Postural instability during attacks of migraine without aura

Romberg's test revisited: Changes in classical and advanced sway metrics in patients with pure sensory neuropathy

OBJECTIVES

The Romberg test, undoubtedly a classical and well-established method in physical neurological assessment of patients with sensory ataxia, has long been suspected to be prone to several limitations. Here, we quantified upright stance before and after visual deprivation in a selected cohort of patients with pure sensory neuropathy.

METHODS

Static balance was assessed in sensory neuropathy patients during quiet stance on a force platform under different visual and proprioceptive feedback conditions. Sural nerve neurography was employed to evaluate the severity of peripheral neuropathy. Conventional and advanced postural sway metrics were investigated to draw a quantitative analogy to the clinical Romberg test.

RESULTS

Posturographic analyses showed that patients displayed Romberg and vestibular Romberg quotient values around 2, indicating an approximately twofold increase in body sway in the absence of vision. However, the diagnostic discrimination ability between patients and controls was only modest. Even less impactful were the diagnostic contributions of frequency domain and non-linear sway analyses. This was primarily attributed to the heightened body sway exhibited by patients with sensory neuropathy under 'eyes open' conditions, diminishing the contrast with the 'eyes closed' condition as assessed in the classical Romberg test.

CONCLUSION

We conclude that the Romberg test, even in its quantitative form with the aid of an apparatus, had an unsatisfactory classification value in terms of distinguishing patients from healthy controls. Instead, it should be interpreted within the comprehensive context of the broader neurological examination and the electrodiagnosis of peripheral nerve function.

Static and Dynamic Imbalance in Patients with Breast Cancer-Related Lymphedema

Background: Breast cancer-related lymphedema (BCRL) was associated with postural imbalance, but the immature knowledge introduced debate about which component of the balance was affected by BCRL in the literature. The aim of this study was to determine the static and dynamic balance of patients with BCRL in comparison with healthy subjects. Methods and Results: This case-control designed study recruited 30 BCRL patients and 30 healthy individuals. The demographic and clinical variables of the subjects were recorded. The static balance stability parameters on four conditions (eyes opened-stable ground, eyes closed-stable ground, eyes opened-unstable ground, eyes closed-unstable ground) and dynamic stability of all participants were evaluated. The values of both stable ground conditions were similar between the groups (p < 0.05). However, values of both eyes opened-unstable ground (p = 0.032) and eyes closed-unstable ground (p = 0.034) conditions were significantly impaired in BCRL in comparison with controls. Besides, comparison of sway area of the opened versus closed eyes conditions on unstable ground (p = 0.036), and movement speed while correcting the center of pressure on unstable ground (with opened and closed eyes, p = 0.014 and p = 0.004 respectively) revealed increased values in the BCRL group. Likewise, the dynamic stability was significantly disrupted in the BCRL group (p = 0.043). Conclusion: Closing eyes did not affect the postural balance in patients with BCRL, whereas the deterioration of ground altered the balance significantly in the BCRL group compared with healthy subjects. We suggest the inclusion of balance exercises and guidance for selection of correct shoes and insoles in routine lymphedema rehabilitation program.

Electrodermal and postural responses in dizzy adults: Diagnostic indicators of vestibular migraine

INTRODUCTION

No reliable biometric measurement of vestibular involvement with migraine is currently available.

OBJECTIVE

Measures of autonomic nervous system and postural responses could serve as quantifiable indicators of vestibular involvement with migraine.

METHODS

A convenience sample of 22 young healthy adults (34±9 years old) and 23 young adults (34±8 years old) diagnosed with vestibular migraine (VM) participated. A rod and frame test and clinical outcome measures of dizziness and mobility were administered. Participants stood on foam while viewing two dynamic virtual environments. Trunk acceleration in three planes and electrodermal activity (EDA) were assessed with wearable sensors. Linear mixed models were used to examine magnitude and smoothness of trunk acceleration and tonic and phasic EDA. A Welch's t-test and associations between measures were assessed with a Pearson Correlation Coefficient. Effect sizes of group mean differences were calculated using Cohen's d.

RESULTS

Visual dependence was present in 83% of the VM population. Individuals with VM exhibited lower baseline EDA (t(4.17) = -7.2, p = 0.001) and greater normalized trunk accelerations in the vertical (t(42.5) = 2.861, p = 0.006) and medial (t(46.6) = 2.65, p = 0.01) planes than healthy participants. Tonic EDA activity increased significantly across the period of the trial (F (1,417) = 23.31, p = 0.001) in the VM group. Significant associations appeared between vertical trunk acceleration and EDA, Dizziness Handicap Inventory, and Activities of Balance Confidence tools.

CONCLUSIONS

Higher tonic EDA activity in healthy adults results in more accurate postural reactions. Results support the supposition that EDA activity and postural acceleration are significantly different between VM and healthy individuals when accommodating for postural instability and visual-vestibular conflict.

