'Excess anxiety' and 'less anxiety': both depend on vestibular function

Bilateral vestibulopathy - Loss of vestibular function and experience of emotions

OBJECTIVE

The vestibular system is closely connected to emotion-processing neuronal circuits. Patients with bilateral vestibulopathy (BVP), a chronic loss of vestibular function, show remarkably lower rates of psychiatric comorbidities and vertigo-related anxiety (VRA) than those with episodic vertigo/dizziness (v/d). This study aimed to evaluate whether patients with BVP differ from those with episodic v/d in terms of VRA, general anxiety, and cognitions about body and health.

METHODS

This cross-sectional study involved a subsample of 202 patients with episodic v/d (i.e., vestibular migraine, vestibular paroxysmia, or Menière's disease) and 43 patients with BVP. All patients underwent standardised neurological/neurotological examinations, structured clinical interviews (SCID-I), and self-report questionnaires, such as the Vertigo Handicap Questionnaire (VHQ), Beck Anxiety Inventory (BAI), Trait Anxiety from the State-Trait-Anxiety Inventory (STAI-T), and Cognitions About Body and Health questionnaire (CABAH). Non-parametric tests were used for analysis. Due to multiple testing, the significance level was set at p ≤ .008.

RESULTS

Patients with episodic v/d exhibited higher VRA levels than those with BVP. However, this difference was not statistically significant (p = .04; r = 0.15, small effect). Additionally, patients with BVP reported more catastrophizing cognitions (p < .001; r = 0.25, small effect) and bodily weakness (p = .003; r = 0.22, small effect) compared to those with episodic v/d. There were no differences in general anxiety levels (BAI and STAI-T) between patients with v/d and those with BVP.

CONCLUSION

Patients with episodic v/d and BVP differed in their appraisal (cognition). The difference in VRA (subjective feeling) was not statistically significant. These preliminary results are discussed using a component approach to emotions.

Psychiatric Comorbidities and Quality of Life in Patients with Vestibular Migraine and Migraine without Vertigo: A Cross-Sectional Study from a Tertiary Clinic

Background Clinical studies suggest that vestibular migraine patients have psychiatric comorbidities and low life quality. However, the absence of a multidisciplinary approach to vestibular migraine patients, including otorhinolaryngologists and psychiatrists, is concerning. We aimed to investigate these patients comprehensively and to compare the results of three questionnaires-the Hospital Anxiety and Depression Scale (HADS), Dizziness Handicap Inventory (DHI), and Short Form Health Survey (SF-36)-between patients with definite vestibular migraine (dVM), migraine without vertigo (MO), and healthy controls (HCs).

METHODS

A total of 104 participants were divided into 3 groups: dVM patients (19 participants), MO patients (22 participants), and HCs (63 participants). The scores of the three questionnaires across the three groups were compared using analysis of variance, and linear regression was used to examine the associations between the questionnaire scores within each group.

RESULTS

Compared to MO patients and HCs, dVM patients had significantly higher total scores on the HADS (p < 0.0001) and DHI (p < 0.0001) scales, and lower scores for all nine components of the SF-36, indicating poorer health. In the vestibular migraine group, the DHI score was strongly negatively correlated with the Physical Functioning subscale of the SF-36.

CONCLUSIONS

Anxiety and depression are more prevalent in patients with definite vestibular migraine compared to patients with migraine without vertigo and healthy controls. The physical functioning of patients with definite vestibular migraine is highly affected by their dizziness, resulting in a lower quality of life. Timely screening for psychiatric comorbidity in vestibular migraine patients is essential to prevent psychiatric consequences.

Exploration of sleep quality and rest-activity rhythms characteristics in Bilateral Vestibulopathy patients

Sleep and circadian timing systems are constantly regulated by both photic and non-photic signals. Connections between the vestibular nuclei and the biological clock raise the question of the effect of peripheral vestibular loss on daily rhythms, such as the sleep-wake cycle and circadian rhythm. To answer this question, we compared the sleep and rest-activity rhythm parameters of 15 patients with bilateral vestibulopathy (BVP) to those of 15 healthy controls. Sleep and rest-activity cycle were recorded by a device coupling actimetry with the heart rate and actigraphy at home over 7 days. Subjective sleep quality was assessed by the Pittsburgh Sleep Quality Index (PSQI). Sleep efficiency and subjective sleep quality were significantly reduced, and sleep fragmentation was increased in BVP patients compared to controls. BVP patients displayed a damped amplitude of the rest-activity rhythm and higher sleep fragmentation, reflected by a higher nocturnal activity compared to controls. These results suggest that both rest-activity and sleep cycles are impaired in BVP patients compared to healthy controls. BVP patients seem to have greater difficulty maintaining good sleep at night compared to controls. BVP pathology appears to affect the sleep-wake cycle and disturb the circadian rhythm synchronization. Nevertheless, these results need further investigation to be confirmed, particularly with larger sample sizes.

French adaptation and validation of the Niigata PPPD Questionnaire: measure of severity of Persistent Postural-Perceptual Dizziness and its association with psychiatric comorbidities and perceived handicap

Persistent Postural-Perceptual Dizziness (PPPD) is a functional vestibular condition. Despite being the most common chronic neuro-otologic disorder, it remains undertreated. The Niigata PPPD Questionnaire (NPQ), developed by Yagi et al. in 2019 to assess the severity of PPPD, could be a useful tool to help in the screening and diagnosis of this condition. This study aimed to validate a French version of the NPQ and make it an available assessment tool. Moreover, we aimed to understand the characteristics of PPPD patients better. The NPQ was translated and adapted into French. 50 PPPD patients, 50 patients with vestibular disorders without PPPD, and 50 healthy controls were included. They answered the adapted NPQ and additional questionnaires assessing trait (STAI) and state anxiety (HADS-A), depression (HADS-D) and handicap related to dizziness (DHI). The NPQ's reliability was assessed by Cronbach's alpha. Intergroup comparisons and multiple linear regressions were conducted to examine the characteristics of PPPD patients compared to vestibular patients and healthy controls, to validate NPQ's reliability, and to explore the effect of clinical parameters and treatment with selective serotonin reuptake inhibitors. Receiver operating characteristic (ROC) curves were carried out to determine the diagnostic values of the NPQ total score and sub-scores. Relations between NPQ and reported handicap, depression and anxiety were evaluated by correlations between questionnaire scores. The internal consistency was high (>0.8) for all NPQ subscales and the total score. Intergroup comparisons showed a significantly higher NPQ total score and sub-scores in the PPPD group compared to the two others. The ROC curve analysis showed a significant, but poor, discrimination of NPQ (AUC = 0.664) and its subscales. DHI scores, depressive symptoms and trait anxiety were significantly higher in PPPD patients than in vestibular patients and healthy controls. State anxiety did not differ between patients with PPPD and vestibular patients without PPPD. Finally, there was a significant correlation between the NPQ and the DHI. Our study provides a better understanding of PPPD symptomatology and its assessment. It showed that the NPQ is a reliable tool that can assist in symptom assessment for a French-speaking population.

Association of Vestibular Disorders and Cognitive Function: A Systematic Review

OBJECTIVES

The purpose of this study is to consolidate and condense the available evidence about the potential association between vestibular diseases and cognitive impairment.

DATA SOURCES AND METHODS

A systematic search was conducted on four English databases (PubMed, Embase, Web of Science, Cochrane Library) from the time of library construction to March 2024. The study incorporated various keywords such as "vestibular disorders," "vertigo," "dizziness," "Meniere's disease," "benign paroxysmal positional vertigo," "vestibular migraine," "vestibular neuritis," "labyrinthitis," "bilateral vestibular disease," as well as "cognitive function" and "cognitive dysfunction." A qualitative review was conducted to look for and assess pertinent studies.

RESULTS

A total of 45 publications were incorporated, encompassing prevalent vestibular disorders, mostly targeting individuals in the middle-aged and older demographic. The findings indicate that individuals with vestibular disorders experience varying levels of cognitive impairment, which is evident in different aspects, with visuospatial cognitive deficits being more prominent. Furthermore, patients with chronic vestibular syndromes are more prone to cognitive dysfunction. Lastly, the hippocampus plays a crucial role in the intricate vestibular neural network.

