Insensitivity of the “Romberg Test of Standing Balance on Firm and Compliant Support Surfaces” to the Results of Caloric and VEMP Tests

Hearing, Balance, and Mortality: Sex-Specific Patterns in a Longitudinal Study

OBJECTIVES

Assess the association of hearing on sex-specific overall mortality and death from acute cardiovascular disease and evaluate if these effects are modulated by postural balance.

STUDY DESIGN

Cohort study.

SETTING

Otolaryngology department at an academic hospital.

METHODS

Patients underwent standard clinical examination, laboratory examination including stabilometry and audiometry. Pure tone average on the best hearing ear was calculated from 0.5, 1, 2, and 3 kHz. Cause of death was retrieved from the Norwegian Cause of Death Registry.

RESULTS

A total of 1036 patients (58.8% women) were followed for 26 ± 3 years. In Cox regression analyses for overall mortality adjusted for age, past medical history, and vestibular disease, 10 dB increase in hearing threshold was associated with a 14% increase in mortality among men (hazard ratio 95% confidence interval: 1.02-1.28, P = .02), but no significant association was seen between hearing and mortality in women (0.92-1.15, P = .60). The same analyses for acute cardiovascular death found that a 10 dB increase in hearing threshold was associated with a 57% increase in hazard ratio in men (1.21-2.05, P < .001), but no significant effect of hearing on survival was seen in women (P = .71). Adjusting for postural balance did not change the association between hearing and mortality.

CONCLUSION

This study finds hearing threshold is associated with overall mortality and acute cardiovascular death among men, with no such association observed among women. Our findings indicate important differences between men and women and suggest that such differences should be taken into consideration in audiological research.

Deterioration of Vestibular Motion Perception: A Risk Factor for Postural Instability and Falls in Elderly With Type 2 Diabetes

AIMS

To assess whether impaired vestibular perception of self-motion is a risk factor for unsteadiness and falls in elderly patients with type 2 diabetes (T2D).

MATERIALS AND METHODS

113 participants (65-75 years old) with T2D underwent tests of roll and pitch discrimination, postural stability (Berg Balance Scale, Modified Romberg Test, and quantitative posturography), clinical examination and blood chemistry analyses. Falls 1-year after enrolment were self-reported. We performed cluster analysis based on the values of the vestibular motion thresholds, and logistic stepwise regression to compare the clinical-biochemical parameters between clusters.

RESULTS

We identified two clusters (VC1 n = 65 and VC2 n = 48 participants). VC2 had significantly (p < 0.001) higher (poorer) thresholds than VC1: mean pitch threshold 1.62°/s (95% CI 1.48-1.78) in VC2 and 0.91°/s (95% CI 0.84-0.98) in VC1, mean roll threshold 1.34°/s (95% CI 1.21-1.48) in VC2 and 0.69°/s (95% CI 0.64-0.74) in VC1. Diabetes duration was significantly (p = 0.024) longer in VC2 (11.96 years, 95% CI 9.23-14.68) than in VC1 (8.37 years, 95% CI 6.85-9.88). Glycaemic control was significantly (p = 0.014) poorer in VC2 (mean HbA1c 6.74%, 95% CI 6.47-7.06) than in VC1 (mean HbA1c 6.34%, 95% CI 6.16-6.53). VC2 had a significantly higher incidence of postural instability than VC1, with a higher risk of failing the Modified Romberg Test C4 (RR = 1.57, χ2 = 5.33, p = 0.021), reporting falls during follow-up (RR = 11.48, χ2 = 9.40, p = 0.002), and greater postural sway in the medio-lateral direction (p < 0.025).

CONCLUSIONS

Assessing vestibular motion thresholds identifies individuals with T2D at risk of postural instability due to altered motion perception and guides vestibular rehabilitation.

The Evaluation and Management of Concussion to Optimize Safe Recovery

Concussion is a mild traumatic brain injury causing temporary neurologic dysfunction. Symptoms following concussion are variable and generally are expected to resolve within about 1 month, but some patients experience persistent and prolonged symptoms. An early return to safe, symptom-limited activity is now favored, using targeted rehabilitation and treatments. Accommodations may be needed to facilitate return-to-school and work following concussion. Athletes should not be cleared for a full return to sport until they have recovered from a concussion and completed a return-to-play progression, in addition to returning to work/school fully.

Multifrequency Analysis of Masseter Vestibular Evoked Myogenic Potentials in Young Adults

PURPOSE

The purpose of this study was to explore the dynamics of multifrequency tone bursts on the masseter vestibular evoked myogenic potential (mVEMP) parameters. Furthermore, it sought to determine the optimal frequency tuning of mVEMP responses.

METHOD

Twenty young adults with normal hearing sensitivity participated in the study. Bilateral tone burst evoked mVEMPs were obtained using the zygomatic montage at 250-, 500-, 750-, 1000-, 1500-, and 2000-Hz stimulation frequencies. Self-monitoring biofeedback was given during the procedure to confirm the tension of the masseter muscle between 49.9 and 150.6 rms. Furthermore, the electromyography (EMG) scaling was done to avoid any muscle-related irregularities.

