Can a Chronic BPPV With a History of Trauma be the Trigger of Symptoms in Vestibular Migraine, Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS), and Whiplash Associated Disorders (WAD)? A Retrospective Cohort Study

Good Health-Related Quality of Life in Older Patients One Year after mTBI despite Incomplete Recovery: An Indication of the Disability Paradox?

Background: Older adults (OAs) with mild traumatic brain injury (OA-mTBI) are a growing population, but studies on long-term outcomes and quality of life are scarce. Our aim was to determine the health-related quality of life (HRQoL) in OA-mTBI one year after injury and to assess the early predictors of HRQoL. Methods: Data from a prospective follow-up study of 164 older (≥60 years) and 289 younger mTBI patients (<60 years) admitted to the emergency department were analyzed. Post-traumatic complaints, emotional distress and coping were evaluated 2 weeks post-injury using standardized questionnaires. At 12 months post-injury, HRQoL and functional recovery were determined with the abbreviated version of the World Health Organization Quality of Life scale and Glasgow Outcome Scale Extended (GOSE), respectively. Results: One year post-injury, 80% (n = 131) of the OA-mTBI rated their HRQoL as "good" or "very good", which was comparable to younger patients (79% (n = 226), p = 0.72). Incomplete recovery (GOSE <8) was present in 43% (n = 69) of OA-mTBI, with 67% (n = 46) reporting good HRQoL. Two weeks post-injury, fewer OA-mTBI had (≥2) post-traumatic complaints compared to younger patients (68% vs. 80%, p = 0.01). In the multivariable analyses, only depression-related symptoms (OR = 1.20 for each symptom, 95% CI = 1.01-1.34, p < 0.01) were predictors of poor HRQoL in OA-mTBI. Conclusions: Similar to younger patients, most OA-mTBI rated their HRQoL as good at one year after injury, although a considerable proportion showed incomplete recovery according to the GOSE, suggesting a disability paradox. Depression-related symptoms emerged as a significant predictor for poor HRQoL and can be identified as an early target for treatment after mTBI.

Modulation of Central Nociceptive Transmission by Manual Pressure Techniques in Patients with Migraine: An Observational Study

Background: Manual pressure in the upper cervical spine is used to provoke and reduce the familiar migraine headache. Information is scarce on the segmental levels, myofascial structure provocation, and reduction occurrences. The required dosage (amount of pressure, number of repetitions, and duration) has not been objectified yet. Methods: Prospective observational study. Thirty patients with migraine were examined interictally. Manual pressure was applied at four sites: the posterior arch of C1, the articular pillar of C2, the rectus capitis posterior major muscle, and the obliquus capitis inferior muscle, bilaterally. On sites where the familiar headache was provoked, the pressure was sustained to induce pain reduction (three repetitions). Provocation of familiar headache (yes/no), headache intensity (numerical pain rating scale), time to obtain a reduction of the headache (seconds), and applied pressure (g/cm2) were recorded. Results: Provocation of the familiar headache occurred at the posterior arches C1 in 92%, and at one of the articular pillars of C2 in 65.3% of cases. At one of the rectus capitis major muscles, the familiar headache was provoked in 84.6% of cases; at one of the oblique capitis inferior muscles, the familiar headache was provoked in 76.9% of cases. The applied mean pressure ranged from 0.82 to 1.2 kg/cm2. Maintaining the pressure reduced headache pain intensity significantly between the start and end of each of the three consecutive trials (p < 0.04). This reduction occurred faster in the third application than in the first application (p = 0.03). Conclusion: Manual pressure at upper cervical segments provokes familiar referred migraine headaches, with low manual pressure. Maintaining the pressure reduces the referred head pain significantly, indicating modulation of central nociceptive transmission.

Broadening vestibular migraine diagnostic criteria: A prospective cohort study on vestibular migraine subtypes

BACKGROUND

Current Bárány Society criteria for vestibular migraine (VM) include only episodic symptoms. Anecdotal observations suggest that some patients have episodic forms and others have chronic forms of VM, with interplay and evolution of both subtypes over time.

OBJECTIVE

To better understand VM subtypes and evaluate a more inclusive diagnostic schema.

