Efficacy of Vestibular Rehabilitation Following Acute Vestibular Neuritis: A Randomized Controlled Trial

Health education intervention and its impact on patients with unilateral vestibular dysfunction: An information-motivation-behavioral model approach

Unilateral vestibular dysfunction is a one-sided impairment of vestibular function in one ear. Incorporating health education in treatment and rehabilitation plans can improve vestibular function, keep negative emotions at bay, and reduce the extent of the condition. This letter investigates the impact of the information-motivation-behavioral skills model as a medium for health education on patient outcomes. While offering encouraging observations, there are certain limitations, such as the study’s retrospective design, small sample size, use of subjective measures, and lack of longer follow-ups that challenge the cogency of the study. The study is a step toward transforming vestibular dysfunction treatment through health education.

Early vestibular rehabilitation training of peripheral acute vestibular syndrome-a systematic review and meta-analysis

Objective

This study aimed to investigate the impact of early vestibular rehabilitation training combined with corticosteroids initiated within 2 weeks, compared with corticosteroid treatment, after the peripheral acute vestibular syndrome (pAVS) onset.

Data sources

PubMed, CINAHL, EMBASE, and SCOPUS. From inception to January 24, 2024. The International Prospective Register of Systematic Reviews approved this study (CRD42023422308).

Results

Five studies involving 235 patients were included in this systematic review and meta-analysis. The subjective outcome measure Dizziness Handicap Inventory (DHI) was pooled for a meta-analysis and was statistically significantly in favor of early vestibular rehabilitation training (early VRT) plus corticosteroids compared with corticosteroids alone: at one-month follow-up (p = 0.00) and 12 months follow-up (p = 0.01). DHI was a critical outcome for measuring the differences in effect of early VRT. The objective outcome measures of caloric lateralization, cervical vestibular-evoked myogenic potentials, and posturography were gathered for a narrative synthesis.

Conclusion

This meta-analysis showed that early VRT in combination with corticosteroids was more effective for treating pAVS than corticosteroid treatment alone. No adverse effects were reported for early VRT.

Post-stroke dizziness, depression and anxiety

OBJECTIVE

Vestibular and psychiatric disorders are very closely related. Previous research shows that the discomfort and dysfunction caused by dizziness in patients can affect psychological processes, leading to anxiety and depression, and the irritation of anxiety and depression can aggravate the discomfort of dizziness. But the causal relationship between dizziness in the recovery period of stroke and Post-stroke depression (PSD) / Post-stroke anxiety (PSA) is not clear. Identifying the causal relationship between them can enable us to conduct more targeted treatments.

METHODS

We review the epidemiology and relationship of dizziness, anxiety, and depression, along with the related neuroanatomical basis. We also review the pathophysiology of dizziness after stroke, vestibular function of patients experiencing dizziness, and the causes and mechanisms of PSD and PSA. We attempt to explore the possible relationship between post-stroke dizziness and PSD and PSA.

CONCLUSION

The treatment approach for post-stroke dizziness depends on its underlying cause. If the dizziness is a result of PSD and PSA, addressing these psychological factors may alleviate the dizziness. This can be achieved through targeted treatments for PSD and PSA, such as psychotherapy, antidepressants, or anxiolytics, which could indirectly improve dizziness symptoms. Conversely, if PSA and PSD are secondary to vestibular dysfunction caused by stroke, a thorough vestibular function assessment is crucial. Identifying the extent of vestibular impairment allows for tailored interventions. These could include vestibular rehabilitation therapy and medication aimed at vestibular restoration. By improving vestibular function, secondary symptoms like anxiety and depression may also be mitigated.

Efficacy of vestibular rehabilitation and its facilitating and hindering factors from real-world clinical data

Background and purpose

Customized vestibular rehabilitation improved dizziness and imbalance in several randomized controlled trials. In the present study, we determined the efficacy of customized vestibular rehabilitation using real-world observational data.

Methods

In this retrospective observational study, we recruited 64 patients (median age = 60, interquartile range = 48-66.3) who completed the customized vestibular rehabilitation from January to December 2022. The outcomes of rehabilitation were evaluated using the dizziness handicap inventory (DHI) or vestibular disorders activities of daily living scale (VADL). The factors associated with outcomes were assessed with a generalized linear model, of which covariates included patients' age, sex, duration of illness, type of vestibular disorders, initial DHI and VADL scores, exercise compliance, and initial hospital anxiety and depression scale (HADS) scores.

Results

After the median of 6 (4-6) weeks of rehabilitation, DHI and VADL scores significantly improved in patients with either peripheral or central vestibular disorders (Wilcoxon signed-rank test, p < 0.05). The initial DHI and VADL scores showed a positive while the sum of HADS scores showed a negative correlation with the outcome. In contrast, the age, sex, duration of illness, types of vestibular disorders, and exercise compliance did not affect the outcome.