CONCLUSION

The findings of this comprehensive review indicate that vestibular disorders can result in impairments across various aspects of cognitive functioning, particularly in visuospatial cognition. The underlying mechanism may be associated with a decrease in the size of the hippocampus. Individuals suffering from chronic vestibular dysfunction exhibit a higher likelihood of experiencing cognitive deficits.

LEVEL OF EVIDENCE

NA Laryngoscope, 2024.

Relationships between vestibular issues, noise sensitivity, anxiety and prolonged recovery from mild traumatic brain injury among adults: a scoping review

BACKGROUND

We investigated the extent of literature and findings on relationships between vestibular issues, noise sensitivity (NS), and anxiety. We were interested in how relationships among these factors impacted adults' recovery three months or more after mild traumatic brain injury (mTBI).

METHODS

We conducted a scoping review to evaluate the extent of evidence linking relationships between vestibular issues, NS and anxiety with recovery after mTBI. Data relating to study characteristics and key findings were extracted and used to inform a critical narrative synthesis of findings.

RESULTS

After screening and full-text review, we included two studies. Both studies considered the combination of vestibular issues, NS and anxiety and mTBI recovery. Vestibular issues, NS and anxiety were all significantly associated with one another and their presence was the strongest indicator that symptoms would extend beyond three-months after mTBI.

CONCLUSION

Few studies have focused on the relationships that vestibular issues, NS and anxiety have with one another and recovery after mTBI. Given the apparent strong relationships between these factors and prolonged recovery, we highlight this as an area warranting further investigation.

Combination of UPLC-Q-TOF/MS and network pharmacology to reveal the mechanism of Chaihu-jia-Longgu-Muli decoction for treating vertigo with anxiety disorder

Chaihu-jia-Longgu-Muli decoction (CLMD) has been proven clinically effective in treating vertigo with anxiety disorder. However, the mechanism is not clear. This study aimed to explore the mechanism of CLMD in treating vertigo with anxiety disorder based on ultra-performance liquid chromatography-quadrupole time-of-flight/mass spectrometry (UPLC-Q-TOF/MS) and network pharmacology. UPLC-Q-TOF/MS was performed to identify the compounds in blood and the targets of compounds of CLMD in vertigo and anxiety were searched using databases. A protein-protein interaction network was built to screen the core targets. The core targets were analyzed by Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses. In addition, the vertigo with anxiety rat model was used to verify the results. A total of 22 compounds were absorbed into the blood. Eighty-one potential targets associated with CLMD for vertigo with anxiety disorder were identified through network pharmacological analysis. Subsequently, GO and KEGG analysis showed that CLMD treatment for vertigo with anxiety disorder is associated with neurotransmitter levels and other pertinent physiological processes. The results of the animal experiments showed that CLMD decreased the levels of serotonin, norepinephrine and dopamine, alleviating the symptoms of vertigo and anxiety disorder in model rats. The study revealed CLMD could alleviate vertigo and anxiety symptoms through reducing the levels of neurotransmitters.

Prenatal Maternal Psychological Distress During the COVID-19 Pandemic and Newborn Brain Development

Importance

Elevated maternal psychological distress during pregnancy is associated with altered fetal brain development. During the COVID-19 pandemic, prenatal maternal psychological distress more than doubled.

Objective

To examine the association of the pandemic and rising maternal psychological distress with brain growth in newborns using quantitative 3-dimensional volumetric magnetic resonance imaging (MRI).

Design, Setting, and Participants

This prospective cross-sectional study recruited mother-infant dyads at Children's National Hospital, Washington, DC, during the COVID-19 pandemic (June 1, 2020, to June 30, 2022) into a longitudinal infant brain development study and compared them with an existing normative healthy cohort (recruited March 1, 2014, to December 31, 2019). Exclusion criteria included multiple gestation pregnancy, known or suspected congenital infection, documented chromosomal abnormalities, or any maternal contraindication to MRI, as well as prenatal COVID-19 exposure. Infants with structural brain abnormalities or a postnatal confirmation of a genetic syndrome were excluded.

Exposure

Psychological distress during COVID-19 pandemic.

Main Outcomes and Measures

Prenatal maternal mental health was evaluated using the Spielberger State-Trait Anxiety Inventory and the Perceived Stress Scale. Neonates underwent nonsedated brain MRI. An ordinary least squares linear regression model was used to measure the differences in regional brain volumes of neonates born before vs during the pandemic with and without exposure to elevated prenatal maternal psychological distress after adjustment for neonatal sex and gestational age at MRI and maternal age and educational level.

Results

A total of 159 mother-infant dyads were included in the analysis: 103 before and 56 during the pandemic (median gestational age of infants, 39.6 [IQR, 38.4-40.4] weeks; median maternal age, 34.5 [IQR, 31.0-37.0] years). Eighty-three infants (52.2%) were female. Among the mothers, 130 (81.8%) had a college degree and 87 (54.7%) had a graduate degree. Forty-four mothers (27.7%) identified as Asian, Hispanic, or multiracial; 27 (17.0%), as Black; and 88 (55.3%), as White. Scores on anxiety and stress measures were significantly increased in the pandemic cohort. Infants of mothers with elevated maternal distress showed median reductions in white matter (-0.36 [95% CI, -0.61 to -0.11] cm3; Q < .001), right hippocampal (-0.35 [95% CI, -0.65 to -0.06] cm3; Q = .04), and left amygdala (-0.49 [95% CI, -0.84 to -0.13] cm3; Q = .03) volumes compared with infants of mothers with low distress levels. After adjusting for the cohort effect of the pandemic, elevated trait anxiety remained significantly associated with decreased left amygdalar volumes (-0.71 [95% CI, -1.12 to -0.29]; Q < .001).

Conclusions and Relevance

In this cross-sectional study of maternal-infant dyads prior to and during the COVID-19 pandemic, regional neonatal brain volumes were associated with elevated maternal psychological distress.

Vestibular dysfunction in Parkinson's disease: a neglected topic

Dizziness and postural instability are frequently observed symptoms in patient with Parkinson's disease (PD), potentially linked to vestibular dysfunction. Despite their significant impact on quality of life, these symptoms are often overlooked and undertreated in clinical practice. This review aims to summarize symptoms associated with vestibular dysfunction in patients with PD and discusses vestibular-targeted therapies for managing non-specific dizziness and related symptoms. We conducted searches in PubMed and Web of Science using keywords related to vestibular dysfunction, Parkinson's disease, dizziness, and postural instability, alongside the reference lists of relevant articles. The available evidence suggests the prevalence of vestibular dysfunction-related symptoms in patients with PD and supports the idea that vestibular-targeted therapies may be effective in improving PD symptoms.

Mental Health Education and Utilization Among Patients with Vestibular Disorders

To explore the receipt of mental health education, assessment, and referrals, and mental health service use among individuals with vestibular disorders. Patients with vestibular disorders living in the US, Australia, Canada, and the UK were surveyed through social media forums. Questionnaires assessed demographics, anxiety (Generalized Anxiety Disorder-7), depression (Center for Epidemiological Studies Depression-10), dizziness (Dizziness Handicap Inventory), and type of professional providing mental health education, assessment, referral, and treatment. The 226 participants were largely White (90%), educated (67% holding an associate's degree or higher) women (88%) with an average age of 45 who self-identified as having chronic vestibular symptoms (78%), as opposed to episodic ones (22%). Fifty-two percent reported never receiving verbal education, written education (69%), mental health assessment (54%), or referral (72%). Participants were more likely to receive mental health treatment in the past if they had received verbal resources and/or referrals from clinicians. The majority of patients with vestibular disorders report that medical professionals have not provided education, mental health assessment, or a mental health referral.

