strategies that prevent compensation. Addressing physical dysfunction and enhancing body awareness directly and dizziness indirectly may help patients with unilateral vestibular hypofunction break a self-sustaining cycle of dizziness and musculoskeletal problems. Considering the body as a functional unit and including both musculoskeletal and vestibular systems in examination and treatment may be important.

Differences in Symptoms among Adults with Canal versus Otolith Vestibular Dysfunction: A Preliminary Report

Despite the importance of symptomatology in the diagnosis of vestibular dysfunction, the qualitative nature of the symptoms related to semicircular canal (canal) versus otolith dysfunction is not fully understood. The purpose of this study was to compare symptoms, and their severity, in individuals with canal versus otolith peripheral vestibular dysfunction. A subjective tool, the Descriptive Symptom Index (DSI), was developed to enable categorization of symptoms as rotary, linear, imbalance or falls, and nondistinct. Fourteen adults were recruited and grouped based on vestibular function testing: canal only dysfunction, otolith only dysfunction, or canal and otolith dysfunction. Also, the Dizziness Handicap Inventory (DHI) was used to grade the severity of perceived limitations due to symptoms. The DSI was reliable and differentiated those with canal (rotary symptoms) versus otolith (linear symptoms) dysfunction. Most individuals with otolith only dysfunction did not report rotary symptoms. DHI scores were significantly higher in those with otolith dysfunction, regardless of canal functional status. All who experienced falls had otolith dysfunction and none had canal only dysfunction. Results support the importance of using linear and rotary descriptors of perceived disorientation as part of diagnosing vestibular dysfunction.

Performance of high school adolescents on functional gait and balance measures

PURPOSE

To describe the performance of high school adolescents during common functional gait and balance measures used in vestibular physical therapy.

METHODS

A cross-sectional study of 91 participants determined their performance on the Activities-specific Balance Confidence (ABC) scale, Dynamic Gait Index, Functional Gait Assessment, Timed "Up and Go" (TUG), Five Times Sit to Stand (FTSTS) test, tests of gait speed (GS), and the Balance Error Scoring System. In a subset of this sample, GS, TUG, and the FTSTS were repeated twice to examine test-retest reliability.

RESULTS

The measures of GS, TUG, and FTSTS were normally distributed. The Activities-specific Balance Confidence, Dynamic Gait Index, and Functional Gait Assessment exhibited a ceiling effect. The timed measures exhibited moderate to good reliability.

CONCLUSIONS

These performance scores may provide end points for discharge from vestibular physical therapy. However, clinicians should be aware of the ceiling effect exhibited by some measures.

Exercise prescription patterns in patients treated with vestibular rehabilitation after concussion

BACKGROUND AND PURPOSE

Individuals with concussion often complain of persistent dizziness and imbalance, and these problems have been treated with vestibular rehabilitation exercises. The purpose of this study is to describe the vestibular rehabilitation exercise prescriptions provided to individuals after concussion.

METHODS

A retrospective chart review of vestibular rehabilitation home exercise programmes prescribed by physical therapists for 104 participants who were diagnosed with concussion was conducted. Each of the exercises was classified by exercise type, duration and frequency. Frequency counts of the most common exercise types were recorded. Exercise progression patterns were examined by determining how exercise types were modified from visit to visit.

RESULTS

Eye-head coordination exercises were the most commonly prescribed exercise type (in 95% of participants), followed by standing static balance exercises (in 88% of participants), and ambulation exercises (in 76% of participants).

CONCLUSIONS

Understanding the prescription patterns of expert clinicians may elucidate the vestibular-related impairments of individuals after concussion and may provide a resource for therapists who may be starting vestibular rehabilitation programmes for management of individuals with concussion. To improve quality of care, future research should be directed to relate outcomes to the exercise prescription patterns.