The effects of visual context on visual-vestibular mismatch revealed by electrodermal and postural response measures

BACKGROUND

No objective criteria exist for diagnosis and treatment of visual-vestibular mismatch (VVM).

OBJECTIVE

To determine whether measures of electrodermal activity (EDA) and trunk acceleration will identify VVM when exposed to visual-vestibular conflict.

METHODS

A modified VVM questionnaire identified the presence of VVM (+ VVM) in 13 of 23 young adults (34 ± 8 years) diagnosed with vestibular migraine. Rod and frame tests and outcome measures for dizziness and mobility were administered. Participants stood on foam while viewing two immersive virtual environments. Trunk acceleration in three planes and electrodermal activity (EDA) were assessed with wearable sensors. Linear mixed effect (LME) models were used to examine magnitude and smoothness of trunk acceleration and tonic and phasic EDA. Welch's t-test and associations between measures were assessed with a Pearson Correlation Coefficient. Effect sizes of group mean differences were calculated.

RESULTS

Greater than 80% of all participants were visually dependent. Outcome measures were significantly poorer in the + VVM group: tonic EDA was lower (p < 0.001) and phasic EDA higher (p < 0.001). Postural accelerations varied across groups; LME models indicated a relationship between visual context, postural, and ANS responses in the + VVM group.

CONCLUSIONS

Lower tonic EDA with + VVM suggests canal-otolith dysfunction. The positive association between vertical acceleration, tonic EDA, and visual dependence suggests that increased vertical segmental adjustments are used to compensate. Visual context of the spatial environment emerged as an important control variable when testing or treating VVM.

Involvement of the cerebellum in migraine

Migraine is a disabling neurological disease characterized by moderate or severe headaches and accompanied by sensory abnormalities, e.g., photophobia, allodynia, and vertigo. It affects approximately 15% of people worldwide. Despite advancements in current migraine therapeutics, mechanisms underlying migraine remain elusive. Within the central nervous system, studies have hinted that the cerebellum may play an important sensory integrative role in migraine. More specifically, the cerebellum has been proposed to modulate pain processing, and imaging studies have revealed cerebellar alterations in migraine patients. This review aims to summarize the clinical and preclinical studies that link the cerebellum to migraine. We will first discuss cerebellar roles in pain modulation, including cerebellar neuronal connections with pain-related brain regions. Next, we will review cerebellar symptoms and cerebellar imaging data in migraine patients. Lastly, we will highlight the possible roles of the neuropeptide calcitonin gene-related peptide (CGRP) in migraine symptoms, including preclinical cerebellar studies in animal models of migraine.

Spectral Composition of Body Sway in Persistent Postural-Perceptual Dizziness

OBJECTIVE

Previous studies in phobic postural vertigo patients showed characteristic frequency changes in body sway fluctuations, raising the question whether similar spectral changes can be also observed in the recently defined syndrome of persistent postural-perceptual dizziness (PPPD).

STUDY DESIGN

Cross-sectional prospective study.

SETTING

Tertiary referral center.

SUBJECTS

Sixty-one PPPD patients and 41 healthy controls.

INTERVENTIONS

Static balance was assessed while standing on firm surface with eyes open or closed (conditions 1 and 2) and while standing on foam with eyes open or closed (conditions 3 and 4). Postural sway was analyzed by means of time (sway area and standard deviation) and frequency domain metrics. The latter was based on comparisons of the percentage of energy in each of three frequency bands: low (0-0.5 Hz), middle (0.05-2 Hz), and high frequency (2-20 Hz).

MAIN OUTCOME MEASURE

Stabilometric time and frequency domain parameters.

RESULTS

Time domain metrics deteriorated significantly from conditions 1 through condition 4 in patients and controls. Spectral changes, however, were more abundant in PPPD subjects than in controls. Patients showed increased low frequency, but decreased high frequency spectral power in condition 3 as compared to condition 2. Dizziness Handicap Inventory score was positively correlated with middle frequency and negatively correlated with low frequency fluctuations.

CONCLUSIONS

We conclude that PPPD patients exhibit a time domain sway pattern in different conditions which is grossly similar to that of controls. However, sensory feedback conditions with equal sway area show unique differences in their spectral content in PPPD patients. Moreover, perceived severity of dizziness is associated with greater body oscillations in the middle frequency band.

Misperception of Visual Verticality in Patients with Primary Headache Disorders: A Systematic Review with Meta-Analysis

Migraine and tension-type headache (TTH) are the two most prevalent primary headache disorders (PHDs) that may involve visual and vestibular impairments, neck pain, and postural unsteadiness. The perception of visual verticality (VV) has been studied in patients diagnosed with PHD to assess balance disorders showing varying findings. Our study aimed to assess the VV perception in patients diagnosed with PHD in comparison to healthy controls. A systematic review with meta-analysis was carried out in PubMed MEDLINE, Scopus, WOS, CINAHL, and SciELO. The Cohen standardized mean difference (SMD) was used to estimate the differences between exposed and healthy controls. Seven studies with 816 participants were included. The quality of included studies, according to the Newcastle–Ottawa Scale (NOS), was moderate (mean score of 5.2). Patients diagnosed with PHD showed a moderate misperception of VV as assessed with the subjective visual vertical (SVV) test (SMD = 0.530; 95% CI = 0.225, 0.836; p < 0.001). Specifically, a misperception of the SVV was found in patients with migraine (SMD = 0.369; 95% CI = 0.1, 0.638; p = 0.007) and with TTH (SMD = 1.122; 95% CI = 0.540, 1.704; p < 0.001). This review shows a misperception of VV in patients with migraine and TTH when assessed with the SVV test, being higher in patients with TTH, although the THH sample size was low.