Prevalence and Contributing Factors of Anxiety and Depression in Patients with Vestibular Migraine

Objective: Anxiety and depression are psychiatric comorbidities potentially associated with dizziness and migraine, which can influence disease state, prognosis, and clinical outcomes. Vestibular migraine (VM) is a disease that causes repeated vestibular symptoms in people with a history of migraines. We investigated the prevalence and contributing factors of anxiety and depression in patients with VM. Methods: A total of 74 patients with VM were enrolled in this study. All patients underwent pure-tone audiometry, the examination of spontaneous nystagmus, Dix-Hallpike maneuver or supine-roll test, video head impulse test, and caloric testing on the day of the visit. We used the Hospital Anxiety and Depression Scale (HADS) to assess the symptoms of anxiety and depression. Dizziness Handicap Inventory was used to measure the intensity of vestibular symptoms. The participants were divided into normal and abnormal groups based on their HADS anxiety and depression scores, and demographic and clinical factors were analyzed. To identify factors associated with anxiety and depression, multivariate logistic regression analyses were performed. Results: A total of 36 (48.6%) patients demonstrated clinically relevant anxiety levels, and 24 (32.4%) demonstrated depression. Twenty-five (33.8%) patients were diagnosed with peripheral vestibular dysfunction. In the multivariable analyses, peripheral vestibular dysfunction and severe intensity vestibular symptoms were significantly associated with anxiety and depression. None of migraine features were significantly associated with anxiety and depression. Conclusion: The prevalence of anxiety in patients with VM is considerably higher than in the depression. VM patients with peripheral vestibular dysfunction are particularly susceptible to anxiety and depression. Therefore, timely screening for vestibular function and psychiatric disorders in VM patients should be considered.

Associations between benign paroxysmal positional vertigo and seven mental disorders: a two-sample Mendelian randomization study

Background

The association between benign paroxysmal positional vertigo (BPPV) and various mental disorders is still controversial. This study used the Mendelian randomization (MR) method to clarify the correlation between BPPV and seven mental disorders (bipolar disorder, depression, anxiety disorder, schizophrenia, suicidality, neuroticism, and mood swings) to aid in the exploration of BPPV complications and prevention and early treatment of mental disorders.

Methods

The datasets for BPPV and seven mental disorders were obtained from genome-wide association studies (GWASs). Two-sample MR was used to analyze the correlation between exposure (BPPV) and various outcomes (bipolar disorder, depression, anxiety disorder, schizophrenia, suicidality, neuroticism, and mood swings). A reverse MR study was also performed. The inverse variance weighting (IVW) method, the MR-Egger method, the simple mode method, the weighted mode method, and the weighted median method were selected.

Results

The MR analysis and the reverse MR analysis results did not reveal significant associations between BPPV and bipolar disorder, depression, anxiety disorder, schizophrenia, suicidal tendencies, neuroticism, and mood swings. Interestingly, neuroticism (IVW: OR = 1.142, 95% CI: 1.059-1.231, P = 0.001; P-MR-PRESSO adjustment = 0.0002) and mood swings (IVW: OR = 3.119, 95% CI: 1.652-5.884, P = 0.0004) may have a significant association with BPPV. After MR-PRESSO adjustment, there was no horizontal pleiotropy or heterogeneity, and a significant association between neuroticism, mood swings, and BPPV has still been suggested.

Conclusion

We conducted MR analysis on genetic data from European populations and discovered a causal relationship between BPPV and the seven mental disorders. Our research findings suggest that BPPV may not have a significant causal relationship with bipolar disorder, depression, anxiety disorder, schizophrenia, or suicidal tendencies. However, neuroticism and mood swings may be risk factors for BPPV.

Effects of Different Durations and Frequencies of Vestibular Rehabilitation in Patients With Residual Symptoms After Benign Paroxysmal Positional Vertigo Repositioning

OBJECTIVES

This study aimed to explore the effects of different duration and daily frequency of vestibular rehabilitation (VR) in patients with residual symptoms after benign paroxysmal positional vertigo (BPPV) successful repositioning.

METHOD

Patients with successful BPPV repositioning (n = 118) were divided into 3 groups according to VR duration and frequency: group A (n = 30; 15 minutes, 3 times/day), group B (n = 30; 30 minutes, 3 times/day), group C (n = 28; 15 minutes, 6 times/day), and control group D (n = 30; no VR). All patients completed the dizziness handicap inventory (DHI) and vestibular rehabilitation benefit questionnaire (VRBQ) at baseline and after 2 and 4 weeks.

RESULTS

The emotional scores and the proportion of severe dizziness disability in the DHI scores were significant differences between VR groups A to C and control group D after 2 and 4 weeks (all P < .05). There were significant differences in total DHI and VRBQ scores among the VR groups A to C after 2 and 4 weeks (all P < .05). Interestingly, emotion scores were not significantly different in group A (P = .385), group B (P = .569), and group C (P = .340) between 2 and 4 weeks. Meanwhile at 2 weeks, the difference in motion-provoked dizziness score between group A and B was statistically significant (P = .02).

CONCLUSIONS

A total VR duration over 4 weeks can reduce dizziness and improve VR benefits in routine therapy in patients with residual dizziness after successful BPPV repositioning. Emotional improvement can be observed after 2 weeks. VR may help to relieve motion-provoked dizziness earlier if patients are willing to consider increasing the duration to more than 15 minutes.

Causality between alcohol usually taken with meals and Meniere disease: A 2-sample Mendelian randomization study

The recurrence of Meniere disease (MD) strongly affects patient quality of life. Identifying the risk factors for MD is highly important for its prevention and treatment. Previous studies have suggested that alcohol intake may play a role in the development of MD. However, recent studies have shown that the causal relationship between alcohol consumption and MD remains controversial. In this paper, the Mendelian randomization (MR) method was used to determine the causal relationship between alcohol consumption usually consumed with meals and MD, with the aim of providing suggestions for alcohol intake management in individuals with MD and helping in the prevention and treatment of MD. Two-sample MR was used to investigate the causal relationship between alcohol usually taken with meals and MD. We used a dataset from a publicly available large-scale genome-wide association study (GWAS). Inverse variance weighting (IVW), MR-Egger, simple weighting, weighted weighting and the weighted median method were used for analysis. The final results showed that IVW (OR = 0.991, 95% CI: 0.983-0.998, P = .016) results suggested that there was statistical significance, but MR-Egger (OR = 0.978, 95% CI: 0.886-1.080, P = .679), weighted median methods (OR = 0.994, 95% CI: 0.985-1.004, P = .307) and Simple mode (OR = 0.995, 95% CI: 0.980-1.010, P = .566), Weighted mode (OR = 0.995, 95% CI: 0.981-1.010, P = .557) found no significant causal relationship. The results suggest that alcohol usually taken with meals may be negatively correlated with MD.

Central vestibular networking for sensorimotor control, cognition, and emotion

PURPOSE OF REVIEW

The aim of this study was to illuminate the extent of the bilateral central vestibular network from brainstem and cerebellum to subcortical and cortical areas and its interrelation to higher cortical functions such as spatial cognition and anxiety.

RECENT FINDINGS

The conventional view that the main function of the vestibular system is the perception of self-motion and body orientation in space and the sensorimotor control of gaze and posture had to be developed further by a hierarchical organisation with bottom-up and top-down interconnections. Even the vestibulo-ocular and vestibulo-spinal reflexes are modified by perceptual cortical processes, assigned to higher vestibulo-cortical functions. A first comparative fMRI meta-analysis of vestibular stimulation and fear-conditioning studies in healthy participants disclosed widely distributed clusters of concordance, including the prefrontal cortex, anterior insula, temporal and inferior parietal lobe, thalamus, brainstem and cerebellum. In contrast, the cortical vestibular core region around the posterior insula was activated during vestibular stimulation but deactivated during fear conditioning. In recent years, there has been increasing evidence from studies in animals and humans that the central vestibular system has numerous connections related to spatial sensorimotor performance, memory, and emotion. The clinical implication of the complex interaction within various networks makes it difficult to assign some higher multisensory disorders to one particular modality, for example in spatial hemineglect or room-tilt illusion.

SUMMARY

Our understanding of higher cortical vestibular functions is still in its infancy. Different brain imaging techniques in animals and humans are one of the most promising methodological approaches for further structural and functional decoding of the vestibular and other intimately interconnected networks. The multisensory networking including cognition and emotion determines human behaviour in space.

Cognition in vestibular disorders: state of the field, challenges, and priorities for the future

Vestibular disorders are prevalent and debilitating conditions of the inner ear and brain which affect balance, coordination, and the integration of multisensory inputs. A growing body of research has linked vestibular disorders to cognitive problems, most notably attention, visuospatial perception, spatial memory, and executive function. However, the mechanistic bases of these cognitive sequelae remain poorly defined, and there is a gap between our theoretical understanding of vestibular cognitive dysfunction, and how best to identify and manage this within clinical practice. This article takes stock of these shortcomings and provides recommendations and priorities for healthcare professionals who assess and treat vestibular disorders, and for researchers developing cognitive models and rehabilitation interventions. We highlight the importance of multidisciplinary collaboration for developing and evaluating clinically relevant theoretical models of vestibular cognition, to advance research and treatment.