Discussion and conclusion

Customized vestibular rehabilitation is effective for central as well as peripheral disorders, especially when the symptoms are severe and the psychological distress is mild.

Ten-year incidence, predictors and impact of dizziness and vertigo in community-dwelling adults

OBJECTIVES

We used a cohort of community-dwelling adults to establish the 10-year incidence and predictors of dizziness/vertigo, and its impacts on health-related quality of life.

STUDY DESIGN

Of the 1152 participants aged 55 + years who did not have dizziness/vertigo at baseline, 799 and 377 participants were followed up after 5 and 10 years, respectively, and had complete data and so were included in the incidence analysis. Hearing loss was determined as the pure-tone average of audiometric hearing thresholds at 500, 1000, 2000 and 4000 Hz, and any hearing loss was defined as >25 dB hearing level. Tinnitus and migraine were assessed by a positive response to a single question.

MAIN OUTCOME MEASURES

Audiologists screened participants for reported dizziness using a single question. Quality of life was measured using the Short Form 36-item Health Survey (SF-36).

RESULTS

The cumulative 10-year incidence of dizziness/vertigo, vestibular vertigo and non-vestibular vertigo were 39.8 %, 27.1 %, and 11.9 %, respectively. Age and presence of migraine were significant predictors of incident dizziness/vertigo: multivariable-adjusted hazard ratio (HR) 1.03 (95 % confidence interval, CI, 1.01-1.06) and HR 1.63 (95 % CI 1.13-2.35), respectively. A significant decrease in scores for the following SF-36 domains was observed over the 10 years among participants reporting baseline dizziness/vertigo: physical functioning (P-trend ≤ 0.0001), role limitation due to physical problems (P-trend ≤ 0.0001), general health (P-trend = 0.01), and vitality (P-trend = 0.01).

CONCLUSIONS

Dizziness/vertigo was a frequent and detrimental symptom in this population of community-dwelling adults. Our study highlights the burden imposed by dizziness, as evidenced by a significant prospective association with poorer quality of life.

Efficacy of Vestibular Rehabilitation in Vestibular Neuritis: A Systematic Review and Meta-analysis

OBJECTIVE

This study aimed to evaluate the efficacy of vestibular rehabilitation in vestibular neuritis.

DESIGN

A randomized controlled trial was collected from MEDLINE, Embase, Cochrane Library, PEDro, LILACS, and Google Scholar before May 2023.

RESULTS

This study included 12 randomized controlled trials involving 536 patients with vestibular neuritis. Vestibular rehabilitation was comparable with steroids in dizziness handicap inventory score at the first, sixth, and 12th months (pooled mean differences: -4.00, -0.21, and -0.31, respectively); caloric lateralization at the third, sixth, and 12th months (pooled mean difference: 1.10, 4.76, and -0.31, respectively); and abnormal numbers of vestibular-evoked myogenic potentials at the first, sixth, and 12th months. Patients receiving a combination of rehabilitation and steroid exhibited significant improvement in dizziness handicap inventory score at the first, third, and 12th months (mean difference: -14.86, pooled mean difference: -4.63, mean difference: -9.50, respectively); caloric lateralization at the first and third months (pooled mean difference: -10.28, pooled mean difference: -8.12, respectively); and numbers of vestibular-evoked myogenic potentials at the first and third months (risk ratios: 0.66 and 0.60, respectively) than did those receiving steroids alone.

CONCLUSIONS

Vestibular rehabilitation is recommended for patients with vestibular neuritis. A combination of vestibular rehabilitation and steroids is more effective than steroids alone in the treatment of patients with vestibular neuritis.

Patients admitted to hospital for vestibular neuritis in 2011-2021

BACKGROUND

The incidence of vestibular neuritis in Norway is unknown. The disorder causes acute dizziness, which is a common reason for hospital admission. The objective of this study was to analyse the number of patients admitted to Norwegian hospitals for vestibular neuritis over an eleven-year period.

MATERIAL AND METHOD

The number of patients admitted to hospital for vestibular neuritis and reported to the Norwegian Patient Registry in the period 2011-2021 was recorded. The figures were compared with the number of patients admitted for other vertiginous disorders.

RESULTS

The number of patients admitted to hospital for vestibular neuritis was 11.2 per 100,000 inhabitants per year (range 8.2-15.3). The number of patients admitted to hospital in the study period increased by an average of 7.9 % per year and was highest in the final year. Out of 63,884 patients admitted for vertiginous disorders in the study period, 6,450 (10.1 %) had vestibular neuritis.

INTERPRETATION

The number of patients admitted to hospital for vestibular neuritis each year increased considerably in the study period. This is likely to be a reflection of the increased hospitalisation rate and improvements in diagnostic workup more than an actual increase in the incidence of the disorder. A minority of patients admitted for vertiginous disorders had vestibular neuritis.