RESULTS

Tone burst evoked mVEMPs were found to be 100% present at the stimulation frequencies of 250, 500, 750, and 1000 Hz. There were no ear and gender effects seen for any of the frequencies. Significant shortening of the P1 and N1 latencies with increasing stimulation frequencies was observed. The peak-to-peak amplitude was the highest at 500 Hz and lowest at 2000 Hz tone bursts under both EMG scaled and unscaled conditions.

CONCLUSION

The present revealed higher response rates and larger amplitudes study of mVEMP at lower frequencies, and, therefore, the frequency tuning was seen for the stimulation frequency at 500 Hz.

The impact of vestibular dysfunction on falls and postural instability in individuals with type 2 diabetes with and without diabetic polyneuropathy

Aim

This study aimed to determine the association between vestibular dysfunction, falls, and postural instability in individuals with type 2 diabetes (T2D) compared to healthy control individuals and to examine the impact of diabetic polyneuropathy (DPN).

Methods

This cross-sectional study included individuals with T2D with DPN (n = 43), without DPN (n = 32), and healthy controls (n = 32). Cervical and ocular vestibular evoked myogenic potentials (VEMP) were recorded, and latencies and amplitudes were determined. DPN was diagnosed based on nerve conduction studies and clinical scores. Postural instability was examined using a static posturographic balance system and calculated as an instability index (ST). Falls were recorded retrospectively during the past year. Group comparisons were conducted by using univariate and bivariate statistics.

Results

Individuals with T2D experienced more falls than healthy controls (T2D with DPN n = 12[38%], T2D without DPN n = 15[35%], controls n = 5[16%], p = 0.04). Individuals with T2D had decreased postural stability, T2D with DPN, ST (median of 52[iqi = 33; 77]), T2D without DPN, ST (median of 31[iqi = 24; 39]), controls ST (median of 26[iqi = 19; 33], p = 0.01), when comparing all three groups. Individuals with T2D had a greater number of no-responses in oVEMP compared to controls (T2D with DPN, n = 15[46.9%] T2D without DPN n = 25[58.1%], controls n = 9[28.1%], p = 0.04). No difference was found in cVEMP and oVEMP amplitudes in any of the groups. Irrespectively of DPN, fallers with T2D had decreased oVEMP and cVEMP latencies on the right ears, when comparing to non-fallers, respectively, n10 (fallers [median of 16, iqi=15;19 ms.] vs. non-fallers [median of 25 iqi=16;35 ms]); p13 (fallers [median of 16, iqi=15;17 ms.] vs. non-fallers [median of 15, iqi=8;16 ms.], p < 0.05).

Conclusion

Falls and postural instability were more frequent in individuals with T2D compared to healthy controls. Fallers with T2D had vestibular end-organ impairments based on the oVEMP and cVEMP latencies on the right but not the left ears, irrespective of DPN. Individuals with T2D had more frequent no-response of the oVEMP, indicating impaired vestibular nerve function.

Vestibular perceptual testing from lab to clinic: a review

Not all dizziness presents as vertigo, suggesting other perceptual symptoms for individuals with vestibular disease. These non-specific perceptual complaints of dizziness have led to a recent resurgence in literature examining vestibular perceptual testing with the aim to enhance clinical diagnostics and therapeutics. Recent evidence supports incorporating rehabilitation methods to retrain vestibular perception. This review describes the current field of vestibular perceptual testing from scientific laboratory techniques that may not be clinic friendly to some low-tech options that may be more clinic friendly. Limitations are highlighted suggesting directions for additional research.

Increased roll tilt thresholds are associated with subclinical postural instability in asymptomatic adults aged 21 to 84 years

Background

Balance assessments that intentionally alter the reliability of visual and proprioceptive feedback (e.g., standing on foam with eyes closed) have become a standard approach for identifying vestibular mediated balance dysfunction in older adults. However, such assessments cannot discern which specific element of the vestibular system (e.g., semicircular canal, otolith, or combined canal-otolith) underlies the observed age-related changes in balance performance. The present study was designed to determine the associations between specific sources of vestibular noise and quantitative measures of quiet stance postural control measured during standard "vestibular" balance conditions.

Methods

A group of 52 asymptomatic adults (53.21 ± 19.7, 21 to 84 years) without a history of vestibular or neurologic disorders volunteered for this study. We measured a battery of five vestibular perceptual thresholds that assay vestibular noise with predominant contributions from the vertical canals, lateral canals, utricles, saccules, and the centrally integrated canal-otolith signal. In addition, participants completed two standard balance assessments that were each designed to prioritize the use of vestibular cues for quiet stance postural control-eyes closed on foam (Condition 4 of the Modified Romberg Balance Test) and eyes closed, on a sway referenced support surface (Condition 5 of the Sensory Organization Test).

Results

In age adjusted models, we found strong positive associations between roll tilt vestibular thresholds, a measure of noise in the centrally integrated canal-otolith signal, and the root mean square distance (RMSD) of the anteroposterior and mediolateral center of pressure (CoP) captured during eyes closed stance on a sway referenced support surface. The strength of the association between roll tilt thresholds and the RMSD of the CoP was between 3-times and 30-times larger than the association between postural sway and each of the other vestibular thresholds measured.