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

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

Histaminergic System and Vestibular Function in Normal and Pathological Conditions

Most neurotransmitter systems are represented in the central and peripheral vestibular system and are thereby involved both in normal vestibular signal processing and the pathophysiology of vestibular disorders. However, there is a special relationship between the vestibular system and the histaminergic system. The purpose of this review is to document how the histaminergic system interferes with normal and pathological vestibular function. In particular, we will discuss neurobiological mechanisms such as neuroinflammation that involve histamine to modulate and allow restoration of balance function in the situation of a vestibular insult. These adaptive mechanisms represent targets of histaminergic pharmacological compounds capable of restoring vestibular function in pathological situations. The clinical use of drugs targeting the histaminergic system in various vestibular disorders is critically discussed.

Appropriate Vestibular Stimulation in Children and Adolescents-A Prerequisite for Normal Cognitive, Motor Development and Bodily Homeostasis-A Review

The structural development of the vestibular part of the inner ear is completed by birth but its central connections continue to develop until adolescence. Their development is dependent on vestibular stimulation-vestibular experience. Studies have shown that vestibular function, modulated by experience and epigenetic factors, is not solely an instrument for body position regulation, navigation, and stabilization of the head and images but also influences cognition, emotion, the autonomous nervous system and hormones. To emphasize the importance of appropriate vestibular stimulation, we present a literature review of its effect on bodily homeostasis, cognition and emotion.

Exploring the relationship between sleep apnea and vestibular symptoms following traumatic brain injury

BACKGROUND

Traumatic brain injury (TBI) is a complex health problem in military veterans and service members (V/SM) that often involves comorbid vestibular impairment. Sleep apnea is another comorbidity that may exacerbate, and/or be exacerbated by, vestibular dysfunction.

OBJECTIVE

To examine the relationship between sleep apnea and vestibular symptoms in V/SM diagnosed with TBI of any severity.

DESIGN

Multicenter cohort study; cross-sectional sample.

SETTING

In-patient TBI rehabilitation units within five Veterans Affairs (VA) Polytrauma Rehabilitation Centers.

PARTICIPANTS

V/SM with a diagnosis of TBI (N = 630) enrolled in the VA TBI Model Systems study.

INTERVENTION

Not applicable.

METHODS

A multivariable regression model was used to evaluate the association between sleep apnea and vestibular symptom severity while controlling for relevant covariates, for example, posttraumatic stress disorder (PTSD).

MAIN OUTCOME MEASURES

Lifetime history of sleep apnea was determined via best source reporting. Vestibular disturbances were measured with the 3-item Vestibular subscale of the Neurobehavioral Symptom Inventory (NSI).

RESULTS

One third (30.6%) of the sample had a self-reported sleep apnea diagnosis. Initial analysis showed that participants who had sleep apnea had more severe vestibular symptoms (M = 3.84, SD = 2.86) than those without sleep apnea (M = 2.88, SD = 2.67, p < .001). However, when the data was analyzed via a multiple regression model, sleep apnea no longer reached the threshold of significance as a factor associated with vestibular symptoms. PTSD severity was shown to be significantly associated with vestibular symptoms within this sample (p < .001).

CONCLUSION

Analysis of these data revealed a relationship between sleep apnea and vestibular symptoms in V/SM with TBI. The significance of this relationship was affected when PTSD symptoms were factored into a multivariable regression model. However, given that the mechanisms and directionality of these relationships are not yet well understood, we assert that in terms of clinical relevance, providers should emphasize screening for each of the three studied comorbidities (sleep apnea, vestibular symptoms, and PTSD).

Anxiety and physical impairment in patients with central vestibular disorders

BACKGROUND

There is increasing evidence for close interrelations between vestibular and emotional brain networks. A study in patients with bilateral peripheral vestibulopathy (BVP) showed relatively low vertigo-related anxiety (VRA), despite high physical impairment. The current working hypothesis proposes the integrity of the peripheral vestibular system as a prerequisite for development of VRA. Here we contribute by evaluating VRA and vestibular-related handicap in central vestibular disorders.

METHODS

Of 6396 patients presenting in a tertiary vertigo centre, 306 were identified with four clear central vestibular disorders: pure cerebellar ocular motor disorder (COD; 61), cerebellar ataxia (CA; 63), atypical parkinsonian syndromes (APS; 28), vestibular migraine (VM; 154). Their results of the Vertigo Handicap Questionnaire (VHQ), with its subscales for anxiety and handicapped activity, were compared to those of 65 BVP patients. Postural instability was measured on a force-plate. Multivariate linear regression was used to adjust for patient demographics.

RESULTS

Patients with chronic central vestibular disorders (COD, CA, APS) had relatively low VRA levels comparable to those in BVP, independent of increased handicapped activity or postural instability. Only VM patients showed significantly higher VRA, although their activity impairment and postural instability were lowest. No significant differences within chronic central vestibular disorders were found for VRA and subjective activity impairment.

CONCLUSIONS

Subjective and objective vestibular-related impairment are not necessarily correlated with vestibular-related anxiety in central vestibular disorders. Our findings rather support the hypothesis that, in addition to an intact peripheral, an intact central vestibular system could also serve as a prerequisite to develop specific VRA.

P300 Event-Related Potential Predicts Cognitive Dysfunction in Patients with Vestibular Disorders

OBJECTIVE

Our aim was to determine the correlation between cognitive impairment and P300 event-related potential (ERP) in older adults with vertigo and imbalance, which further provides a reference for clinical diagnosis and patients' rehabilitation.

METHODS

A total of 79 older adult patients with vertigo and imbalance in our outpatient department from January 2022 to December 2022 were selected and divided into the mild group (n = 20), moderate group (n = 39), and severe group (n = 20) according to the Dizziness Handicap Inventory (DHI). The auditory P300 component of event-related potentials (ERPs), Generalized Anxiety Disorder Questionnaire-7 (GAD-7), Patient Health Questionnaire-9 (PHQ-9), and Mini-Mental State Examination (MMSE) were used to evaluate depression, anxiety, and cognitive function in these patients, respectively.

RESULTS

The P300 latencies of the different severity groups were 292 ± 10 ms, 301 ± 8 ms, and 328 ± 5 ms, respectively, and the differences were statistically significant (p = 0.010). The P300 amplitudes of the different severity groups were 14.4 ± 2.6 μV, 3.9 ± 0.8 μV, and 5.1 ± 1.4 μV, respectively, and the differences were also statistically significant (p = 0.004). There was no statistically significant difference in the DHI evaluation or VAS visual simulation scoring between the two groups (p = 0.625, and 0.878, respectively). Compared with the short-course group, the long-course group showed prolonged P300 latency and decreased amplitude, higher scores in PHQ-9 and GAD-7, and lower scores in MMSE, and all the differences were statistically significant (p = 0.013, 0.021, 0.006, 0.004, and 0.018, respectively).

CONCLUSION

Older patients with more severe symptoms of vertigo and imbalance are at higher risk of developing abnormal cognitive function. The P300 can be used as an objective neurophysiological test for the assessment of cognitive function relevant to elderly patients with vertigo and imbalance.

The effect of accompanying anxiety and depression on patients with different vestibular syndromes

Objective

This study aims to investigate the situation of vertigo disorder combined with anxiety and depression in patients with different types of vestibular syndrome.

Methods

A total of 330 patients with vertigo in otolaryngology outpatient department were selected, and clinical information such as age, gender, and scores of Dizziness handicap inventory (DHI), Generalized anxiety disorder-7 (GAD-7), and Patient Health Questionnaire-9 (PHQ-9) were collected. Analyzed the differences among acute vestibular syndrome (AVS), episodic vestibular syndrome (EVS) and chronic vestibular syndrome (CVS) in terms of age, gender, comorbid anxiety and depression, and the multivariate ordered logistic regression analysis was used to evaluate the relationship between the above factors and the degree of vertigo disorder.

