Persistent vertigo and dizziness after mild traumatic brain injury

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.

Comparison of effectiveness between different interventions in postconcussive symptoms in adolescents and young people: a literature review

INTRODUCTION

Currently, concussion considers a problem of great magnitude, adolescents and young people being the population at risk, since it is in the process of maturation. Our goal has been to compare the effectiveness of different interventions (exercise therapy, vestibular rehabilitation and rest) in adolescents and young people with concussion.

DEVELOPMENT

A bibliographic search was carried out in the main databases. Once the inclusion/exclusion criteria and the PEDro methodological scale were applied, 6 articles were reviewed. The results support the use of exercise and vestibular rehabilitation in the initial stages to reduce post-concussion symptoms. According to most authors, therapeutic physical exercise and vestibular rehabilitation report greater benefits, although a protocol that unifies assessment scales, study variables and analysis parameters would be needed to be able to make the inference in the target population. CONCLUSIóN: From the moment of hospital discharge, the combined application of exercise and vestibular rehabilitation could be the best option to reduce post-concussion symptoms.

A Proposed Mechanism for Visual Vertigo: Post-Concussion Patients Have Higher Gain From Visual Input Into Subcortical Gaze Stabilization

Purpose

Post-concussion syndrome (PCS) is commonly associated with dizziness and visual motion sensitivity. This case-control study set out to explore altered motion processing in PCS by measuring gaze stabilization as a reflection of the capacity of the brain to integrate motion, and it aimed to uncover mechanisms of injury where invasive subcortical recordings are not feasible.

Methods

A total of 554 eye movements were analyzed in 10 PCS patients and nine healthy controls across 171 trials. Optokinetic and vestibulo-ocular reflexes were recorded using a head-mounted eye tracker while participants were exposed to visual, vestibular, and visuo-vestibular motion stimulations in the roll plane. Torsional and vergence eye movements were analyzed in terms of slow-phase velocities, gain, nystagmus frequency, and sensory-specific contributions toward gaze stabilization.

Results

Participants expressed eye-movement responses consistent with expected gaze stabilization; slow phases were fastest for visuo-vestibular trials and slowest for visual stimulations (P < 0.001) and increased with stimulus acceleration (P < 0.001). Concussed patients demonstrated increased gain from visual input to gaze stabilization (P = 0.005), faster slow phases (P = 0.013), earlier nystagmus beats (P = 0.003), and higher relative visual influence over the gaze-stabilizing response (P = 0.001), presenting robust effect sizes despite the limited population size.

Conclusions

The enhanced neural responsiveness to visual motion in PCS, combined with semi-intact visuo-vestibular integration, presented a subcortical hierarchy for altered gaze stabilization. Drawing on comparable animal trials, findings suggest that concussed patients may suffer from diffuse injuries to inhibiting pathways for optokinetic information, likely early in the visuo-vestibular hierarchy of sensorimotor integration. These findings offer context for common but elusive symptoms, presenting a neurological explanation for motion sensitivity and visual vertigo in PCS.

Delayed Hearing Recovery After Transverse Temporal Bone Fracture with Otic Capsule violation - Case Report and Literature Review

We present a patient who suffered a temporal bone fracture (TBF) encompassing the bony labyrinth. Sensorineural hearing loss was confirmed with an unfavorable prognosis for recovery. Thirteen years later, there is regression of the hearing loss.

Self-Reported Symptoms of Vertigo and Imbalance Are Prevalent Among Adults With Chronic Moderate-Severe Traumatic Brain Injury: A Preliminary Analysis

PURPOSE

Dizziness and imbalance are common symptoms during the acute phase of traumatic brain injury (TBI). However, there is evidence to suggest that these symptoms persist into the chronic phase of injury. Few prospective studies have examined the frequency and type of dizziness and imbalance in adults with chronic moderate-severe TBI. The aim of this preliminary analysis was to investigate the prevalence of these symptoms in adults with chronic moderate-severe TBI.

METHOD

Twenty-four adults with chronic moderate-severe TBI and a group of 19 age-, sex-, and education-matched noninjured comparison participants were recruited. Self-reported dizziness and imbalance were measured using a modified version of a standard case history form. Significant associations between group (TBI group or noninjured comparison [NC] participants) and self-reports of dizziness, imbalance, and related symptoms (endorsed "yes" or "no") were explored.

RESULTS

The TBI group most reported lightheadedness (75%), vertigo (38%), and imbalance and/or falling (46%). The most common related symptom reported by the TBI group was headache (63%) and nausea (46%). Significant associations revealed that the TBI group responded "yes" in higher percentages than the NC group across all categories (dizziness, imbalance, and related symptoms). There were no statistically significant relationships among dizziness, imbalance, or headache symptoms within the TBI group.

CONCLUSIONS

These preliminary findings suggest that dizziness and imbalance are prevalent in adults with chronic moderate-severe TBI. Persistent vertiginous symptoms may point to an underlying vestibular impairment. However, further research is needed to characterize vestibular function in chronic moderate-severe TBI.