Effects of Early Vestibular Rehabilitation in Patients With Acute Vestibular Disorder: A Systematic Review and Meta-Analysis

OBJECTIVES

To investigate the effect of early vestibular rehabilitation on physical function and dizziness in patients with acute vestibular disorders.

DATABASES REVIEWED

The electronic databases examined included PubMed (MEDLINE), Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE (via Dialog), and PEDro.

METHODS

The inclusion criteria in terms of the study participants were patients 20 years and older with an acute unilateral peripheral vestibular disorder. We included individual randomized controlled trials (RCTs), cluster-RCTs, quasi-RCTs, and crossover trials. The outcomes were gait, balance (eyes open, eyes close), activities of daily living, dizziness, and vestibular function. Early vestibular rehabilitation was defined as rehabilitation within 14 days of vestibular disorder onset or surgery. Main outcome measures were gait, balance (eyes open, eyes close), activities of daily living, dizziness, and vestibular function.

RESULTS

Twelve trials involving 542 participants were included. Early vestibular rehabilitation improved the Dizziness Handicap Inventory by -7.18 (95% confidence interval [CI], -10.48 to -3.88), balance during eyes close by -1.40 (95% CI, -2.42 to -0.39), and dizziness by -1.47 (95% CI, -2.74 to -0.21) compared with no intervention or placebo.

CONCLUSION

The present study demonstrated that early vestibular rehabilitation improved the Dizziness Handicap Inventory, balance (eyes close), and subjective dizziness in a patient with acute vestibular disorders. This result indicates that early vestibular rehabilitation can promote vestibular compensation.

Utility of VestAid to Detect Eye-Gaze Accuracy in a Participant Exposed to Directed Energy

INTRODUCTION

The VestAid is a tablet-based application that provides feedback about a patient's eye/head movements during exercise after concussion. The goal of this case series was to determine if VestAid could be used to detect eye-gaze accuracy in a participant exposed to directed energy (DE).

MATERIALS AND METHODS

The VestAid results of a participant with DE were compared to an age- and gender-matched healthy control, a participant post-concussion, and a participant with vestibular neuritis. A tablet with VestAid software was utilized to record eye-gaze accuracy and head speed during VORx1 exercises using eye and facial recognition as participants were exposed to 12 visual scenes.

RESULTS

The participant with DE consistently had difficulty with eye-gaze accuracy when the head was rotated towards the right for all trials. The participant with DE had poor eye-gaze accuracy during all phases of the head turn cycle compared to the control participant (mean 47.91%, [SD = 7.32%] for the DE participant versus mean 94.28%, [SD = 5.87%] for the control participant). Post-exercise dizziness and perceived difficulty in the 12 exercises completed by the participant with DE were strongly related (Spearman's rho = 0.7372, P = .0062). The participant with DE had the lowest scores on 10 of the 12 head movement trials.

CONCLUSIONS

VestAid provided unique information about eye-gaze accuracy that detected eye movement abnormalities in the participants with DE exposure, concussion, and vestibular neuritis. The objective metrics of eye-gaze stability correlate with participants' symptoms and perceived difficulty of the eye/head movements.

Effectiveness of Vestibular Rehabilitation in Improving Health Status and Balance in Patients with Fibromyalgia Syndrome: A Single-Blind Randomized Controlled Trial

BACKGROUND

Fibromyalgia Syndrome (FMS) is a highly prevalent health problem whose main symptom is widespread pain, although it presents as other manifestations, such as loss of balance, that seem to mainly affect visuo-vestibular information.

OBJECTIVE

to compare the effects of a Vestibular Rehabilitation (VR) program versus those of a Conventional Physical Exercise (CPE) program on the health status of patients with FMS.

METHODS

A single-blind randomized controlled trial was performed. Patients with FMS were randomly assigned to VR or CPE programs. The protocols were performed in 40 min group sessions, twice weekly, for 16 sessions. Perceived health status, static and dynamic balance, verticality perception, confidence in balance, sensitization and kinesiophobia were measured at baseline, post-treatment and at the three-month follow-up and analyzed using an intention-to-treat approach.

RESULTS

Forty-eight subjects were randomly assigned, of whom thirty-five completed the planned VR (n = 19) or CPE (n = 16) program. At the three-month follow-up, there were differences in physical health status measured with the SF-12 (mean = -4.36, SE = 1.88, p = 0.027), balance during walking (mean = 1.90, SE = 0.57, p = 0.002), the perception of verticality in degrees (mean = 3.61, SE = 1.51, p = 0.024) and the anteroposterior position of the center of pressure (mean = -7.88, SE = 2.80, p = 0.009), as well as a decrease in the number of falls (mean = 0.98, SE = 0.44, p = 0.033), favoring the VR group.