Conclusion

We posit that noise in the centrally estimated canal-otolith "tilt" signal may be the primary driver of the subclinical postural instability experienced by older adults during the "vestibular" conditions of balance assessments. Additional testing in adults with clinical balance impairment are needed to identify if roll tilt thresholds may also serve as a surrogate metric by which to detect vestibular mediated balance dysfunction and/or fall risk.

Perspectives: Evaluation of Older Adult Cochlear Implant Candidates for Fall Risk in a Developing Country Setting

Dizziness, vertigo, and falls are common in older adults. Data suggest that cochlear implant candidates are no different and could be argued to be at elevated risk due to the presence of hearing loss and likely vestibular involvement. Perspectives contextualizes current testing and screening paradigms for vestibular deficits and fall risk and suggests a protocol suitable for use in developing country settings.

Measuring Vestibular Contributions to Age-Related Balance Impairment: A Review

Aging is associated with progressive declines in both the vestibular and human balance systems. While vestibular lesions certainly contribute to imbalance, the specific contributions of age-related vestibular declines to age-related balance impairment is poorly understood. This gap in knowledge results from the absence of a standardized method for measuring age-related changes to the vestibular balance pathways. The purpose of this manuscript is to provide an overview of the existing body of literature as it pertains to the methods currently used to infer vestibular contributions to age-related imbalance.

A Battery of Easily Accessible, Simple Tools for the Assessment of Concussion in Children

OBJECTIVE

To determine whether a non-proprietary, novel testing battery can identify recently concussed children within 8 weeks of injury.

STUDY DESIGN

In total, 568 clinic outpatients aged 10-18 years were sorted into 3 groups: 316 had never been concussed, 162 had ever been concussed before 8 weeks earlier, and 90 had been recently concussed within 8 weeks. At initial and any subsequent visits, a neurologic examination and 4 procedures were performed: Stick Drop, Wall Ball, Sharpened Modified Romberg (SMR), and Animal Naming. Analysis included inter-group and intra-person performance differences using a series of t tests on the Stick Drop, Wall Ball, SMR, and Animal Naming.

RESULTS

The recently concussed group performed worse (P < .01 for all) on Stick Drop, total Wall Ball bounces and drops, and SMR compared with never-concussed and ever-concussed groups. This effect for Stick Drop, SMR, and Wall Ball but not Animal Naming persisted beyond the 4 weeks commonly stated to define recovery. Of 59 recently concussed subjects who returned for ≥1 visit, there were improvements in Stick Drop average (P = .004) and maxima (P = .02) as well as SMR (P = .01) but not Animal Naming between initial and subsequent visits.

CONCLUSIONS

This novel, rapid testing battery distinguished groups of children ages 10-18 years who had and had not experienced a recent concussion. A view that physical concussion symptoms resolve within a month of injury may be incomplete. Deployment of this readily available, inexpensive and non-proprietary battery should be compared with other tools and studied further in serial assessments.

The Relationship Between Vestibular Sensory Integration and Prosthetic Mobility in Community Ambulators With Unilateral Lower Limb Amputation

OBJECTIVE

The modified Clinical Test of Sensory Interaction and Balance (mCTSIB) is used to clinically assess vestibular sensory integration (VSI), the process by which the central nervous system integrates vestibular afference to maintain balance. The rate and effects of impaired VSI (IVSI) on prosthetic mobility in people with lower limb amputation (LLA) is unknown. The objective of this study was to use the mCTSIB to classify VSI in active community ambulators with LLA and to examine the relationship between IVSI and prosthetic mobility, as measured by the Component Timed Up and Go (cTUG) test.

METHODS

This was a cross-sectional study with a convenience sample of 130 community ambulators with unilateral LLA. Classification of VSI was determined based on a time-based pass/fail mCTSIB performance. Participants were classified as having normal sensory integration (NSI) if they could balance for 30 seconds in every mCTSIB condition. Participants who failed condition 4 exclusively were classified as IVSI. Prosthetic mobility, as measured by the cTUG, was compared between NSI and IVSI groups.

RESULTS

Of the 130 participants, 29 (22%) were classified as IVSI and 95 (73%) were classified as having NSI. Prosthetic mobility significantly differed between IVSI and NSI groups, with IVSI participants performing all components of the cTUG significantly slower. Medium to large effect sizes were found between groups during cTUG.

CONCLUSIONS

These results suggest that 1 in 5 community ambulators with LLA have IVSI, with associated limitations in balance confidence and prosthetic mobility.

IMPACT

The ability to integrate vestibular information was found to have a strong relationship with prosthetic mobility in active community ambulators with LLA, especially with performing a 180-degree step turn. Physical therapists can use the mCTSIB to classify sensory integration during prosthetic rehabilitation and develop an appropriate balance intervention.

LAY SUMMARY

Active adults with LLA can use information from their senses to maintain their standing balance. Adults with LLA who have difficulty balancing on foam with closed eyes were slower to get in and out of a chair, walk, and perform a 180-degree step turn.

The Antwerp Vestibular Compensation Index (AVeCI): an index for vestibular compensation estimation, based on functional balance performance

PURPOSE

To create an index that is a measure of the amount of vestibular compensation and for which only functional balance performance is needed.