METHODS

Four VM groups were studied: definite episodic (dVM), probable episodic (pVM), definite chronic (dCVM), and probable chronic (pCVM). Chronic VM was defined as having more than 15 dizzy days per month. Sociodemographic and clinical characteristics were analyzed, along with Dizziness Handicap Inventory (DHI) and Vestibular Migraine Patient Assessment Tool and Handicap Inventory (VM-PATHI) scores.

RESULTS

54 adults with a mean age of 47.0 years (SD 13.7) were enrolled. 10 met criteria for dVM, 11 pVM, 22 dCVM, and 11 pCVM. Overall, there were strong similarities in clinical characteristics between dVM, pVM, dCVM, and pCVM. Compared to subjects with episodic VM, those with chronic VM had a higher average number of VM triggers (8.7 vs. 6.4, P = 0.019), including motion (93.9% vs. 66.7%, P = 0.009), scrolling on a screen (78.8% vs. 47.6%, P = 0.018), skipped meal (57.6% vs. 23.8%, P = 0.015), and air travel (57.6% vs. 23.8%, P = 0.015). They also had higher symptom severity (DHI = 53.3, P = 0.194) and burden of disease (VM-PATHI = 48.2, P = 0.030) scores.

CONCLUSIONS

Many patients do not meet current Bárány Society criteria for VM based on their duration of vestibular symptoms. Yet, these patients with chronic VM endorse several indistinguishable symptoms from those who do meet criteria. A more inclusive diagnostic schema should be adopted where patients with vestibular symptoms shorter than 5 minutes or longer than 72 hours are also recognized as having VM.

High score of dizziness-handicap-inventory (DHI) in patients with chronic musculoskeletal pain makes a chronic vestibular disorder probable

OBJECTIVES

In patients with a vestibular disorder a high score of dizziness-handicap-inventory (DHI) is common. Patients with chronic lithiasis of multiple canals benign paroxysmal positional vertigo (mc-BPPV) can have incapacitating symptoms, e.g. headache, neck pain, musculoskeletal pain, and cognitive dysfunction. Patients with chronic musculoskeletal pain with few objective findings at an ordinary examination of the musculoskeletal system together with unsuccessful interventions can either receive a diagnosis of a biopsychosocial disorder or a diagnosis connected to the dominant symptom. The aim of this investigation is to examine if the DHI- and the DHI subscale scores are abnormal in 49 patients with chronic musculoskeletal pain disorders. In addition, explore the possibility of a chronic mc-BPPV diagnosis.

METHODS

Consecutive prospective observational cohort study at five different physiotherapy clinics. A personal interview using a structured symptom questionnaire consisting of 15 items. Modified Dizziness Handicap Inventory (DHI) including the Physical-, Catastrophic- and Emotional impact DHI subscale scores suggested by the Mayo Clinic was applied.

RESULTS

Eighty-four percent of the 49 patients have a pathological DHI-score and a potential underlying undiagnosed vestibular disorder. Very few patients have scores at the catastrophic subscale. A correlation is found between the number of symptoms of the structured scheme and the DHI-score. Results from all five physiotherapy clinics were similar.

CONCLUSIONS

Patients with a high number of symptoms and a high DHI-score can have a potential underlying treatable balance disorder like mc-BPPV. Increased awareness and treatment of mc-BPPV may reduce suffering and continuous medication in patients with chronic musculoskeletal pain. Regional Ethical Committee (No IRB 00001870).

Prevalence and distribution of musculoskeletal pain in patients with dizziness—A systematic review

Background and purpose

Musculoskeletal disorders are among the leading causes of disability globally, but their role in patients with dizziness and imbalance is not well understood or explored. Such knowledge may be important as musculoskeletal pain and dizziness can mutually influence each other, leading to a complex condition requiring more comprehensive approaches to promote successful recovery. We conducted a systematic review to examine the extent and characteristic of reported musculoskeletal pain in patients with dizziness.

Methods

A comprehensive literature search in Medline, Embase, Cochrane, Scopus, Amed, Google Scholar, SveMed+, and Web of Science was conducted in March 2021. Inclusion criteria were studies examining patients with a vestibular diagnosis, patients with cervicogenic dizziness and patients included based on having dizziness as a symptom; and reported musculoskeletal pain. Data regarding age, sex, sample size, diagnosis and musculoskeletal pain was extracted. The Crowe Critical Appraisal Tool was used for assessing methodical quality of the included studies.