CONCLUSIONS

Vestibular Rehabilitation can be as beneficial as conventional exercise in improving the state of health in patients with Fibromyalgia Syndrome, providing additional improvements in physical health status, body balance, the perception of verticality and the number of falls.

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

OBJECTIVE

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

STUDY DESIGN

Prospective randomized trial.

SETTING

Audiology-neurootology laboratory in a general public hospital.

PATIENTS

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

INTERVENTIONS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Dynamic change of vestibular function and the long-term prognosis of vestibular neuritis

AIM

To comprehensively evaluate the dynamic change of vestibular function during long-term follow-up of vestibular neuritis, as well as the co-relationship with the outcomes of vestibular neuritis (VN), which provides the recommendations for vestibular function tests during the course of VN.

METHODS

A prospective cohort study was conducted on 16 patients with acute VN. Caloric test, vHIT, rotatory chair tests, VEMP, dizziness handicap inventory (DHI) score, and dynamic dizzy scales (VAS-DD) was first performed within 7 days of neuritis onset, which were further re-evaluated during the 6-12 months of follow-up. The dynamic changes on multiple objective vestibular examinations were analyzed during the acute and recovery stage of VN. We further evaluated the co-relationship between the vestibular dysfunction scales and the prognosis of VN.

RESULTS

In more than 6 months of follow-up, 44% of the ultralow frequency, 94% of the low-to-mid frequency, and 44% of the high-frequency function of the horizontal semicircular canal returned to normal (p < 0.05). The change degree in symmetry of the rotatory chair test was correlated with the gain of the horizontal semicircular canal on the vHIT and the unilateral weakness (UW) value on the caloric test (p < 0.05). The change in DHI score was correlated with the phase; change in VAS-DD level correlated with the symmetry and TC of the rotatory chair test at VN recovery stage (p < 0.05). There was no significant correlation between the change in DHI score or change in VAS-DD and the degree of vestibular function recovery (p > 0.05).

CONCLUSION

In general, vestibular function improved during the course of VN. The rotatory chair test can be used to evaluate the overall function of the vestibular system and the compensatory state in patients with VN.

[Correlation between video head impulse test parameters and DHI score in patients with vestibular neuritis]

Objective:To explore the correlation between the parameters of video head impulse test （vHIT）and dizziness handicap inventory （DHI） score in patients with vestibular neuritis. Methods:Clinical data of 46 patients with vestibular neuritis were retrospectively analyzed. All the patients underwent DHI evaluation and vHIT examination. They were divided into mild handicap group, moderate handicap group and severe handicap group according to DHI score. The correlations between the parameters of vHIT and DHI score were compared among the three groups. The important parameters of vHIT were compared including vestibulo-ocular reflex （VOR） gain, gain asymmetry ratio （GA）, abnormal saccade dispersion （PR%）. Results:Of the 46 patients, 10 were in the mild handicap group, 21 in the moderate handicap group, and 15 in the severe handicap group. ①In the comparison of the mean value of lateral semicircular canal VOR gain, the vHIT gain of patients with mild, moderate and severe handicap were 0.64±0.06, 0.53±0.11 and 0.37±0.10, respectively, the mean value of VOR gain was negatively correlated with DHI score among the three groups（r=-0.545, P<0.001）, and the pairwise comparisons among the three groups was statistically significant（P<0.05）. In comparison of the mean values of lateral semicircular canal GA, the GA values of mild, moderate and severe handicap groups were 46.40±21.81, 47.59±15.17 and 56.57±17.39, respectively, there was no significant linear correlation between GA values and DHI scores among the three groups（r=0.246, P>0.05）, there was no significant difference between the three groups（P>0.05）. In comparison of the mean PR% of the lateral semicircular canal, the mean PR% of patients with mild, moderate and severe handicap group were 32.00±10.62, 53.82±17.09 and 76.00±10.01, respectively, PR% was positively correlated with DHI score（r=0.726, P<0.001）, and the comparison among the three groups was statistically significant（P<0.05）. ②The vertical semicircular canal vHIT gain of patients with mild, moderate and severe handicap was 0.63±0.06, 0.52±0.15 and 0.38±0.16, respectively, the mean of VOR gain was negatively correlated with DHI score among the three groups（r=-0.487, P<0.01）, the comparison of mild-severe and moderate-severe group was statistically significant（P<0.05）, while there was no significant difference between the mild and moderate group（P>0.05）. In the comparison of the mean values of vertical semicircular canal GA, the GA values of mild, moderate and severe handicap groups were 40.40±15.31, 46.10±19.59 and 47.87±18.05, respectively, there was no significant linear correlation between GA values and DHI scores among the three groups（r=0.047, P>0.05）, there was no significant difference in GA among the three groups（P>0.05）. The PR% of patients with mild, moderate and severe handicap were 42.40±15.39, 54.14±17.60 and 64.93±10.95, respectively, there was a positive significant correlation between PR% and DHI score（r=0.454, P<0.05）, there was statistically significant in the comparison of mild-severe group（P<0.05）, while there was no statistical significance between the other groups（P>0.05）. Conclusion:The VOR gain and PR% value of vHIT in patients with vestibular neuritis are closely related to the DHI score, which can evaluate the vestibular function and the degree of vertigo.