METHODS

The medical charts of 62 eligible peripheral vestibular dysfunction (PVD) patients were analyzed retrospectively. To be included, the following vestibulo-ocular reflex (VOR) and balance performance data had to be available: (1) caloric and sinusoidal harmonic acceleration test (SHA) and (2) standing balance sum-eyes closed (SBS-EC), Timed Up and Go Test and Dynamic Gait Index. Patients were divided into three groups: normal caloric- and SHA test (group 1), abnormal caloric- and normal SHA test (group 2, PVD compensated) and abnormal caloric- and SHA test (group 3, PVD uncompensated). Next to the use of non-parametric tests to study the VOR and balance variables, logistic regression was used to identify the balance measures that predict whether PVD patients were compensated or uncompensated. This resulted also in the construction of a continuous measure representing the degree of compensation.

RESULTS

Logistic regression identified SBS-EC and age to classify uncompensated from compensated patients with sensitivity of 83.9% and specificity of 72.4%. Then an index was created, called the Antwerp Vestibular Compensation Index, AVeCI = - 50 + age × 0.486 + SBS-EC × 0.421. A patient belongs to the uncompensated group when AVeCI < 0 and to the compensated group when AVeCI > 0, with respective group means of - 5 and 5.

CONCLUSION

AVeCI stages the degree of compensation of PVD patients and can serve to evaluate rehabilitation effects.

Preseason to Postseason Changes on the BTrackS Force Plate in a Sample of College Athletes

CONTEXT

Balance testing is a vital component in the evaluation and management of sport-related concussion. Few studies have examined the use of objective, low-cost, force-plate balance systems and changes in balance after a competitive season.

OBJECTIVE

To examine the extent of preseason versus postseason static balance changes using the Balance Tracking System (BTrackS) force plate in college athletes.

DESIGN

Pretest, posttest design.

SETTING

Athletic training facility.

PARTICIPANTS

A total of 47 healthy, Division-I student-athletes (33 males and 14 females; age 18.4 [0.5] y, height 71.8 [10.8] cm, weight 85.6 [21.7] kg) participated in this study.

MAIN OUTCOME MEASURES

Total center of pressure path length was measured preseason and postseason using the BTrackS force plate. A Wilcoxon signed-rank test was conducted to examine preseason and postseason changes. SEM and minimal detectable change were also calculated.

RESULTS

There was a significant difference in center of pressure path length differed between preseason (24.6 [6.8] cm) and postseason (22.7 [5.4] cm) intervals (P = .03), with an SEM of 3.8 cm and minimal detectable change of 10.5 cm.

CONCLUSIONS

Significant improvements occurred for center of pressure path length after a competitive season, when assessed using the BTrackS in a sample of college athletes. Further research is warranted to determine the effectiveness of the BTrackS as a reliable, low-cost alternative to force-plate balance systems. In addition, clinicians may need to update baseline balance assessments more frequently to account for improvements.

Diabetes and the Vestibular System

Falls are among the most injurious, costly, and feared conditions affecting older adults. Patients with diabetes have a significantly greater risk for falling due to complications affecting the sensory systems required for balance: vision, proprioception, and vestibular. The effects of diabetes mellitus on the vestibular system are perhaps the least understood of these systems. The vestibular system is complex, includes multiple structures, and is difficult and expensive to thoroughly assess. There is pathophysiologic evidence suggesting a direct effect of diabetes mellitus complications on the vestibular system, but there is limited clinical evidence regarding which specific vestibular structures are most adversely affected. Nevertheless, large population-based studies show that patients with diabetes are more likely to have vestibular loss, have a high prevalence of a specific vestibular disorder called benign paroxysmal positional vertigo, and are at a greater risk for falling. Based on the available evidence, a balance screening and an evaluation of benign paroxysmal positional vertigo, a common but easy to treat pathology, in patients with diabetes is recommended as well as counseling on falls risk and home modifications.

Failure on the Foam Eyes Closed Test of Standing Balance Associated With Reduced Semicircular Canal Function in Healthy Older Adults

OBJECTIVES

Standing on foam with eyes closed (FOEC) has been characterized as a measure of vestibular function; however, the relative contribution of vestibular function and proprioceptive function to the FOEC test has not been well described. In this study, the authors investigate the relationship between peripheral sensory systems (vestibular and proprioception) and performance on the FOEC test in a cohort of healthy adults.

DESIGN

A total of 563 community-dwelling healthy adults (mean age, 72.7 [SD, 12.6] years; range, 27 to 93 years) participating in the Baltimore Longitudinal Study of Aging were tested. Proprioceptive threshold (PROP) was evaluated with passive motion detection at the right ankle. Vestibulo-ocular reflex (VOR) gain was measured using video head impulses. Otolith function was measured with cervical and ocular vestibular-evoked myogenic potentials. Participants stood on FOEC for 40 sec while wearing BalanSens (BioSensics, LLC, Watertown, MA) to quantify center of mass sway area. A mixed-model multiple logistic regression was used to examine the odds of passing the FOEC test based on PROP, VOR, cervical vestibular-evoked myogenic potential, and ocular vestibular-evoked myogenic potential function in a multisensory model while controlling for age and gender.

RESULTS

The odds of passing the FOEC test decreased by 15% (p < 0.001) for each year of increasing age and by 8% with every 0.1 reduction in VOR gain (p = 0.025). Neither PROP nor otolith function was significantly associated with passing the FOEC test.