Effect of Tai Chi on body balance: randomized controlled trial in elderly men with dizziness

The purpose of this study was to assess the effect of 18-week Tai Chi training on body balance in a dynamic trial among elderly men with dizziness. The study covered subjects aged 60 to 80 years. We identified 40 men who reported a history of dizziness. The subjects were recruited using direct mailings and a community information campaign. The participants were randomly assigned to either the exercise intervention (n = 20) or control group (n = 20). The Tai Chi group participated in an 18-week exercise class held for 45 minutes twice a week. Body balance was studied in two ways: using the "8 foot up and go test" (Rikli and Jones 2001) and using a Computer Posturographic System PE 90 (manufactured by Military Institute of Aviation Medicine in Warsaw and outfitted with Pro-Med modified software). The ability to perform specific tasks (maximal deflections in four directions) was measured on the posturographic platform. The variation in results obtained on the first and second date of tests in the experimental and control groups was confirmed statistically using four parameters, i.e. "8 foot up to and go test (H = 8.21;p = 0.003), forward deflection (H = 3.70;p = 0.050), backward deflection (H = 5.04;p = 0.024) and maximum sway area (H = 8.86;p = 0.002). Consequently, we found that the 18-week period of Tai-Chi exercises, with a frequency of twice a week for 45 minutes, is beneficial for dynamic balance, which is important for the reduction of fall risk factors among elderly men with dizziness.

Clinical and cost effectiveness of booklet based vestibular rehabilitation for chronic dizziness in primary care: single blind, parallel group, pragmatic, randomised controlled trial

OBJECTIVE

To determine the clinical and cost effectiveness of booklet based vestibular rehabilitation with and without telephone support for chronic dizziness, compared with routine care.

DESIGN

Single blind, parallel group, pragmatic, randomised controlled trial.

SETTING

35 general practices across southern England between October 2008 and January 2011.

PARTICIPANTS

Patients aged 18 years or over with chronic dizziness (mean duration >five years) not attributable to non-vestibular causes (confirmed by general practitioner) and that could be aggravated by head movement (confirmed by patient).

INTERVENTIONS

Participants randomly allocated to receive routine medical care, booklet based vestibular rehabilitation only, or booklet based vestibular rehabilitation with telephone support. For the booklet approach, participants received self management booklets providing comprehensive advice on undertaking vestibular rehabilitation exercises at home daily for up to 12 weeks and using cognitive behavioural techniques to promote positive beliefs and treatment adherence. Participants receiving telephone support were offered up to three brief sessions of structured support from a vestibular therapist.

MAIN OUTCOME MEASURES

Vertigo symptom scale-short form and total healthcare costs related to dizziness per quality adjusted life year (QALY).

RESULTS

Of 337 randomised participants, 276 (82%) completed all clinical measures at the primary endpoint, 12 weeks, and 263 (78%) at one year follow-up. We analysed clinical effectiveness by intention to treat, using analysis of covariance to compare groups after intervention, controlling for baseline symptom scores. At 12 weeks, scores on the vertigo symptom scale in the telephone support group did not differ significantly from those in the routine care group (adjusted mean difference -1.79 (95% confidence interval -3.69 to 0.11), P=0.064). At one year, both intervention groups improved significantly relative to routine care (telephone support -2.52 (-4.52 to -0.51), P=0.014; booklet only -2.43 (-4.27 to -0.60), P=0.010). Analysis of cost effectiveness acceptability curves showed that both interventions were highly cost effective; at very low QALY values, the booklet only approach was most likely to be cost effective, but the approach with additional telephone support was most likely to be cost effective at QALY values more than £1200 (€1488; $1932). Using the booklet approach with telephone support, five (three to 12) patients would need to be treated for one patient to report subjective improvement at one year.

CONCLUSIONS

Booklet based vestibular rehabilitation for chronic dizziness is a simple and cost effective means of improving patient reported outcomes in primary care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00732797.