Dizziness-Related Disability One Year after a Mild-to-Moderate TBI-A Follow-Up Study

Persisting dizziness and balance problems after mild-to-moderate traumatic brain injury (mmTBI) may result in considerable disability. The primary aim of this study was to explore the factors associated with dizziness-related disability one year post-injury. Data from 64 participants (mean age 39.4 [SD 13.0] years; 45 [70.3%] women) with mmTBI from a previous randomised controlled trial were analysed using simple and multiple regression analyses (Clinical Trials Registry #NCT01695577). The Dizziness Handicap Inventory one year (12.1, [SD1.6] months) post-injury was the dependent variable. Demographic and injury-related variables, clinical findings, and measures of post-injury symptoms and functioning (Rivermead Post-Concussion Symptoms Questionnaire, RPQ; Vertigo Symptom Scale-short form, VSS-SF; Hospital Anxiety and Depression Scale; Balance Error Scoring System; and High-Level Mobility Assessment Tool, HiMAT) at baseline (3.5 [SD 2.1] months post-injury) were the independent variables. Dizziness-related disability at one year was associated with pre-injury comorbidity, neck pain, higher RPQ, higher VSS-SF, and lower HiMAT scores (adjusted R2 = 0.370, F = 6.52 p < 0.001). In conclusion, the factors associated with dizziness-related disability one year post-injury, such as pre-injury comorbidity, neck pain, increased post-concussion symptom burden, increased dizziness symptom severity, and reduced balance and mobility, should be addressed early in the rehabilitation process to reduce patient burden.

Risk of Migraine after Traumatic Brain Injury and Effects of Injury Management Levels and Treatment Modalities: A Nationwide Population-Based Cohort Study in Taiwan

Traumatic brain injury (TBI) causes several long-term disabilities, particularly headaches. An association between TBI and subsequent migraine has been reported. However, few longitudinal studies have explained the link between migraine and TBI. Moreover, the modifying effects of treatment remain unknown. This retrospective cohort study used records from Taiwan's Longitudinal Health Insurance Database 2005 to evaluate the risk of migraine among patients with TBI and to determine the effects of different treatment modalities. Initially, 187,906 patients, aged ≥ 18 years, who were diagnosed as TBI in 2000, were identified. In total, 151,098 patients with TBI and 604,394 patients without TBI were matched at a 1:4 ratio according to baseline variables during the same observation period. At the end of follow-up, 541 (0.36%) and 1491 (0.23%) patients in the TBI and non-TBI groups, respectively, developed migraine. The TBI group exhibited a higher risk of migraine than the non-TBI group (adjusted HR: 1.484). Major trauma (Injury Severity Score, ISS ≥ 16) was associated with a higher migraine risk than minor trauma (ISS < 16) (adjusted HR: 1.670). However, migraine risk did not differ significantly after surgery or occupational/physical therapy. These findings highlight the importance of long-term follow-up after TBI onset and the need to investigate the underlying pathophysiological link between TBI and subsequent migraine.

Effectiveness of non-pharmacological treatments for vestibular and oculomotor dysfunction in patients with persistent post-concussive symptoms: protocol for a systematic review and meta-analysis

INTRODUCTION

Concussion is a form of mild traumatic brain injury that disrupts brain function. Although symptoms are mostly transient, recovery can be delayed and result in persistent postconcussive symptoms (PPCS). Vestibular and oculomotor dysfunction are among the most debilitating impairments associated with PPCS. However, pharmacological interventions for these impairments are associated with deleterious side effects. Accordingly, increasing research has examined the utility of non-pharmacological interventions for PPCS. The aim of this review is to synthesise and evaluate the effectiveness of non-pharmacological interventions for the treatment of vestibular and oculomotor dysfunction for patients with PPCS.

METHODS AND ANALYSIS

Systematic searches of MEDLINE, PubMed, Web of Science and Scopus will identify randomised controlled trials employing non-pharmacological treatments for vestibular and/or oculomotor dysfunction for PPCS. Such interventions may include, but are not limited to, vestibular rehabilitation, optokinetic stimulation and vestibulo-ocular reflex exercises. Assessments of oculomotor function will include versional eye movements, vergence eye movements, visual-fixation movements and accommodation response. Assessments of vestibular function will include the Fukuda Step test, functional balance tests, force displacement tests, and subjective reports of balance disruption or vertigo. Where appropriate, meta-analyses of standardised mean differences will be conducted using a random effects model for continuous outcomes. For dichotomous outcomes (improved vs not improved following treatment), effects will be expressed as relative risk. The impact of heterogeneity will be calculated using the I² statistic. The Physiotherapy Evidence Database scale will be used to determine the methodological quality of individual studies and Grading of Recommendations, Assessment, Development and Evaluations used to assess the certainty and quality of evidence for each outcome.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review. Findings will be disseminated through peer-reviewed publications and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42021254720.