CONCLUSIONS

Failure to maintain balance during FOEC may serve as a proxy for rotational vestibular contributions to postural control. Semicircular canals are more sensitive to low-frequency motion than otoliths that may explain these relationships because standing sway is dominated by lower frequencies. Lower VOR gain and increased age independently decreased the odds of passing the test.

Clinical predictors of symptom resolution for children and adolescents with sport-related concussion

OBJECTIVE

The goal of this study was to determine which variables assessed during an initial clinical evaluation for concussion are independently associated with time until symptom resolution among pediatric patients.

METHODS

Data collected from a prospective clinical registry of pediatric patients with concussion were analyzed. The primary outcome variable was time from injury until symptom resolution. Predictor variables assessed within 10 days after injury included preinjury factors, Health and Behavior Inventory scores, headache severity, and balance, vestibular, and oculomotor test performances. The researchers used univariate Cox proportional models to identify potential predictors of symptom resolution time and constructed a multivariate Cox proportional hazards model in which total duration of concussion symptoms remained the outcome variable.

RESULTS

The sample consisted of 351 patients (33% female, mean age 14.6 ± 2.2 years, evaluated 5.6 ± 2.6 days after concussion). Univariate Cox proportional hazards models indicated that several variables were associated with a longer duration of symptoms, including headache severity (hazard ratio [HR] 0.90 [95% CI 0.85-0.96]), headache frequency (HR 0.83 [95% CI 0.71-0.96]), confusion (HR 0.79 [95% CI 0.69-0.92]), forgetfulness (HR 0.79 [95% CI 0.68-0.92]), attention difficulties (HR 0.83 [95% CI 0.72-0.96]), trouble remembering (HR 0.84 [95% CI 0.72-0.98]), getting tired often (HR 0.86 [95% CI 0.76-0.97]), getting tired easily (HR 0.86 [95% CI 0.76-0.98]), dizziness (HR 0.86 [95% CI 0.75-0.99]), and abnormal performance on the Romberg test (HR 0.59 [95% CI 0.40-0.85]). A multivariate Cox proportional hazards model indicated that an abnormal performance on the Romberg test was independently associated with a longer duration of symptoms (HR 0.65 [95% CI 0.44-0.98]; p = 0.038).

CONCLUSIONS

For children and adolescents evaluated within 10 days after receiving a concussion, abnormal performance on the Romberg test was independently associated with a longer duration of symptoms during recovery. In line with findings of other recent studies investigating predictors of symptom resolution, postural stability tests may provide useful prognostic information for sports medicine clinicians.

Hearing as an Independent Predictor of Postural Balance in 1075 Patients Evaluated for Dizziness

Objective

To evaluate the association between hearing and postural balance.

Study Design

Retrospective cross-sectional study.

Setting

Tertiary care otolaryngology clinic.

Subjects and Methods

Patients examined for suspected vestibular disorder were included in this study. The outcome variable was postural sway measured by static posturography during quiet standing with eyes closed. The predictor variable was pure-tone average hearing threshold on the best hearing ear at 0.5, 1, 2, and 3 kHz. Covariates were age, sex, and vestibular disease or vestibular asymmetry assessed by bithermal caloric irrigation.

Results

In total, 1075 patients were included. Increased hearing threshold was a strong predictor of increased postural sway (path length) after correcting for age and sex. A 10-dB increase in hearing loss on the best hearing ear predicted a mean 6.0% increase in path length (confidence interval, 2.9%-9.3%, P < .001). Of the covariates, increasing age ( P < .001) and male sex ( P = .009) were significant predictors of increased postural sway. The effect of increased hearing threshold was also significant after adjusting for vestibular disease.

Conclusion

Increased hearing threshold was an independent predictor of increased postural instability, and this effect was strongest for the best hearing ear. Unilateral vestibular disease did not seem to explain this association between hearing and postural balance. Reduced hearing is associated with impaired balance, and interventions to prevent falls should be considered for patients at risk.

Association Between Psychotropic Medication Polypharmacy and an Objective Measure of Balance Impairment Among Middle-Aged Adults: Results from the US National Health and Nutrition Examination Survey

OBJECTIVE

Psychotropic medications (e.g., antidepressants, anxiolytics, and neuroleptics) are increasingly prescribed with two or more taken concurrently (polypharmacy), and have been associated with an increased risk of falling. The aim of this study was to examine the association between psychotropic medication use and balance impairment using an objective balance measure.

METHODS

We derived data from participants aged 40 years and older in the US National Health and Nutrition Examination Survey (1999/00-2003/04) who completed the Modified Clinical Trial of Sensory Interaction and Balance and indicated current medications (n = 3090). Balance impairment was defined as failing the Modified Clinical Trial of Sensory Interaction and Balance condition 4 (standing on foam surface, eyes closed). Medication use included specific psychotropic classes, a count of psychotropic medications, and a count of non-psychotropic medications taken concurrently. Nested multiple logistic regression assessed relationships between medication use and balance impairment, adjusting for covariates and complex sampling.

RESULTS

One third of participants had balance impairment. After accounting for medical comorbidities, there was no relationship between individual classes of psychotropic medications and balance impairment. After adjusting for all covariates, there was a dose-response relationship between the number of psychotropic medications taken and balance impairment, with every additional medication associated with a 35% higher odds (odds ratio = 1.35; 95% confidence interval 1.07-1.70). In comparison, there was no increase in the odds of balance impairment associated with each additional medication taken for participants only taking non-psychotropic medications.