Vestibular rehabilitation strategies and factors that affect the outcome

Ever since the introduction of Cawthorne-Cooksey exercises, vestibular rehabilitation (VR) has been gaining popularity in the treatment of the dizzy patient. Numerous studies support the effectiveness of VR in improving balance/walking skills, eye-head coordination and the quality of life of the patient. Different rehabilitation protocols have been used to treat patients with peripheral and central vestibular disorders. Assessment of the patients' progress is based on the patients' selfperception of dizziness and their functional skills. Factors such as age, medication, time of onset of vertigo and home based VR have been evaluated on their effect on the rehabilitation's outcome. The aim of this review is to evaluate rehabilitation strategies and discuss the factors that affect the outcome.

Effectiveness of conventional versus virtual reality based vestibular rehabilitation in the treatment of dizziness, gait and balance impairment in adults with unilateral peripheral vestibular loss: a randomised controlled trial

Background

Unilateral peripheral vestibular loss results in gait and balance impairment, dizziness and oscillopsia. Vestibular rehabilitation benefits patients but optimal treatment remains unkown. Virtual reality is an emerging tool in rehabilitation and provides opportunities to improve both outcomes and patient satisfaction with treatment. The Nintendo Wii Fit Plus^® (NWFP) is a low cost virtual reality system that challenges balance and provides visual and auditory feedback. It may augment the motor learning that is required to improve balance and gait, but no trials to date have investigated efficacy.

Methods/Design

In a single (assessor) blind, two centre randomised controlled superiority trial, 80 patients with unilateral peripheral vestibular loss will be randomised to either conventional or virtual reality based (NWFP) vestibular rehabilitation for 6 weeks. The primary outcome measure is gait speed (measured with three dimensional gait analysis). Secondary outcomes include computerised posturography, dynamic visual acuity, and validated questionnaires on dizziness, confidence and anxiety/depression. Outcome will be assessed post treatment (8 weeks) and at 6 months.

Discussion

Advances in the gaming industry have allowed mass production of highly sophisticated low cost virtual reality systems that incorporate technology previously not accessible to most therapists and patients. Importantly, they are not confined to rehabilitation departments, can be used at home and provide an accurate record of adherence to exercise. The benefits of providing augmented feedback, increasing intensity of exercise and accurately measuring adherence may improve conventional vestibular rehabilitation but efficacy must first be demonstrated.

Trial registration

Clinical trials.gov identifier: NCT01442623

Head-shaking nystagmus predicts greater disability in unilateral peripheral vestibulopathy

OBJECTIVES

The objective of this study was to determine the association of the bedside test of head-shaking nystagmus (HSN) with patients' self-perceived dizziness handicap as well as this test's sensitivity and specificity in unilateral peripheral vestibular hypofunction.

STUDY DESIGN

A retrospective case-control study was performed.

SETTING

The study was held at an academic, tertiary referral center.

METHODS

Fifty-three adult patients with unilateral peripheral hypofunction defined by the caloric test of the videonystagmography with documented bedside HSN and who had completed questionnaires of self-perceived dizziness handicap were included. The sensitivity and specificity of the bedside HSN in patients and 10 healthy controls in diagnosing unilateral vestibular hypofunction defined by videonystagmographic caloric testing and by abnormal gain and symmetry of the vestibular-ocular reflex by rotary chair testing were determined. Scores of the screening test of the Dizziness Handicap Index and Functional Level Scale questionnaires were taken.

RESULTS

When using the caloric irrigation test as the reference standard for unilateral vestibular hypofunction, the sensitivity, specificity, and positive predictive value of the bedside HSN were 31%, 96%, and 97%, respectively. When comparing with results of rotational chair testing (vestibular-ocular reflex gain and symmetry), the sensitivity of the HSN test increases to 71%. Patients with positive bedside HSN had higher scores (greater self-perceived dizziness handicap) of the Dizziness Handicap Index (P = .049) and higher (worse) scores of the Functional Level Scale (P = .0377) than those with negative bedside HSN (Wilcoxon rank test).

CONCLUSIONS

Greater perceived handicap was correlated with a positive bedside HSN in patients with unilateral peripheral vestibulopathy. The HSN has sufficient sensitivity to be used as screening test of uncompensated vestibulopathy in this series. However, a negative HSN alone does not rule out the diagnosis of peripheral vestibular dysfunction.