Results

The three types of vestibular syndrome had no significant difference in age composition, sex composition, anxiety and depression. There was no significant difference in the probability of anxiety and depression among vertigo patients of different ages and genders. The total score of vertigo disorder and each sub-item score were higher in patients with anxiety and depression. Patients with anxiety mainly manifested in EVS and CVS, while patients with depression mainly manifested in EVS and AVS. The probability of increased vertigo in anxious patients was 4.65 times that of non-anxious patients, and the probability of increased vertigo in depressed patients was 3.49 times that of non-depressed patients. Age and gender had no statistically significant effect on the degree of vertigo. In patients with EVS, anxiety and depression had a significant effect on the degree of vertigo; in patients with CVS, anxiety had a significant effect on the degree of vertigo, but depression had no significant effect.

Conclusion

Age and gender do not significantly affect the degree of vertigo disorder and mental state in various vestibular syndromes. Instead, anxiety and depression are the risk factors for aggravating the degree of vertigo disorder, and manifest differently in each type of vestibular syndrome. Therefore, it is necessary to use a quick scale tool to conduct a standardized screening of the psychological status of patients with vertigo.

Altered brain function in patients with acrophobia: A voxel-wise degree centrality analysis

AIM

To explore the local spontaneous neural activity and whole-brain functional connectivity patterns in the resting brain of acrophobia patients.

METHODS

50 patients with acrophobia and 47 healthy controls were selected for this study. All participants underwent resting-state MRI scans after enrollment. The imaging data were then analyzed using a voxel-based degree centrality (DC) method, and seed-based functional connectivity (FC) correlation analysis was used to explore the correlation between abnormal functional connectivity and clinical symptom scales in acrophobia. The severity of symptoms was evaluated using self-report and behavioral measures.

RESULTS

Compared to controls, acrophobia patients showed higher DC in the right cuneus and left middle occipital gyrus and significantly lower DC in the right cerebellum and left orbitofrontal cortex (p < 0.01, GRF corrected). Additionally, there were negative correlations between the acrophobia questionnaire avoidance (AQ- Avoidance) scores and right cerebellum-left perirhinal cortex FC (r = -0.317, p = 0.025) and between scores of the 7-item generalized anxiety disorder scale and left middle occipital gyrus-right cuneus FC (r = -0.379, p = 0.007). In the acrophobia group, there was a positive correlation between behavioral avoidance scale and right cerebellum-right cuneus FC (r = 0.377, p = 0.007).

CONCLUSIONS

The findings indicated that there are local abnormalities in spontaneous neural activity and functional connectivity in the visual cortex, cerebellum, and orbitofrontal cortex in patients with acrophobia.

Motorist's Vestibular Disorientation Syndrome (MVDS)-Proposed Diagnostic Criteria

Motorist's vestibular disorientation syndrome (MVDS) is a disorder in which patients experience dizziness while driving. MVDS is under-reported in the literature, and in clinical practice, it often goes unrecognized. We identified clinical characteristics of patients with MVDS using data from 24 patients who faced difficulties while driving and were diagnosed with MVDS. Their symptoms, duration of illness, precipitating factors, co-morbidities, history of other neuro-otological disorders, severity of symptoms, and associated anxiety and depression were reviewed. Ocular motor movements were recorded using video-nystagmography. Patients with vestibular disorders that can cause similar symptoms while driving were excluded. The mean age of the patients was 45.7 ± 8.7 years, and most were professional drivers (90.5%). The duration of the illness ranged from eight days to ten years. Most patients presented with disorientation (79.2%) exclusively while driving. The most common triggers for symptoms were higher speeds, i.e., >80 km/h (66.7%), multi-lane roads (58.3%), bends and turns (50%), and looking at other vehicles or signals while driving (41.7%). A history of migraines was reported in 62.5% of the patients, and motion sickness was reported in 50% of the patients. Anxiety was reported in 34.3% of patients, and 15.7% had depression. The video-nystagmography did not show any specific abnormalities. Patients responded to drugs used in prophylactic treatments for migraines such as Amitriptyline, Venlafaxine, Bisoprolol, and Magnesium, and to Pregabalin and Gabapentin. Based on these findings, a classification system and a diagnostic criterion for MVDS were proposed.

Common neural correlates of vestibular stimulation and fear learning: an fMRI meta-analysis

BACKGROUND

A bidirectional functional link between vestibular and fear-related disorders has been previously suggested.

OBJECTIVE

To test a potential overlap of vestibular and fear systems with regard to their brain imaging representation maps.

METHODS

By use of voxel-based mapping permutation of subject images, we conducted a meta-analysis of earlier functional magnetic resonance imaging (fMRI) studies applying vestibular stimulation and fear conditioning in healthy volunteers.

RESULTS

Common clusters of concordance of vestibular stimulation and fear conditioning were found in the bilateral anterior insula cortex, ventrolateral prefrontal cortex and the right temporal pole, bilaterally in the adjacent ventrolateral prefrontal cortex, cingulate gyrus, secondary somatosensory cortex, superior temporal and intraparietal lobe, supplementary motor area and premotor cortex, as well as subcortical areas, such as the bilateral thalamus, mesencephalic brainstem including the collicular complex, pons, cerebellar vermis and bilateral cerebellar hemispheres. Peak areas of high concordance for activations during vestibular stimulation but deactivations during fear conditioning were centered on the posterior insula and S2.

CONCLUSIONS

The structural overlap of both networks allows the following functional interpretations: first, the amygdala, superior colliculi, and antero-medial thalamus might represent a release of preprogramed sensorimotor patterns of approach or avoidance. Second, the activation (vestibular system) and deactivation (fear system) of the bilateral posterior insula is compatible with the view that downregulation of the fear network by acute vestibular disorders or unfamiliar vestibular stimulation makes unpleasant perceived body accelerations less distressing. This also fits the clinical observation that patients with bilateral vestibular loss suffer from less vertigo-related anxiety.

The impact of anxiety on postural control: CO2 challenge model

Anxiety and balance and postural control are linked via common neural pathways, such as the parabrachial nucleus network. A laboratory-based model of general anxiety disorder (GAD) using the CO₂ challenge, has potential to be used to observe this relationship, potentially mimicking subjective, autonomic, and neuropsychological features of GAD. The current feasibility study used the CO₂ challenge to explore postural control changes in healthy adults. It was predicted that during the CO₂ condition, participants would show increased postural sway path length and decreased sway stability, compared with a normal air breathing condition. To assess this, heart and breathing rate, quiet standing postural sway path length, sway dynamic stability, and subjective measures of emotion were measured either before and after or during and after the inhalation conditions. Results demonstrated that CO₂ inhalation led to both an increase in sway path length and reduced sway stability compared to the air breathing conditions; the effect on sway path lasted after the inhalation of CO₂ had ceased. Additionally, replication of HR and subjective measures of emotion were observed when comparing air and CO₂ conditions. This provides experimental evidence that CO₂ inhalation can affect balance, suggestive of shared mechanisms between anxiety and balance performance, as well as indicating that the CO₂ model of GAD is suitable to look at changes in balance performance in healthy adults. Future use of this model to explore factors that can reduce the influence of GAD on balance would be beneficial as would a more detailed exploration of the neural pathways associated with the associated comorbidity.

Impact of episodic and chronic vestibular disorders on health-related quality of life and functioning-results from the DizzyReg patient registry

PURPOSE

Vertigo and dizziness belong to the most frequent syndromes in the primary, secondary and tertiary setting and can be divided into vertigo with episodic or chronic persistent complaints. Episodic vertigo (EVS) is characterized by recurrent attacks of vertigo or dizziness with intermittent symptom-free periods, while chronic vertigo (CVS) presents with persistent vertigo. It is still not completely understood how EVS or CVS affect health-related quality of life (HRQoL) and functioning.

METHODS

Data originates from the DizzyReg patient registry, an ongoing prospective clinical patient registry situated at tertiary clinic at the university hospital, Munich. HRQoL and functioning was measured by self-report. CVS and EVS was categorized after comprehensive neuro-otological work-up in line with the diagnostic guidelines. Association of CVS and EVS was assessed with multivariable linear regression models adjusting for potential risk factors and confounders.

RESULTS

The study included 548 patients (57% female, mean age 51.35). Patients with EVS were significantly younger (48.5 vs. 59.6 years) and were more often female (60 vs. 49%). EVS patients reported significantly better functioning (42.1 vs. 47.8) and HRQoL (63.87 vs. 58.08) than CVS patients. The effect was stable after adjusting for potential confounders.