CONCLUSIONS

Psychotropic medication polypharmacy is associated with an increased odds of balance impairment. Clinicians should exercise caution when prescribing combinations of psychotropic medications, and refer to physical therapy for assessment and treatment if balance impairment is detected.

The Association Between Vestibular Physical Examination, Vertigo Questionnaires, and the Electronystagmography in Patients With Vestibular Symptoms

OBJECTS

Dizziness makes up a diagnostic and treatment challenge. The diagnostic accuracy of the medical history and vestibular physical examination in cases of vestibular symptoms is not clear. The aim of this study is to determine the association between vestibular physical examination, vestibular questionnaires, and electronystagmography (ENG) test in patients with vestibular symptoms.

METHODS

This is a prospective study of 135 adults with vestibular symptoms. The subjects underwent targeted physical examination and filled vestibular questionnaires, including the Dizziness Handicap Inventory (DHI), before ENG testing. The results of the physical examination and questionnaires were compared with the final ENG findings.

RESULTS

Of patients who had normal ENG results, 32.1% (17/52) showed abnormal physical examination, and 48.8% (40/82) of the patient who had normal physical examination showed abnormal ENG results ( P = .46). Among patients with severe disability by DHI, 46.4% (13/28) had an abnormal ENG, and 42.9% (12/28) had a normal ENG ( P = .39).

CONCLUSIONS

This study did not demonstrate association between vestibular physical examination, vestibular questionnaires, and ENG results. Although history (augmented by questionnaires) and physical examination are the initial steps in the evaluation of vertigo, the current study suggests that they should be complemented by objective testing for evaluation of inner ear origin of vertigo.

A Practical Concussion Physical Examination Toolbox

CONTEXT

With heightened awareness of concussion, there is a need to assess and manage the concussed patient in a consistent manner. Unfortunately, concussion physical examination has not been standardized or supported by evidence. Important questions remain about the physical examination.

EVIDENCE ACQUISITION

Review of ClinicalKey, Cochrane, MEDLINE, and PubMed prior to July 2015 was performed using search terms, including concussion, mTBI, physical examination, mental status, cranial nerves, reflexes, cervical, vestibular, and oculomotor. The references of the pertinent articles were reviewed for other relevant sources.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 3.

RESULTS

The pertinent physical examination elements for concussion include evaluation of cranial nerves, manual muscle testing, and deep tendon reflexes; inspecting the head and neck for trauma or tenderness and cervical range of motion; Spurling maneuver; a static or dynamic balance assessment; screening ocular examination; and a mental status examination that includes orientation, immediate and delayed recall, concentration, mood, affect, insight, and judgment. Other examination elements to consider, based on signs, symptoms, or clinical suspicion, include testing of upper motor neurons, cervical strength and proprioception, coordination, pupillary reactivity, and visual acuity; examination of the jaw, temporomandibular joint, and thoracic spine; fundoscopic evaluation; orthostatic vital signs; assessment of dynamic visual acuity; and screening for depression, anxiety, substance abuse disorders, and preinjury psychiatric difficulties.

CONCLUSION

Various elements of the physical examination, such as screening ocular examination, cervical musculoskeletal examination, static and/or dynamic balance assessment, and mental status examination, appear to have utility for evaluating concussion; however, data on validity are lacking.

Impact of Diabetic Complications on Balance and Falls: Contribution of the Vestibular System

Diabetes causes many complications, including retinopathy and peripheral neuropathy, which are well understood as contributing to gait instability and falls. A less understood complication of diabetes is the effect on the vestibular system. The vestibular system contributes significantly to balance in static and dynamic conditions by providing spatially orienting information. It is noteworthy that diabetes has been reported to affect vestibular function in both animal and clinical studies. Pathophysiological changes in peripheral and central vestibular structures due to diabetes have been noted. Vestibular dysfunction is associated with impaired balance and a higher risk of falls. As the prevalence of diabetes increases, so does the potential for falls due to diabetic complications. The purpose of this perspective article is to present evidence on the pathophysiology of diabetes-related complications and their influence on balance and falls, with specific attention to emerging evidence of vestibular dysfunction due to diabetes. Understanding this relationship may be useful for screening (by physical therapists) for possible vestibular dysfunction in people with diabetes and for further developing and testing the efficacy of interventions to reduce falls in this population.

Assessment of functional development of the otolithic system in growing children: a review

OBJECTIVES

Although the caloric test, rotational test, and posturography have been used to investigate balance function conventionally, and they are older than tests of otolithic organs, yet it seems that most clinicians are less familiar with the development of otolithic (saccular and utricular) function in children. This study reviewed the electrophysiological testing used to assess the functional development of the otolithic system in growing children.

METHODS

Based on the literature, studies of cervical vestibular-evoked myogenic potential (cVEMP) and ocular VEMP (oVEMP) tests in children ranging from newborns, small children to adolescents were reviewed. Papers concerning foam posturography in children were also included.