Variables Associated With Outcome in Patients With Unilateral Vestibular Hypofunction

Background. Not all individuals with unilateral vestibular hypofunction (UVH) have fewer subjective complaints and improved function after vestibular rehabilitation. Objective. To identify factors and/or combinations of factors that are strongly associated with rehabilitation outcome in patients with UVH and that ultimately can be used to develop models to predict outcome. Methods. Data from 209 patients with UVH were analyzed. All patients participated in similar vestibular rehabilitation (5 weeks of home exercises and once-weekly clinic visits). Outcome measures included intensity of oscillopsia and dysequilibrium, balance confidence, perceived disability, percentage of time symptoms interfered with activities, gait speed, fall risk, and dynamic visual acuity (DVA). Bivariate correlation and regression analysis were used to determine relationships between baseline (pretherapy) measures and outcome at discharge. Results. No baseline measure of subjective complaints (eg, symptom intensity) predicted improvement of physical function (eg, gait speed). Similarly, no baseline measure of physical function predicted improvement of subjective complaints. Certain patient characteristics, such as gender and time from onset, were not related to any outcomes. Most comorbidities did not affect outcome; however, anxiety and/or depression were associated with lower balance confidence and higher percentage of time for which symptoms interfered with activities at discharge. Baseline DVA and gait speed were associated with DVA and gait speed at discharge, respectively. Dynamic gait index (DGI) at discharge was affected by age, baseline DGI, and history of falls. Conclusion. These results provide insight into recovery of patients with UVH. Therapists can use this information in the development of expectations for patient outcome and treatment priorities.

Vestibular rehabilitation for unilateral peripheral vestibular dysfunction

BACKGROUND

This is an update of a Cochrane Review first published in The Cochrane Library in Issue 4, 2007.Unilateral peripheral vestibular dysfunction (UPVD) can occur as a result of disease, trauma or postoperatively. The dysfunction is characterised by complaints of dizziness, visual or gaze disturbances and balance impairment. Current management includes medication, physical manoeuvres and exercise regimes, the latter known collectively as vestibular rehabilitation (VR).

OBJECTIVES

To assess the effectiveness of vestibular rehabilitation in the adult, community-dwelling population of people with symptomatic unilateral peripheral vestibular dysfunction.

SEARCH STRATEGY

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The most recent search was 1 July 2010, following a previous search in March 2007.

SELECTION CRITERIA

Randomised trials of adults living in the community, diagnosed with symptomatic unilateral peripheral vestibular dysfunction. We sought comparisons of VR versus control (placebo etc.), other treatment (non-VR, e.g. pharmacological) or another form of VR. We considered the outcome measures of frequency and severity of dizziness or visual disturbance; changes in balance impairment, function or quality of life; and measure/s of physiological status with known functional correlation.

DATA COLLECTION AND ANALYSIS

Both authors independently extracted data and assessed trials for risk of bias.

MAIN RESULTS

We included 27 trials, involving 1668 participants, in the review. Trials addressed the effectiveness of VR against control/sham interventions, medical interventions or other forms of VR. Individual and pooled data showed a statistically significant effect in favour of VR over control or no intervention. The exception to this was when movement-based VR was compared to physical manoeuvres for benign paroxysmal positional vertigo (BPPV), where the latter was shown to be superior in cure rate in the short term. There were no reported adverse effects.

AUTHORS' CONCLUSIONS

There is moderate to strong evidence that VR is a safe, effective management for unilateral peripheral vestibular dysfunction, based on a number of high quality randomised controlled trials. There is moderate evidence that VR provides a resolution of symptoms and improvement in functioning in the medium term. However, there is evidence that for the specific diagnostic group of BPPV, physical (repositioning) manoeuvres are more effective in the short term than exercise-based vestibular rehabilitation; although a combination of the two is effective for longer-term functional recovery. There is insufficient evidence to discriminate between differing forms of VR.