Group Vestibular Rehabilitation Program: A Cost-Effective Outpatient Management Option for Dizzy Patients

OBJECTIVES

This study was performed to evaluate the effectiveness of our novel group vestibular rehabilitation therapy (G-VRT) and to analyze the factors affecting outcomes.

STUDY DESIGN

Retrospective case series.

SETTING

Tertiary referral center.

PATIENTS

Patients with chronic dizziness who received G-VRT between December 2019 and July 2020.

INTERVENTION

The G-VRT program consisted of a 1-hour physical therapy session by an otologist in a small group setting.

MAIN OUTCOME MEASURES

Dizziness Handicap Inventory, visual analog scale, functional level scales, and video head impulse test, as well as the compliance to the program, were evaluated.

RESULTS

All scores of dizziness questionnaires were significantly improved after G-VRT ( p < 0.001). The overall vestibule-ocular reflex gain calculated by video head impulse test increased compared to the initial scores, whereas the average PR scores of all three semicircular canals significantly decreased from the initial scores, indicating enhanced vestibular compensation ( p < 0.05). Enrolled patients showed high compliance to the program.

CONCLUSION

G-VRT program is a cost-effective and efficient way to provide relief for chronic dizzy patients. Further case-control studies in a larger group, as well as comparative studies with generic or customized vestibular exercise, will be needed to validate the clinical value of G-VRT.

Vestibular Rehabilitation Therapy and Corticosteroids for Vestibular Neuritis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background and Objectives: Besides corticosteroids, clinicians found that vestibular rehabilitation therapy (VRT) has a potential effect on vestibular neuritis (VN) improvement. This study aimed to investigate the efficacy of both corticosteroid therapy (CT) compared to VRT, and each group compared to their combination (CT vs. (CT+VRT) and VRT vs. (CT + VRT). Materials and Methods: Systematic searches were performed in PubMed, CINAHL, and Scopus for randomized controlled trials (RCTs) reporting the administration of at least CT and VRT for VN. The outcome of interest was VN’s subjective and objective improvement parameters. Results: Four RCTs involving a total of 182 patients with VN were eligible for systematic review and meta-analysis. The weighted mean difference (WMD) of canal paresis (objective parameter) in the CT group is significantly lower than in the VRT group after a 1 month follow-up (8.31; 95% CI: 0.29, −16.32; p = 0.04; fixed effect). Meanwhile, the WMD of Dizziness Handicap Inventory (DHI) (subjective parameter) in the VRT group is significantly lower than in the CT group after a 1 month follow-up (−3.95; 95% CI: −7.69, −0.21; p = 0.04; fixed effect). Similarly, the WMD of DHI in the combination group (CT+VRT) is significantly lower than in the CT group after a 3 month follow-up (3.15; 95% CI: 1.50, 4.80; p = 0.0002; fixed effect). However, there is no significant difference in all outcomes after 12 months of follow-ups in all groups (CT vs. VRT, CT vs. combination, and VRT vs. combination). Conclusions: This study indicates that CT enhances the earlier canal paresis improvement, as the objective parameter, while VRT gives the earlier DHI score improvement, as the subjective parameter. However, their long-term efficacy does not appear to be different. VRT has to be offered as the primary option for patients with VN, and corticosteroids can be added to provide better recovery in the absence of its contraindication. However, whether to choose VRT, CT, or its combination should be tailored to the patient’s condition. Future studies are still needed to revisit this issue, due to the small number of trials in this field. (PROSPERO ID: CRD42021220615).

Corticosteroids for patients with vestibular neuritis: an evidence synthesis for guidelines for reasonable and appropriate care in the emergency department

BACKGROUND

A short course of corticosteroids is among the management strategies considered by specialists for the treatment of vestibular neuritis (VN). We conducted an umbrella review (systematic review of systematic reviews) to summarize the evidence of corticosteroids use for the treatment of VN.

METHODS

We included systematic reviews of randomized controlled trials (RCTs) and observational studies that evaluated the effects of corticosteroids as compared to placebo or usual care in adult patients with acute VN. Titles, abstracts, and full texts were screened in duplicate. The quality of reviews was assessed with the A MeaSurement Tool to Assess systematic Reviews (AMSTAR-2) tool. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) assessment was used to rate certainty of evidence. No meta-analysis was performed.