Results

Out of 1507 screened studies, 16 studies met the inclusion criteria. The total sample consisted of 1144 individuals with dizziness. The frequency of patients reporting pain ranged between 43% and 100% in the included studies. Pain intensity were scored between 5 and 7 on a 0–10 scale. Pain in the neck and shoulder girdle was most often reported, but musculoskeletal pain in other parts of the body was also evident.

Discussion

In the included studies, musculoskeletal pain was highly prevalent in patients with dizziness, with pain intensity that may have a moderate to severe interference with daily functioning. Pain in the neck and shoulder is well documented, but there are few studies addressing musculoskeletal pain in additional parts of the body. More research is needed to understand the relations between dizziness and musculoskeletal pain.

Associations between Zygoma Fracture and Post-Traumatic Headache: A Study among Taiwanese Population

Few studies have discussed the development of post-traumatic headache (PTH) after zygoma fracture. This research aimed to examine the association between zygoma fracture and PTH and its other associated factors. A total of 3043 patients with zygoma fracture and 3043 patients with non-fracture were included in this analysis. They were matched to a non-fracture cohort from the National Health Insurance database according to age, sex, and index year. The incidence of PTH and its association with zygoma fracture were assessed. The zygoma fracture cohort had a significantly higher cumulative incidence of PTH than the non-fracture cohort in a 10-year follow-up. The confounding risk factors of PTH included zygoma fracture, female sex, and comorbidities, including obesity and depression. Female patients under 40 years old who had zygoma fractures had a higher incidence of PTH than the non-fracture group. Moreover, patients with zygoma fractures commonly developed PTH within three months after injury. Female patients under 40 years old with precedent zygoma fractures had a higher incidence rate of PTH than those without fractures. Moreover, patients with zygoma fractures commonly developed PTH within three months after injury. Nevertheless, before widely applying our results, a prospective study must be conducted to verify the risk factors found in this study.

Possible involvement of the autonomic nervous system in cervical muscles of patients with myalgic encephalomyelitis / chronic fatigue syndrome (ME/CFS)

Background

Patients with myalgic encephalomyelitis / chronic fatigue syndrome (ME/CFS) sometimes present with stiffness of the cervical muscles. To investigate the pathophysiology of ME/CFS, this observational study compared patients with versus without recovery from ME/CFS through local modulation of the cervical muscles.

Methods

Over a period of 11 years, a total of 1226 inpatients with ME/CFS who did not respond to outpatient care were enrolled in this study. All patients received daily cervical muscle physical therapy during hospitalization. Self-rated records documenting the presence or absence of ME/CFS, as well as the representative eight symptoms that frequently accompany it at admission and discharge, were compared. Pupil diameter was also measured to examine autonomic nervous system function involvement.

Results

The recovery rate of ME/CFS after local therapy was 55.5%, and did not differ significantly by sex, age strata, and hospitalization period. The recovery rates of the eight symptoms were variable (36.6–86.9%); however, those of ME/CFS in the symptom subpopulations were similar (52.3–55.8%). The recovery rates of all symptoms showed strong associations with that of ME/CFS (p < 0.001). The pupil diameter was more constricted in the ME/CFS-recovered patients than in the ME/CFS-unrecovered patients in the total population and the subpopulations stratified by sex, age, and hospitalization period.

Conclusions

There was a strong association between the recovery of ME/CFS and other related whole-body symptoms. The recovery of ME/CFS may be partly linked to amelioration of the autonomic nervous system in the cervical muscles.

Trial registration

UMIN000036634. Registered 1 May 2019 - Retrospectively registered.

Vestibular migraine: the chameleon in vestibular disease

Vestibular migraine (VM) has been recently receiving increasing attention as an independent disease concept. It is a common cause of dizziness or headache; however, it was not clearly defined until 2018. Its diagnosis mainly relies on clinical history, including vertigo and migraine, as indicated by the appendix of the 3^rd edition of the International Classification Diagnostic Criteria for Headache Diseases. There is often an overlap of vertigo and migraine across vestibular diseases; therefore, VM often imitates various vestibular diseases. Additionally, VM lacks specific laboratory biomarkers; therefore, it has high misdiagnosis and missed diagnosis rates. Therefore, numerous clinical patients could have inaccurate diagnoses and improper treatment. Therefore, there is a need for further basic research to further clarify the pathogenesis. Moreover, there is a need for clinical trials focusing on specific laboratory biomarkers, including serological, radiological, and electrophysiological examinations, to develop more detailed and complete diagnostic criteria.