CONCLUSION

This is the first study to show worse HRQoL in patients with CVS compared to EVS. The results of the study underpin the experience from clinical practice that mobility and balance control are especially important for patients with CVS.

How vestibular dysfunction transforms into symptoms of depersonalization and derealization?

BACKGROUND

Psychiatric Depersonalization/Derealization (DPDR) symptoms were demonstrated in patients with peripheral vestibular disorders. However, only semicircular canals (SCCs) dysfunction was evaluated, therefore, otoliths' contribution to DPDR is unknown. Also, DPDR symptoms in patients with central vestibular dysfunction are presently unknown. DPDR was also studied in the context of spatial disorientation and anxiety, but the relation of these cognitive and emotional functions to vestibular dysfunction requires clarification.

METHODS

We tested patients with peripheral Bilateral Vestibular Hypofunction (pBVH), Machado Joseph Disease (MJD) with cerebellar and central bilateral vestibular hypofunction, and healthy controls. Participants completed the video Head Impulse Test (vHIT) for SCCs function, cervical Vestibular Evoked Myogenic Potentials test (cVEMPt) for sacculi function, Body Sensation Questionnaire (BSQ) for panic anxiety, Object Perspective-Taking test (OPTt) for spatial orientation and Cox & Swinson DPDR inventory for DPDR symptoms.

RESULTS

pBVH patients showed significant SCCs and sacculi dysfunction, spatial disorientation, elevated panic anxiety, and DPDR symptoms. MJD patients showed significant SCCs hypofunction but preserved sacculi function, spatial disorientation but normal levels of panic anxiety and DPDR symptoms. Only pBVH patients demonstrated a positive correlation between the severity of the DPDR and spatial disorientation and panic anxiety.

CONCLUSIONS

DPDR develops in association with sacculi dysfunction, either with or without SSCs dysfunction. Spatial disorientation and anxiety seem to mediate the transformation of vestibular dysfunction into DPDR symptoms. DPDR does not develop in MJD with central vestibular hypofunction but a normal saccular response. We propose a three-step model that describes the development of DPDR symptoms in vestibular patients.

Persistent positional perceptual dizziness in clinical practice: a scoping review

INTRODUCTION

Dizziness is an important symptom presenting in routine practice and the life time prevalence ranges from 17 to 30%. Persistent positional perceptual dizziness (PPPD) is a common cause of chronic dizziness and has often been labeled as psychogenic dizziness in the past.

DISCUSSION

PPPD is diagnosed based on clinical criteria laid down by the Barany society. The vestibular function tests and imaging of the brain and the inner ear are often normal. Most of the patients have an underlying anxiety trait and most cases of PPPD arise following an attack of acute vertigo like Meniere's disease and vestibular neuritis. It is important to differentiate the condition from bilateral vestibulopathy. There is no role of vestibular sedative in the treatment of such condition. Vestibular rehabilitation therapy (VRT), cognitive behavioral therapy (CBT), and selective serotonin reuptake inhibitors (SSRI) like sertraline have shown benefits. However, long-term outcome is not known.

CONCLUSION

PPPD is a relatively new entity in the ever-expanding field of neurotology that requires a multimodality approach for effective management. The otologists and general physicians must identify the condition so that favorable outcome can be achieved. The long-term effects of treatment with CBT and VRT are not known. It is important to formulate standard guidelines for treatment. Further research is necessary to identify the role of endogenous biomarkers in the outcome of treatment.

Vestibular Migraine

PURPOSE OF REVIEW

To explore recent developments in vestibular migraine (VM).

RECENT FINDINGS

This review discusses the current diagnostic criteria for VM in the adult and pediatric populations, as proposed by the International Headache Society and Bárány Society. Recent VM studies confirm the prior findings and reveal new insights, including the wide range of vestibular symptoms, symptoms in the attack-free period, and triggers. Many patients experience persistent vestibular symptoms, even in the absence of acute attacks, which often significantly impact patients' quality of life. The syndrome of benign recurrent vertigo and its relationship to migraine, VM, and Meniere's disease is also discussed. There is a dearth of randomized controlled trials in VM treatment. Prospective and retrospective studies support the benefit of many migraine treatments are effective in VM, including neuromodulation, and calcitonin gene-related peptide monoclonal antibodies. VM affects almost 3% of the population, but remains under-diagnosed. Recent diagnostic criteria can help clinicians diagnose VM in adults and children.

Estimating the causal effect of frailty index on vestibular disorders: A two-sample Mendelian randomization

Background

Frailty index and vestibular disorders appear to be associated in observational studies, but causality of the association remains unclear.

Methods

A two-sample Mendelian randomization (MR) study was implemented to explore the causal relationship between the frailty index and vestibular disorders in individuals of European descent. A genome-wide association study (GWAS) of frailty index was used as the exposure (n = 175, 226), whereas the GWAS of vestibular disorders was the outcome (n = 462,933). MR Steiger filtering method was conducted to investigate the causal effect of the frailty index on vestibular disorders. An inverse variance weighted (IVW) approach was used as the essential approach to examine the causality. Additionally, the MR-Egger methods, the simple mode analysis, the weighted median analysis, and the weighted mode analysis were used as supplementary methods. The MR-PRESSO analysis, the MR-Egger intercept analysis, and Cochran's Q statistical analysis also were used to detect the possible heterogeneity as well as directional pleiotropy. To evaluate this association, the odds ratio (OR) with 95% confidence intervals (CIs) was used. All statistical analyses were performed in R. The STROBE-MR checklist for the reporting of MR studies was used in this study.

Results

In total, 14 single nucleotide polymorphisms (SNPs) were identified as effective instrumental variables (IVs) in the two sample MR analyses. The significant causal effect of the frailty index on vestibular disorders was demonstrated by IVW method [OR 1.008 (95% CI 1.003, 1.013), p = 0.001]. Results from the various sensitivity analysis were consistent. The “leave-one-out” analysis indicated that our results were robust even without a single SNP. According to the MR-Egger intercept test [intercept = −0.000151, SE = 0.011, p = 0.544], genetic pleiotropy did not affect the results. No heterogeneity was detected by Cochran's Q test. Results of MR Steiger directionality test indicated the accuracy of our estimate of the potential causal direction (Steiger p < 0.001).

Conclusion

The MR study suggested that genetically predicted frailty index may be associated with an increased risk of vestibular disorders. Notably, considering the limitations of this study, the causal effects between frailty index and vestibular disorders need further investigation. These results support the importance of effectively managing frailty which may minimize vestibular disorders and improve the quality of life for those with vestibular disorders.

Long-Term Characteristics of Severe COVID-19: Respiratory Function, Functional Capacity, and Quality of Life

Recovery from pneumonia takes around 3−6 months in individuals with severe COVID-19. In order to detect the isolated damage caused by COVID-19, the 6-month period must pass after the recoveries. However, to our knowledge, no published study analyzes a comprehensive evaluation of individuals with severe COVID-19 after 6 months. We aimed to evaluate long-term consequences of severe COVID patients by comparing respiratory function, functional capacity, quality of life, fatigue, and balance 6 months after the intensive care unit (ICU) discharge with healthy individuals. Method: 26 post-COVID adult patients and 26 healthy individuals (control group) were included in this study. Physical characteristics of both groups and patients’ ICU data, including APACHE II scores, were recorded. Lung function, respiratory, and peripheral muscle strength were measured. The lower limit of normal (LLN) cutoff points for forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) were calculated. A 6-minute walk test (6MWT) was used to assess functional capacity. Time Up and Go test (TUG) with a stadiometer was performed for balance evaluation. Quality of life was evaluated using Nottingham Health Profile (NHP) and St George Respiratory Questionnaire (SGRQ). Results: Percent predicted FVC and FEV1, 6MWT distance, change in oxygen saturation (SpO2) during 6MWT, were lower and NHP, SGRQ, FSS scores and TUG findings were higher in the COVID group than the control group (p < 0.05). The FVC of nine individuals and the FEV1 value of seven individuals in the COVID-19 group were below the LLN values. A moderate correlation was found between ICU length of stay and APACHE II scores with FVC, FEV1, 6MWT distance, and change in SpO2 values in the COVID-19 patients (p < 0.05). Conclusion: Respiratory function, functional capacity, quality of life, and fatigue levels of the individuals with severe COVID-19 infection are impaired at 6 months after ICU discharge. Impaired lung function might be associated with severe inflammation, which starts during the acute infection process and the fibrous tissue during the healing process, impairing lung compliance and diffusion capacity. Infiltration of coronavirus and inflammatory cytokines into the cerebrum and muscle might have increased fatigue and decreased functional capacity. Overall, our study suggests that severe COVID patients need post-discharge care even after 6 months of recovery.