RESULTS

From 149 titles, 5 systematic reviews were selected for quality assessment, and 2 reviews were of higher methodological quality and were included. These 2 reviews included 12 individual studies and 660 patients with VN. In a meta-analysis of 2 RCTs including a total of 50 patients, the use of corticosteroids (as compared to placebo) was associated with higher complete caloric recovery (risk ratio 2.81, 95% CI 1.32 to 6.00, low certainty). It is very uncertain whether this translates into clinical improvement as shown by the imprecise effect estimates for outcomes such as patient-reported vertigo or patient-reported dizziness disability. There was a wide confidence interval for the outcome of dizziness handicap score (1 study, 30 patients, 20.9 points in corticosteroids group vs 15.8 points in placebo, mean difference +5.1, 95% CI -8.09 to +18.29, very low certainty). Higher rates of minor adverse effects for those receiving corticosteroids were reported, but the certainty in this evidence was very low.

CONCLUSIONS

There is limited evidence to support the use of corticosteroids for the treatment of vestibular neuritis in the emergency department.

Health Promotion Combined with Psychological Care Improves Vestibular Function in Patients with Vestibular Neuritis

This study aimed to explore the effect of health education combined with psychological care on patients with vestibular neuritis and the effect on their vestibular function. One hundred patients with vestibular neuritis admitted to our hospital from January 2019 to December 2020 were enrolled and divided into two groups by the random number: the control group (CG) (n= 53, health education) and the study group (SG) (n= 47, health education + psychological care). The Dizziness Handicap Inventory (DHI) scores, Berg Balance Scale (BBS) scores, depression scores (SDS), anxiety scores (SAS), satisfaction with care, compliance, incidence of falls, quality of life (QOF), and clinical symptom scores were compared between the two groups. Compared with the CG, the SG had a more significant reduction in DHI scores and SDS and SAS scores and a significant increase in BBS scores ( $P<0.05$ ). Compared with the CG, the SG had higher nursing satisfaction and compliance and a lower incidence of falls ( $P<0.05$ ). Nursing efficiency was higher in the SG than in the CG ( $P<0.05$ ). QOF scores were higher in the SG than in the CG ( $P<0.05$ ). Clinical symptom scores were lower in the SG than in the CG ( $P<0.05$ ). Health education combined with psychological care can improve vestibular function and bad mood, reduce the incidence of falls, improve the QOF, and result in high patient satisfaction and compliance, which should be widely promoted.

Effects of Different Doses of Clopidogrel plus Early Rehabilitation Therapy on Motor Function and Inflammatory Factors in Patients with Ischemic Stroke

This prospective randomized controlled study was intended to assess the effects of different doses of clopidogrel plus early rehabilitation therapy on motor function and inflammatory factors in patients with ischemic stroke. Between August 2018 and October 2020, 90 cases of ischemic stroke treated in the Second People's Hospital of Yibin were randomized at a ratio of 1 : 1 to receive either oral 50 mg/d clopidogrel plus early rehabilitation therapy (low-dose group) or oral 75 mg/d clopidogrel plus early rehabilitation therapy (high-dose group), with 45 cases in each group. The outcome measures including the Barthel Index (BI), National Institutes of Health Stroke Scale (NIHSS), Fugl-Meyer simplified scale, hypersensitive C-reactive protein (hs-CRP), interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and occurrence of adverse events were collected. After treatment, the high-dose group had higher BI results than the low-dose group. All eligible patients showed significantly declined NIHSS scores, and the high-dose group had markedly lower results (P < 0.05). After treatment, the Fugl-Meyer scores of both upper and lower extremities of the high-dose group were significantly higher than those in the low-dose group. The high-dose group achieved a greater decrease in inflammatory factor levels after treatment versus the low-dose group. The two groups showed a similar incidence of adverse events. High-dose clopidogrel plus early rehabilitation outperforms the low-dose treatment for patients with ischemic stroke by effectively mitigating the inflammatory response in the body, promoting the restoration of neurological function, improving the level of motor function, and enhancing the patient's quality of life, with manageable safety.

Internet-based vestibular rehabilitation versus standard care after acute onset vertigo: a study protocol for a randomized controlled trial

Background

Dizziness and vertigo affect around 15% of adults annually and represent common reasons for contacting health services, accounting for around 3% of all emergency department visits worldwide. Vertigo is also associated with excessive use of diagnostic imaging and emergency care and decreased productivity, primarily because of work absenteeism. Vestibular rehabilitation is an evidence-based treatment for chronic dizziness and supervised group exercise therapy has recently been shown to be effective after vestibular neuritis, a common cause of acute onset vertigo. However, such interventions are not readily available and there is a need for more easily accessible tools. The purpose of this study is to investigate the effects on vestibular symptoms of a 6-week online vestibular rehabilitation tool after acute onset vertigo, with the aim of aiding vestibular rehabilitation by presenting a more accessible tool that can help to reduce recovery time.