Characterization of Post-exertional Malaise in Patients With Myalgic Encephalomyelitis/Chronic Fatigue Syndrome

Background: Myalgic encephalomyelitis/chronic fatigue syndrome is characterized by persistent and disabling fatigue, exercise intolerance, cognitive difficulty, and musculoskeletal/joint pain. Post-exertional malaise is a worsening of these symptoms after a physical or mental exertion and is considered a central feature of the illness. Scant observations in the available literature provide qualitative assessments of post-exertional malaise in patients with myalgic encephalomyelitis/chronic fatigue syndrome. To enhance our understanding, a series of outpatient focus groups were convened. Methods: Nine focus groups totaling 43 patients who reported being diagnosed with myalgic encephalomyelitis/chronic fatigue syndrome were held between November 2016 and August 2019. Focus groups queried post-exertional malaise in daily life and participants' retrospective memory of post-exertional malaise that followed an exercise provocation with a cardiopulmonary exercise test. Data analysis followed the grounded theory method to systematically code and categorize the data to find meaningful patterns. A qualitative software package was used to move text into categories during data coding. Results: A wide range of symptoms were attributed to exertion both in daily lives and following cardiopulmonary exercise testing. While three core symptoms emerged (exhaustion, cognitive difficulties, and neuromuscular complaints), participants' descriptions were notable for their unique individual variations. Of 18 participants who responded to questions centered around symptoms following a cardiopulmonary exercise test, 17 reported that symptoms started within 24 h and peaked in severity within 72 h following the cardiopulmonary exercise test. Patients described post-exertional malaise as interfering with their ability to lead a "normal" life. Conclusion: The experience of post-exertional malaise in myalgic encephalomyelitis/chronic fatigue syndrome varies greatly between individuals and leads to a diminished quality of life. myalgic encephalomyelitis/chronic fatigue syndrome patients describe post-exertional malaise as all-encompassing with symptoms affecting every part of the body, difficult to predict or manage, and requiring complete bedrest to fully or partially recover. Given the extensive variability in patients, further research identifying subtypes of post-exertional malaise could lead to better targeted therapeutic options.

Management of Benign Paroxysmal Positional Vertigo in an Adult With Severe Osteogenesis Imperfecta

The purpose of this case report was to describe the evaluation and management of atypical benign paroxysmal positional vertigo (BPPV) in an adult with severe osteogenesis imperfecta. A 29-year-old male was referred to a physical therapist with extensive experience in vestibular rehabilitation who provided horizontal canal BPPV treatment with a canalith repositioning maneuver over two treatment sessions. The individual's symptoms had reduced by 65% and his nystagmus during the roll test was reduced. Extreme care is needed to safely reposition individuals living with severe osteogenesis imperfecta, but the repositioning can reduce symptoms and improve quality of life. Laryngoscope, 130:2241-2244, 2020.

Can the bending forward test be used to detect a diseased anterior semi-circular canal in patients with chronic vestibular multi-canalicular canalithiasis (BPPV)?

Introduction: Patients with chronic vestibular multi-canalicular canalithiasis (CVMCC) can have serious morbidities, for example, musculoskeletal pain, dizziness, fatigue, and cognitive difficulties. Involvement of the anterior semi-circular canal (SCC) is common in CVMCC. A mono-canalicular diseased anterior SCC is rare.Aim: To examine if the Bending forward test can be used to detect a diseased anterior semi-circular canal in patients with CVMCC.Material and Methods: Prospective consecutive observational cohort study in patients with relapse of an earlier successfully treated chronic CVMCC, where 16 patients have a diseased anterior SCC, 11 without any involvement of the anterior SCC, and 15 healthy controls. Patients are tested in sitting and in bending forward position. The difference in downwards directed nystagmus count and slow phase velocity in the two test positions AND reported movement illusion are the main outcome.Results: The sensitivity of the Bending forward-test is 81%; the specificity 91%. Five of the healthy controls have positional nystagmus without movement illusion. This is interpreted as cupulolithiasis. Positional nystagmus with movement illusion is interpreted as canalithiasis.Conclusions: Bending forward-test is a valuable test. Only positional nystagmus accompanied by a movement illusion, that is canalithiasis, is of clinical relevance.Significance: These findings may assist in diagnosing compound musculoskeletal disorders.