What Predicts Improvement of Dizziness after Multimodal and Interdisciplinary Day Care Treatment?

Background: Vertigo and dizziness are common in community-dwelling people and can be treated in specialized multidisciplinary settings. To develop tailored interventions, however, we have to explore risk factors for favorable and unfavorable outcomes. Methods: We prospectively investigated patients with chronic vertigo and dizziness subjected to our 5-day multimodal and interdisciplinary day care treatment in the Center for Vertigo and Dizziness of Jena University Hospital, Germany. The Vertigo Severity Scale (VSS), the Body Sensations Questionnaire (BSQ), the Hospital Anxiety and Depression Scale (HADS), the Agoraphobic Cognitions Questionnaire (ACQ), the Mobility Inventory (MI), and the burden and intensity of dizziness (using a visual analogue scale) were assessed at baseline (n = 754) and after 6 months (n = 444). In addition, 14 Likert-scaled questions were used to quantify the change in personal attitude and behavior towards the complaints after 6 months. Results: Dizziness-related burden and intensity improved with a large effect size. The largest improvement was seen in the attitudes towards dizziness, the understanding of somatic causes, and the perceived ability to influence dizziness. However, the ability to work and to carry out professional activity was improved to a lesser extent. The overall improvement of dizziness was associated with the absence of a depressive mood, a short duration of vertigo, a lower VSS, a lower perceived intensity of vertigo, and distinct vertigo diagnoses, namely Meniere’s disease, vestibular migraine, vestibular neuritis, vestibular paroxysmia, and vestibular schwannoma. Worsening of dizziness/vertigo was associated with depressive symptoms, permanent vertigo, distinct vertigo diagnoses (central vertigo, multisensory deficit), and a higher perceived burden due to vertigo. Conclusion: The six-month outcome of patients with dizziness presented to a specialized outpatient clinic appears to be favorable. Nevertheless, people with the abovementioned risk factors at baseline have less benefit and probably need adapted and tailored vertigo interventions to improve long-term outcome.

Chronic vestibular syndromes in the elderly: Presbyvestibulopathy - an isolated clinical entity?

BACKGROUND

Recently, the Classification Committee of the Bárány Society defined the new syndrome of "presbyvestibulopathy" for elderly patients with chronic vestibular symptoms due to a mild bilateral peripheral vestibular hypofunction. However, control of stance and gait requires multiple functioning systems, e.g. the somatosensory, visual, auditory, musculoskeletal and cardio- and cerebrovascular system. The aim of this cross-sectional database-driven study was to evaluate the frequency and characteristics of presbyvestibulopathy and additional gait relevant comorbidities.

METHODS

In total 707 patients ≥ 60 years with chronic vertigo/dizziness were admitted to our tertiary hospital and received detailed neurological, neuroorthoptic and laboratory audio-vestibular examination. Medical history, comorbidities, functional impairment and quality of life (DHI, EQ-5D-3L, VAP) were compared between presbyvestibulopathy and bilateral vestibulopathy in a matched-paired study.

RESULTS

In 95.5% of patients, complaints were better accounted for by another vestibular, neurological, cardiac or psychiatric disease and 32 patients (4.5%) met the diagnostic criteria for presbyvestibulopathy. Out of these 32 patients, the majority showed further relevant comorbidities in other sensorimotor systems. Only one patient out of 707 had "isolated" presbyvestibulopathy (0.14%). The mean total DHI scores indicated lower moderate impairment in presbyvestibulopathy than in bilateral vestibulopathy (40.6 vs. 49.0), which was confirmed by significant differences in the matched-paired analysis (p < 0.001).

CONCLUSIONS

Isolated presbyvestibulopathy is a very rare entity. It is regularly accompanied by other multisensory dysfunctions. These results indicate a potential role of mild vestibular hypofunction as a co-factor in multifactorial impairment. Thus, patients should be treated in an interdisciplinary setting aware of diverse comorbidities.

[Vestibular rehabilitation in patients with vestibular peripheral vertigo]

Objective:To evaluate the efficacy of vestibular rehabilitation in patients with anterior peripheral vertigo and analyze its influencing factors. Methods:From January 2018 to June 2021, 153 cases with peripheral vertigo diseases（including 47 cases of benign positional paroxysmal vertigo, 38 cases of Meniere's disease, 26 cases of sudden deafness with vertigo, 23 cases of vestibular migraine and 19 cases of vestibular neuritis） were enrolled. One hundred and three cases were treated with vestibular rehabilitation combined with drugs, and 50 cases only treated with drugs were used as controls. Self-rating scale and vertigo disorder scale were evaluated at the beginning of treatment, 4 weeks and 8 weeks, respectively. The curative effects of the two groups were tested by t-test, and the independent risk factors affecting the curative effects were analyzed by multiple linear regression. Results:There was no difference in clinical data, self-assessment scale and vertigo disorder scale between the two groups（P>0.05）. At 4 and 8 weeks, the scores of self-assessment scale and vertigo disorder scale in the experimental group were better than those in the control group（all P<0.01）, and the curative effect at 8 weeks was better than that at 4 weeks, especially the decrease of emotional score during walking and the proportion of severe vertigo disability（all P<0.01）. The scores of self-rating scale and vertigo disorder scale of the cases with benign positional paroxysmal vertigo and vestibular neuritis were better than Meniere's disease, vestibular migraine and sudden deafness with vertigo（P<0.05）. Headache（P<0.05） and severe vertigo disorder before intervention（P<0.01） were independent risk factors affecting the efficacy of vestibular rehabilitation. Conclusion:Vestibular rehabilitation combined with anti-vertigo drugs in the treatment of vestibular peripheral vertigo is better than that of only using drugs, especially in improving the degree of emotional disorder and vertigo disability. It is more suitable for benign positional paroxysmal vertigo and vestibular neuritis, while the effect of combined headache or severe vertigo is relatively poor.

Oculomotor Deficits and Symptom Severity Are Associated With Poorer Dynamic Mobility in Chronic Mild Traumatic Brain Injury

Oculomotor deficits, vestibular impairments, and persistent symptoms are common after a mild traumatic brain injury (mTBI); however, the relationship between visual-vestibular deficits, symptom severity, and dynamic mobility tasks is unclear. Twenty-three individuals (mean age 55.7 ± 9.3 years) with persistent symptoms after mTBI, who were between 3 months to 2 years post-injury were compared with 23 age and sex-matched controls. Oculomotor deficits [depth perception, near-point convergence, baseline visual acuity (BLVA), perception time], vestibular deficits (dynamic visual acuity in the pitch and yaw planes), dynamic mobility measured by the Functional Gait Assessment (FGA), and symptoms measured by the Post-Concussion Symptom Scale (PCSS) and Dizziness Handicap Inventory (DHI) were compared between groups. Participants with mTBI had poorer performance on the FGA (p < 0.001), higher symptom severity on the PCSS (p < 0.001), and higher DHI scores (p < 0.001) compared to controls. Significant differences were seen on specific items of the FGA between individuals with mTBI and controls during walking with horizontal head turns (p = 0.002), walking with vertical head tilts (p < 0.001), walking with eyes closed (p = 0.003), and stair climbing (p = 0.001). FGA performance was correlated with weeks since concussion (r = −0.67, p < 0.001), depth perception (r = −0.5348, p < 0.001), near point convergence (r = −0.4717, p = 0.001), baseline visual acuity (r = −0.4435, p = 0.002); as well as with symptoms on the PCSS (r = −0.668, p < 0.001), and DHI (r = −0.811, p < 0.001). Dynamic balance deficits persist in chronic mTBI and may be addressed using multifaceted rehabilitation strategies to address oculomotor dysfunction, post-concussion symptoms, and perception of handicap due to dizziness.