Neck Pain- and Unsteadiness-Inducing Activities and their Relationship to the Presence, Intensity, Frequency, and Disability of Headaches

(1) Background: Headache is a significant public health problem. Despite the association between headache and neck pain, little is known about the relationships among specific activities that generate neck pain and headache. The aim of this study was to identify the specific activities that result in neck pain and unsteadiness, and determine how they are linked to headache in university students. (2) Methods: One hundred and six patients with physician-diagnosed headache and 92 healthy university students completed surveys assessing demographics; the presence, frequency, intensity, and disability of headaches; and activities generating neck pain and unsteadiness. (3) Results: The presence of headache was related to female gender (p = 0.001), neck pain when reading or watching television (p = 0.024), and unsteadiness when moving the head (p = 0.005). Headache-related disability was associated with intensity of neck pain (p < 0.001), neck pain when reading or watching television (p = 0.033), and stumbling (p < 0.001). Headache frequency was related to smoking (p = 0.004), the duration of neck pain-associated symptoms (p = 0.047), and neck pain when driving (p = 0.039). Intensity of headache was associated with female gender (p = 0.002), smoking (p = 0.013), and neck pain-related sleep alterations (p = 0.024). (4) Conclusions: Female gender, smoking, neck pain, and unsteadiness when moving the head are factors related to headache in university students.

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.

Physical therapy and migraine: musculoskeletal and balance dysfunctions and their relevance for clinical practice

BACKGROUND

Migraine is a primary headache with high levels of associated disability that can be related to a variety of symptoms and comorbidities. The role of physical therapy in the management of migraine is largely unknown. Therefore, the aim of this review is to highlight and critically discuss the current literature and evidence for physical therapy interventions in individuals with migraines.

METHODS

A narrative review of the literature was performed.

RESULTS

Physical therapists assessing and treating patients with migraine should focus on two primary aspects: (1) musculoskeletal dysfunctions, and (2) vestibular symptoms/postural control impairment. Signs and symptoms of musculoskeletal and/or vestibular dysfunctions are prevalent among individuals with migraines and different disability levels can be observed depending on the presence of aura or increment of the migraine attacks.

CONCLUSION

A proper physical examination and interview of the patients will lead to a tailored treatment plan. The primary aim regarding musculoskeletal dysfunctions is to reduce pain and sensitization, and physical therapy interventions may include a combination of manual therapy, exercise therapy, and education. The aim regarding postural control impairment is to optimize function and reduce vestibular symptoms, and interventions should include balance exercises and vestibular rehabilitation. However, consistent evidence of benefits is still lacking due to the lack of and therefore need for tailored and pragmatic clinical trials with high methodological quality.

A case-control study of visually evoked postural responses in childhood with primary headaches

BACKGROUND

Disorientation, nausea, confusion, dizziness, and displacement are frequently complained by headache-suffering children. Anyhow, the cause of these symptoms is still unclear, and a dysfunction of vestibular pathways or their alteration due to central pain pathways hyper-activation, has been proposed. The aim of this study is to use posturography to explore the balance function of headache-suffering children during pain-free periods.

METHODS

Posturography was performed on 19 migraineurs, 11 tension-type headache sufferers, and 20 healthy controls. Posturographic measures were performed during headache-free periods under different conditions: with eyes opened, eyes closed, and during right and left optokinetic stimulation. The last 2 conditions were used to mimic unreliable visual signals that can confound vestibular system.

RESULTS

During eyes-closed conditions, headache-suffering children displayed higher displacements than healthy controls, since statokinesiogram surface was higher in tension-type headache sufferers and migraineurs compared with controls (P value = 0.0095). Romberg's index, indicating the overall stability of the subject, was lower in healthy controls than in headache sufferers (P = 0.0139), thus suggesting a vestibular impairment in the seconds. Moreover, both during right and left optokinetic stimulation, the statokinesiogram length was higher in headache-suffering children (P < 0.0001). Thereafter, statokinesiogram surface was higher in migraineurs during right optokinetic stimulation (P = 0.0388) than in tension-type headache sufferers when stimulation was directed on the opposite side (P = 0.0249).

CONCLUSIONS

These results suggest a central alteration of vestibular pathways in headache-suffering children, that makes balance function more dependent from visual inputs than healthy subjects, even in inter-ictal phases.