RESULTS

The cVEMPs can be elicited in newborns at day 5, whereas the oVEMPs are absent in neonatal period. When children grow to 2 years old, the oVEMPs can be induced with eyes closed condition, while the oVEMPs with eyes up condition can be elicited in children aged >3 years old, with the characteristic parameters similar to adult levels. In contrast with cVEMPs, it is until the neck length >15.3cm (aldolesence), one need not account for neck length in evaluating cVEMP latency. Additionally, foam posturography indicated by the Romberg quotient of the sway velocity/area on foam pad is considered to reflect the otolithic function, which reached adult levels when the children at 12 years old.

CONCLUSIONS

For the functional development of the otolithic system in growing children to approach adult levels, the earliest occurrence is the oVEMP test, followed by the foam posturography, and cVEMP test.

Short-term risk of falling after cochlear implantation

Cochlear implantation is a highly effective intervention for hearing loss, but insertion of an implant into the cochlea is often accompanied by loss of residual hearing function. Sometimes, postoperative testing also shows loss of function in the semicircular canals or otolith organs. The effect of this loss on equilibrium, particularly in the short term following surgery, and the risk of falling due to this loss is unknown. We prospectively measured balance in 16 consecutive adult cochlear implant patients before and 2 weeks after surgery. Subjects stood on a foam pad with eyes closed, feet together and arms at the side. The length of time over which this posture could be maintained was recorded up to a maximum value of 30 s indicating normal performance. Ten of 16 subjects reached a maximal time on preoperative testing. Nine of 16 subjects lost balance function after surgery. Four of the 10 subjects with normal preoperative balance function lost function. Subjects older than the age of 60 were more likely to lose balance function than younger subjects. We used previously published values relating balance performance on foam to risk of falling to calculate the fall risk among our subjects. The relative risk of falling increased after surgery by more than threefold in some patients. Imbalance after cochlear implantation may be much more common, particularly in the short term, than previously appreciated. This imbalance is accompanied by an increased risk of falling in many patients. Careful preoperative counseling before implantation and postoperative therapeutic intervention to improve comfort and reduce the chance of falling may be warranted, particularly in patients at a risk for injuries from falls (level of evidence: 2b).

Screening people in the waiting room for vestibular impairments

OBJECTIVE

Primary care physicians need good screening tests of the vestibular system to help them determine whether patients who complain of dizziness should be evaluated for vestibular disorders. The goal of this study was to determine whether current, widely used screening tests of the vestibular system predict subsequent performance on objective diagnostic tests of the vestibular system (ENG).

METHODS

Of 300 subjects who were recruited from the waiting room of a primary care clinic and were screened there, 69 subjects subsequently volunteered for ENGs in the otolaryngology department. The screening study included age, history of vertigo, head impulse tests, Dix-Hallpike maneuvers, and the Clinical Test of Sensory Integration and Balance with the head still and the head pitching at 0.33 Hz. The ENG included Dix-Hallpike maneuvers, vestibular-evoked myogenic potentials, bithermal water caloric tests, and low-frequency sinusoids in the rotatory chair in darkness.

RESULTS

The scores on the screening were related to the total ENG, but odds ratios were not significant for some variables, probably because of the small sample size.

CONCLUSIONS

A larger sample may have yielded stronger results, but in general the high odds ratios suggest a relation between the ENG score and Dix-Hallpike responses and between the ENG scores and some Clinical Test of Sensory Integration and Balance responses.

Clinical efficacy of the Romberg test using a foam pad to identify balance problems: a comparative study with the sensory organization test

The modified Romberg test using a foam pad ("MRuFP") as a bedside examination has been used to assess the function of the complex sensory input needed for upright stance. The objective of this study was to assess its clinical value detecting vestibular falls in comparison with the sensory organization test (SOT), the gold standard. In total, 80 patients who had undergone the MRuFP, SOT, and bithermal caloric tests were included in this study. The MRuFPs were performed on two (height 12 cm, MRu2FP) or three (18 cm, MRu3FP) layers of foam pads. The odds ratios of falling on SOT were calculated. Iterative algorithms were used for linear curve fitting between the balance time on the MRuFP and SOT equilibrium score (ES). The diagnostic performance of MRuFP under different conditions was poor, with low sensitivity (0.07-0.63), when the results of SOT were used as the gold standard. However, the odds ratios of failing SOT condition 5 were 6.78 (95% CI = 1.26-36.50) for patients with abnormal findings on eyes closed (EC)-MRu2FP and 10.91 (95% CI = 2.58-46.11) for those on the EC-MRu3FP in patients without caloric weakness. In patients with caloric weakness, the odds ratio of failing SOT condition 5 for patients with abnormal findings on EC-MRu2FP was 7.0 (95% CI = 0.69-70.74, p > 0.05), and 32.0 for those on EC-MRu3FP (95% CI = 2.81-364.7). A linear equation was presented as the model fit (adjusted R(2) = 0.355) predicting the SOT condition 5 ES according to the balance time on EC-MRu3FP. In conclusion, the EC-MRu3FP, as a bedside examination, correlated well with SOT condition 5 as an objective measure.