Methods

Three hundred twenty individuals diagnosed with acute vestibular syndrome (AVS) will be recruited from multiple hospitals in Sweden and the effects of an online vestibular rehabilitation tool, YrselTräning, on vestibular symptoms after acute onset vertigo will be compared to standard care (written instructions leaflet) in a two-armed, evaluator-blinded, multicenter randomized controlled trial. The primary outcome will be the Vertigo Symptom Scale Short Form (VSS-SF) score at 6 weeks after symptom onset. Secondary outcomes include effects of the intervention on activities of daily living, mood and anxiety, vestibular function recovery, mobility measures, health economic effects, and the reliability of the Swedish VSS-SF translation.

Discussion

Participants using the online vestibular rehabilitation tool are expected to recover earlier and to a greater extent from their symptoms as compared to standard care. Since up to 50% of people with AVS without treatment develop persistent symptoms, effective treatment of AVS will likely lead to a higher quality of life and help reduce the societal costs associated with dizziness and vertigo.

Trial registration

Clinicaltrials.gov NCT05056324. Registered on September 24, 2021.

White Matter Hyperintensities (WMH) and clinical outcome after vestibular neuritis

OBJECTIVES

Identification of patients at high risk for chronic dizziness after Vestibular Neuritis (VN) would allow these patients to be the target of focused therapies. However, there is a discrepancy between studies with regard to which factors best predict symptom recovery. The present study provides a comprehensive evaluation of Vestibular Neuritis and the major predictors for the development of chronic vestibular insufficiency.

METHODS

All subjects (n = 54) with acute vestibular neuritis admitted to the Department of Neurology of Beijing Luhe Hospital affiliated to Capital Medical University from 2018 to 2020 were retrospectively identified . Forty-three subjects who received a 4-test battery as well as 3.0T brain MRI, were included in the study. Patients were divided into two groups: Group 1 with complete recovery and Group 2 without recovery, as determined by symptoms 3 months after the VN episode. In addition, we recruited 21 healthy subjects to characterize the profiles of acute VN .

RESULTS

The total WMH score negatively correlated with a clinical recovery (Phi coefficient = -0.808, p value = 0.000). Statistical regression for predicting the outcome of clinical recovery using cerebral white matter changes as an independent variable was significant (p = 0.004). However, clinical recovery was not associated with the nerve divisions (Phi coefficient = 0.108, p = 0.492), age (p = 0.247) and the grade of nystagmus (p = 0.797)   .

CONCLUSIONS

A 4-test battery provides essential information to identify vestibular nerve dysfunction. Cerebral white matter change on MRI was predictive of chronic vestibular insufficiency after vestibular neuritis.

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.

The Outpatient Approach to Dizziness

The evaluation of the dizzy patient is complicated by many common pitfalls. The patient's description of symptoms and the standard neurologic examination are often nonspecific or unrevealing, and neuroimaging is most often normal. Over the past several years, research has demonstrated that a refocusing of history taking results in more reliable and diagnostically helpful information. This can guide a targeted expansion of the exam, often with an emphasis on eye movements.

Exploratory fall risk and preventive intervention in acute vestibular neuritis

Objective

To analyze recovery from dizziness in patients with acute vestibular neuritis (AVN) after applying the “Dizziness & Fall Risk Assessment and Intervention (DFRAI)”.

Methods

This prospective study involved patients with AVN who underwent a survey of dizziness and fall risk. The patients received medical treatment and customized vestibular rehabilitation, and vestibular function was evaluated at the initial attack and 3 months later.

Results

Forty-one patients underwent subjective questionnaire assessments, which showed significant improvement in visual analog scale-dizziness handicap inventory-fear of falling (VAS-DHI-FOF) results from the initial vertigo attack to 3 months later. In the sensory organization test (SOT), the initial composite score was 63 ± 13.1, which improved to 77.5 ± 4.9 3 months later. In caloric testing, the canal paresis (CP) score was 42.9 ± 35.2, which improved to 29.9 ± 23.5 3 months later.

Conclusions

Subjective improvement in dizziness and objective recovery of vestibular function were confirmed. DFRAI is a comprehensive solution for dizziness, and appropriate application of the DFRAI is expected to have a positive effect on recovery from dizziness and fall prevention in patients with AVN.