Characteristic differences between vestibular migraine and migraine only patients

BACKGROUND

Vestibular migraine (VM) is one of the most common causes of vertigo in clinical practice but it is not always easy to make the correct diagnosis. Our aims were to find out how VM patients differ from migraine only (MO) patients, to evaluate co-morbid depression in these two groups and to determine if their disease has an effect on their quality of life.

METHODS

We studied 50 definite VM and 35 MO patients. Each patient was asked about: age of onset, duration of headaches, presence of aura, headache characteristics, triggering factors, associated features, motion sickness history and family history of migraine. VM patients were also asked about their vertigo attacks and accompanying symptoms. Each patient also completed the following questionnaires: (1) Migraine Disability Assessment Scale (MIDAS); (2) headache severity with VAS (Visual Analog Scale); (3) Allodynia Symptom Checklist (ASC-12); (4) Beck Depression Inventory (BDI); (5) World Health Organization Quality of Life Questionnaire Short Form-12 (WHOQL-SF12); (6) Activities Specific Balance Confidence Scale (ABC). VM patients also completed the Dizziness Handicap Inventory (DHI).

RESULTS

We found that VM patients were more likely than MO patients to be female, post-menopausal, depressed, motion sick, complaining of imbalance and of food-triggered headaches. In contrast, MO patients were more likely than VM patients to have severe headaches and that these can be triggered by certain odors and by noise.

CONCLUSION

Our findings showed differences between VM and MO patients and attention to these differences could help clinicians diagnose, characterize and manage their VM patients.

Subdiagnosis, but not presence of vestibular symptoms, predicts balance impairment in migraine patients - a cross sectional study

Background

Vestibular symptoms and balance changes are common in patients with migraine, especially in the ones with aura and chronic migraine. However, it is not known if the balance changes are determined by the presence of vestibular symptoms or migraine subdiagnosis. Therefore, the aim of this study was to verify if the migraine subdiagnosis and/or the presence of vestibular symptoms can predict balance dysfunction in migraineurs.

Methods

The study included 49 women diagnosed with migraine with aura, 53 without aura, 51 with chronic migraine, and 54 headache-free women. All participants answered a structured questionnaire regarding migraine features and presence of vestibular symptoms, such as dizziness/vertigo. The participants performed the Modified Sensory Organization Test on an AMTI© force plate. The data were analysed using a linear mixed-effect regression model.

Results

The presence of vestibular symptoms did not predict postural sway, but the subdiagnosis was a significant predictor of postural sway. Migraine with aura patients exhibited more sway than migraine patients without aura when the surface was unstable. Additionally, we found high effect sizes (ES > 0.79) for postural sway differences between patients with chronic migraine or with aura compared to controls or migraine without aura, suggesting that these results are clinically relevant.

Conclusions

The subdiagnosis of migraine, instead of the presence of vestibular symptoms, can predict postural control impairments observed in migraineurs. This lends support to the notion that balance instability is related to the presence of aura and migraine chronicity, and that it should be considered even in patients without vestibular symptoms.

Acrophobia and visual height intolerance: advances in epidemiology and mechanisms

Historical descriptions of fear at heights date back to Chinese and Roman antiquity. Current definitions distinguish between three different states of responses to height exposure: a physiological height imbalance that results from an impaired visual control of balance, a more or less distressing visual height intolerance, and acrophobia at the severest end of the spectrum. Epidemiological studies revealed a lifetime prevalence of visual height intolerance including acrophobia in 28% of adults (32% in women; 25% in men) and 34% among prepubertal children aged 8–10 years without gender preponderance. Visual height intolerance first occurring in adulthood usually persists throughout life, whereas an early manifestation in childhood usually shows a benign course with spontaneous relief within years. A high comorbidity was found with psychiatric disorders (e.g. anxiety and depressive syndromes) and other vertigo syndromes (e.g. vestibular migraine, Menière’s disease), but not with bilateral vestibulopathy. Neurophysiological analyses of stance, gait, and eye movements revealed an anxious control of postural stability, which entails a co-contraction of anti-gravity muscles that causes a general stiffening of the whole body including the oculomotor apparatus. Visual exploration is preferably reduced to fixation of the horizon. Gait alterations are characterized by a cautious slow walking mode with reduced stride length and increased double support phases. Anxiety is the critical factor in visual height intolerance and acrophobia leading to a motor behavior that resembles an atavistic primitive reflex of feigning death. The magnitude of anxiety and neurophysiological parameters of musculoskeletal stiffening increase with increasing height. They saturate, however, at about 20 m of absolute height above ground for postural symptoms and about 40 m for anxiety (70 m in acrophobic participants). With respect to management, a differentiation should be made between behavioral recommendations for prevention and therapy of the condition. Recommendations for coping strategies target behavioral advices on visual exploration, control of posture and locomotion as well as the role of cognition. Treatment of severely afflicted persons with distressing avoidance behavior mainly relies on behavioral therapy.

Cognitive functions in acute unilateral vestibular loss

Cognitive deficits mainly involving visuospatial functions have been defined in patients with bilateral and even unilateral vestibular loss (UVL). We compared the cognitive test results of 21 patients with acute UVL with age- and education-matched healthy controls. The diagnosis of UVL was based on the clinical findings, a normal magnetic resonance imaging with diffusion-weighted sequence and canal paresis on the affected side on caloric testing. Cognitive tests assessing visuospatial functions (Benton’s Judgment of Line Orientation test, Verbal and non-verbal Cancellation tests, Rey–Osterrieth Complex Figure test) and global mental status, verbal memory, learning, retention of information, and recalling (Mini Mental State Examination, Oktem Verbal Memory Process Test, Forward and Backward Digit span) were used in addition to Beck depression and Anxiety inventories. Abnormalities in verbal and non-verbal cancellation tests (p < 0.005), Benton’s Judgment of Line Orientation test (p = 0.042) and backward digit span (p = 0.029) was found. A very prominent difference regarding Beck depression (p = 0.012) and anxiety inventories (p < 0.001) was present. On multiple regression analysis, the abovementioned cognitive tests’ results lost their statistical significance (p > 0.05) when depression and anxiety scores were taken into consideration. The severity of canal paresis was found to be correlated with Benton’s Judgment of Line Orientation test (p = 0.008, r = − 0.5639) and Rey–Osterrieth Complex Figure test copying scores (p = 0.029, r = − 0.477). Comparison of all the results in right- and left-sided lesions did not reveal a significant difference (p > 0.05). Vestibular patients are prone to develop anxiety, and depression. Deficits in visuospatial functions, mental manipulation, psychomotor speed and short-term memory detected in our patients with acute UVL seem to be enhanced by accompanying anxiety and depression. The extent of vestibular dysfunction was correlated with the severity of deficits in visuospatial skills. Lesion side did not cause alterations in cognitive or emotional status.

Effects of galvanic vestibular stimulation on resting state brain activity in patients with bilateral vestibulopathy

We examined the effect of galvanic vestibular stimulation (GVS) on resting state brain activity using fMRI (rs‐fMRI) in patients with bilateral vestibulopathy. Based on our previous findings, we hypothesized that GVS, which excites the vestibular nerve fibers, (a) increases functional connectivity in temporoparietal regions processing vestibular signals, and (b) alleviates abnormal visual–vestibular interaction. Rs‐fMRI of 26 patients and 26 age‐matched healthy control subjects was compared before and after GVS. The stimulation elicited a motion percept in all participants. Using different analyses (degree centrality, DC; fractional amplitude of low frequency fluctuations [fALFF] and seed‐based functional connectivity, FC), group comparisons revealed smaller rs‐fMRI in the right Rolandic operculum of patients. After GVS, rs‐fMRI increased in the right Rolandic operculum in both groups and in the patients' cerebellar Crus 1 which was related to vestibular hypofunction. GVS elicited a fALFF increase in the visual cortex of patients that was inversely correlated with the patients' rating of perceived dizziness. After GVS, FC between parietoinsular cortex and higher visual areas increased in healthy controls but not in patients. In conclusion, short‐term GVS is able to modulate rs‐fMRI in healthy controls and BV patients. GVS elicits an increase of the reduced rs‐fMRI in the patients' right Rolandic operculum, which may be an important contribution to restore the disturbed visual–vestibular interaction. The GVS‐induced changes in the cerebellum and the visual cortex were associated with lower dizziness‐related handicaps in patients, possibly reflecting beneficial neural plasticity that might subserve visual–vestibular compensation of deficient self‐motion perception.