Reliability and validity evidence of multiple balance assessments in athletes with a concussion

CONTEXT

An estimated 300 000 sport-related concussion injuries occur in the United States annually. Approximately 30% of individuals with concussions experience balance disturbances. Common methods of balance assessment include the Clinical Test of Sensory Organization and Balance (CTSIB), the Sensory Organization Test (SOT), the Balance Error Scoring System (BESS), and the Romberg test; however, the National Collegiate Athletic Association recommended the Wii Fit as an alternative measure of balance in athletes with a concussion. A central concern regarding the implementation of the Wii Fit is whether it is reliable and valid for measuring balance disturbance in athletes with concussion.

OBJECTIVE

To examine the reliability and validity evidence for the CTSIB, SOT, BESS, Romberg test, and Wii Fit for detecting balance disturbance in athletes with a concussion.

DATA SOURCES

Literature considered for review included publications with reliability and validity data for the assessments of balance (CTSIB, SOT, BESS, Romberg test, and Wii Fit) from PubMed, PsycINFO, and CINAHL.

DATA EXTRACTION

We identified 63 relevant articles for consideration in the review. Of the 63 articles, 28 were considered appropriate for inclusion and 35 were excluded.

DATA SYNTHESIS

No current reliability or validity information supports the use of the CTSIB, SOT, Romberg test, or Wii Fit for balance assessment in athletes with a concussion. The BESS demonstrated moderate to high reliability (interclass correlation coefficient = 0.87) and low to moderate validity (sensitivity = 34%, specificity = 87%). However, the Romberg test and Wii Fit have been shown to be reliable tools in the assessment of balance in Parkinson patients.

CONCLUSIONS

The BESS can evaluate balance problems after a concussion. However, it lacks the ability to detect balance problems after the third day of recovery. Further investigation is needed to establish the use of the CTSIB, SOT, Romberg test, and Wii Fit for assessing balance in athletes with concussions.

Low bone mineral density is associated with balance and hearing impairments

PURPOSE

Bone demineralization affects the skeletal system, including the temporal bone, which contains the cochlea and the vestibular labyrinth. However, research on the association of bone mineral density (BMD) with balance and hearing sensitivity is limited with conflicting results. Therefore, we examined the relationship in a population representative sample.

METHODS

We analyzed 8863 participants to the National Health and Nutrition Examination Survey (1999-2004) aged 40 years and older. Total and head BMD were measured by dual energy x-ray absorptiometry. Balance was evaluated using the Romberg Test of Standing Balance on Firm and Compliant Support Surfaces condition 4, also indicative of vestibular dysfunction. Hearing condition was self-reported. The associations of total and head BMD with balance and hearing were assessed using multiple and multinomial logistic regressions adjusting for covariates.

RESULTS

On multiple logistic regression, low total BMD was associated with balance impairment (odds ratio [OR], 2.21; 95% confidence interval [CI], 1.43-4.75), especially in older adults (≥65 years old; OR, 3.72; 95% CI, 1.07-12.85). In multinomial regression, low total BMD was associated with report of significant hearing impairment in older adults (OR, 5.30; 95% CI, 1.20-23.26).

CONCLUSIONS

Low BMD is associated with balance and hearing impairments, especially in older adults.

Standing balance tests for screening people with vestibular impairments

OBJECTIVES/HYPOTHESIS

To improve the test standards for a version of the Romberg test and to determine whether measuring kinematic variables improved its utility for screening.

STUDY DESIGN

Healthy controls and patients with benign paroxysmal positional vertigo, postoperative acoustic neuroma resection, and chronic peripheral unilateral weakness were compared.

METHODS

Subjects wore Bluetooth-enabled inertial motion units while standing on the floor or medium-density, compliant foam, with eyes open or closed, with head still or moving in pitch or yaw. Dependent measures were time to perform each test condition, number of head movements made, and kinematic variables.

RESULTS

Patients and controls did not differ significantly with eyes open or with eyes closed while on the floor. With eyes closed, on foam, some significant differences were found between patients and controls, especially for subjects older than 59 years. Head movement conditions were more challenging than with the head still. Significantly fewer patients than controls could make enough head movements to obtain kinematic measures. Kinematics indicated that lateral balance control is significantly reduced in these patients compared to controls. Receiver operator characteristics and sensitivity/specificity analyses showed moderately good differences with older subjects.

CONCLUSIONS

Tests on foam with eyes closed, with head still or moving, may be useful as part of a screening battery for vestibular impairments, especially for older people.

LEVEL OF EVIDENCE

3b.

Noninvasive radioelectric asymmetric conveyor brain stimulation treatment improves balance in individuals over 65 suffering from neurological diseases: pilot study

Purpose

In the elderly population, problems with walking and balance are very common. These problems seriously affect the quality of life of the elderly. When gait and balance problems are caused by neurological disease, these problems can be more serious and difficult to handle. The aim of this pilot study was to verify the effect of a noninvasive radioelectric conveyor asymmetric brain stimulation protocol, named neuropostural optimization (NPO), to improve balance in neurological elderly.

Patients and methods

Twelve patients suffering from various neurological diseases participated in this study. They were assessed with the Romberg test, which was performed on a computerized stabilometric platform before, immediately following, and 72 hours after NPO was used to improve balance.

Results

The results showed that a stabilization of balance was recorded in all subjects a few minutes after administration of NPO. This stabilization increased 72 hours after treatment.

Conclusion

The results show that NPO could be a valuable therapeutic approach to improve sensory-motor strategies and neurological control of balance in elderly patients suffering from various neurological diseases.