[Betahistine in vestibular disorders: current concepts and perspectives]

The goal of this paper is to review the pharmacological profile of betahistine and evidence for using it in the treatment of common vestibular disorders. Betahistine is a weak agonist for histamine H1 receptors and strong antagonist for histamine H3 receptors. It demonstrates the maximum benefit in different types of peripheral vertigo, especially in Meniere's disease. The best results in decreasing intensity of vertigo, frequency of attacks and stimulation of vestibular compensation were obtained in daily dose 48 mg during 3 months. In benign paroxysmal positional vertigo betahistine is used to treat residual dizziness after successful treatment of otolithiasis and to reduce the severity of vertigo during repositioning maneuvers. In vestibular neuritis betahistine stimulates central compensation during vestibular rehabilitation. A new once-daily drug formulation of modified-release betahistine is non-inferior to traditional and has a comparable safety profile, and could improve patient adherence. The implication of betahistine in the treatment of central vestibular disorders is under-researched. The efficacy of betahistine in increasing of vestibular compensation in post-stroke central vestibular disorders, persistent postural-perceptual dizziness and its role in vestibular migraine need further investigation.

The Gait Disorientation Test: A New Method for Screening Adults With Dizziness and Imbalance

OBJECTIVE

To develop and evaluate a new method for identifying gait disorientation due to vestibular dysfunction.

DESIGN

The gait disorientation test (GDT) involves a timed comparison of the ability to walk 6.096 m with eyes open versus eyes closed. In this prospective study, participants were grouped based on vestibular function. All participants completed a clinical examination, self-report- and performance-based measures relevant to vestibular rehabilitation, and the tasks for the GDT. Vestibular-impaired participants underwent the criterion standard, videonystagmography and/or rotational chair testing.

SETTING

Ambulatory clinic, tertiary referral center.

PARTICIPANTS

Participants (N=40) (20 vestibular-impaired, 30 women, 49.9±16.1years old) were enrolled from a convenience/referral sample of 52 adults.

MAIN OUTCOME AND MEASURE(S)

We determined test-retest reliability using the intraclass correlation coefficient model 3,1; calculated the minimal detectable change (MDC); examined concurrent validity through Spearman correlation coefficients; assessed criterion validity with the area under the curve (AUC) from receiver operator characteristic analysis; and computed the sensitivity, specificity, diagnostic odds ratio (DOR), likelihood ratios for positive (LR+) and negative (LR-) tests, and posttest probabilities of a diagnosis of vestibulopathy. The 95% confidence interval demonstrates measurement uncertainty.

RESULTS

Test-retest reliability was 0.887 (0.815, 0.932). The MDC was 3.7 seconds. Correlations with other measures ranged from 0.59 (0.34, 0.76) to -0.85 (-0.92, -0.74). The AUC was 0.910 (0.822, 0.998), using a threshold of 4.5 seconds. The sensitivity and specificity were 0.75 (0.51, 0.91) and 0.95 (0.75, 1), respectively. The DOR=57 (6, 541.47), LR+ =15 (2.18, 103.0), and LR- =0.26 (0.12, 0.9). Positive posttest probabilities were 89%-94%.

CONCLUSIONS AND RELEVANCE

The GDT has good reliability, excellent discriminative ability, strong convergent validity, and promising clinical utility.

Predictors of Physical Therapy Referral Among Persons With Peripheral Vestibular Disorders in the United States

OBJECTIVE

To determine the rate of physical therapy (PT) referral and patient and physician characteristics associated with PT referral for benign paroxysmal positional vertigo (BPPV) and other peripheral vestibular disorders (PVD) in ambulatory care clinics in the United States.

DESIGN

Cross-sectional analysis of the National Ambulatory Medical Care Survey 2004-2015 SETTING: Ambulatory care clinics in the United States.

PARTICIPANTS

We identified 5.6 million weighted adult visits for BPPV (International Classification of Diseases-9th Revision-Clinical Modifications (ICD-9-CM): 386.11) and 6.6 million weighted visits for other PVDs (ICD-9-CM: 386.1-386.9, excluding 386.11 and 386.2) made by patients 18 years and older from 2004 through 2015.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Patient, clinical, and physician characteristics were extracted, and descriptive statistics were stratified by referral to PT. Two multivariable logistic regression models were estimated for each diagnostic group (BPPV and other PVDs) to identify predictors of PT referral.

RESULTS

PT referrals for BPPV increased from 6.2% in the period from 2004 to 2006 to 12.9% in the period from 2013 to 2015, whereas PT referrals for other PVDs decreased from 3.8% in the period from 2004 to 2006 to 0.5% in the period from 2013 to 2015. Other insurance coverage (versus private) and neurologists and other specialists (versus otolaryngologists) were associated with a greater odds of PT referral for BPPV. Visits made in the Midwest and West (versus the Northeast) and in rural versus metropolitan areas had greater odds of PT referral for BPPV. Relative to otolaryngologists, primary care physicians were less likely to refer to PT for other PVDs. Visits made in metropolitan versus rural areas and visits with 1 or more comorbidities (versus none) had greater odds of PT referral for other PVDs.

CONCLUSIONS

PT referrals remain low for ambulatory care visits for BPPV and other PVDs in the United States. Referral to PT for BPPV and other PVDs varied by insurance type, physician specialty, and office location.