Using interpretative phenomenological analysis to probe the lived experiences of persistent postural-perceptual dizziness (PPPD)

BACKGROUND

Persistent Postural-Perceptual Dizziness (PPPD) is a chronic neuro-vestibular condition characterised by subjective dizziness, non-spinning vertigo, and postural imbalance. Symptoms are typically induced by situations of visuo-vestibular conflict and intense visual-motion.

OBJECTIVE

Little research has focused on the lived experiences of people with PPPD. Therefore, our objective was to present an in-depth exploration of patient experiences and sense-making, and the effect of PPPD on psycho-social functioning.

METHODS

We conducted semi-structured interviews with 6 people with PPPD, who were recruited from an Audiovestibular department in Wales. We present a case-by-case Interpretive Phenomenological Analysis (IPA) for each participant and present common themes.

RESULTS

Our analysis revealed a range of superordinate and subordinate themes, individualised to each participant, but broadly described under the following headings: dismissal and non-belief, identity loss, dissociative experiences, poor psychological well-being and processes of sense-making.

CONCLUSION

The qualitative experiences documented in this study will help clinicians and researchers to better understand the lived experiences of PPPD, how PPPD patients make sense of their symptoms, and the psycho-social impacts of the condition.

Dizziness After Traumatic Brain Injury: A Prospective TRACK-TBI Analysis of Risk Factors, Quality of Life, and Neurocognitive Effects

OBJECTIVE

To determine the longitudinal incidence of dizziness and its association with demographic factors, neurocognitive effects, functionality, and quality of life.

STUDY DESIGN

Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) is a prospective, longitudinal cohort study in which TBI patients were assessed at the emergency department and 2-week, 3-month, 6-month, and 12-month follow-up via telephone and/or in-person visits.

SETTING

Multicenter study in emergency departments of 18 academic medical centers in the United States.

PATIENTS

A total of 1,514 patients 17 years or older with a diagnosis of TBI, injury occurrence within 24 hours of admission, fluency in English or Spanish, and completed Rivermead Post-Concussion Symptoms Questionnaire (RPQ) at 12 months were enrolled between February 2014 and August 2018.

MAIN OUTCOME MEASURE

RPQ, Short Form-12 Version 2, Wechsler Adult Intelligence Scale IV, Trail Making Test, Patient Health Questionnaire-9, PROMIS-PAIN, and Glasgow Outcome Scale-Extended Revised. The primary outcome measure was a self-report of "feelings of dizziness" on RPQ at 12 months post-TBI.

RESULTS

Of the 1,514 participants, 1,002 (66%) were male and 512 (34%) were female. The mean age was 41.6 (SD, 17.4) years. At 12 months, 26% experienced dizziness, with 9% experiencing moderate or severe dizziness. Dizziness was strongly associated with headache (odds ratio [OR], 3.45; 95% confidence interval [CI], 2.92-4.07; p < 0.001), nausea (OR, 4.43; 95% CI, 3.45-5.69; p < 0.001), worse hearing (OR, 3.57; 95% CI, 2.64-4.82; p < 0.001), noise sensitivity (OR, 3.02; 95% CI, 2.54-3.59; p < 0.001), and light sensitivity (OR, 3.51; 95% CI, 2.91-4.23; p < 0.001). In multivariable regression models, participants with severe dizziness demonstrated lower performance compared with those without new or worse dizziness on the Wechsler Adult Intelligence Scale IV (-6.64; p < 0.001), Trail Making Test part A (7.90; p = 0.003) and part B (19.77; p = 0.028), and Short Form-12 physical (-13.60; p < 0.001) and mental health (-11.17; p < 0.001), after controlling for age, sex, education, and TBI severity.

CONCLUSION

Dizziness is common among TBI patients and relates to quality of life and neurocognitive performance.

'I had nothing. It's just life experience that helped me through that situation': Australian audiologists' perspectives on audiological clinical practice for traumatic brain injury and rehabilitation

OBJECTIVE

Australian Audiologists' perspectives on standard non-specialized clinical practice in the context of Traumatic Brain Injury (TBI) were examined, including the perceived barriers to optimal service provision.

DESIGN

A qualitative research design utilizing semi-structured interviews was conducted using purposive sampling. Nine participants were interviewed about their understanding of the impact of TBI on hearing and balance; identification, diagnosis and management of auditory and vestibular dysfunction following TBI; barriers to service delivery; training relating to complex clients (i.e., TBI); and awareness of referral pathways.

RESULTS

Three major themes, each with subthemes, were evident in the data. The major themes reflected general considerations of audiological professional culture and specific issues related to knowledge of TBI and clinical practice with patients. Analysis revealed that professional culture seemed to act as a contextual barrier and interacted with the perceived lack of TBI related knowledge to hinder optimal clinical practice in this patient population.

CONCLUSION

Application of the biopsychosocial model, including interdisciplinary care in the management of patients with TBI, is needed. An improvement in theoretical and practical knowledge encompassing the wide-ranging effects of TBI is critical for the optimal audiological service delivery.

Vestibulo-ocular dysfunction in mTBI: Utility of the VOMS for evaluation and management – A review

BACKGROUND: Individuals who have suffered a concussion/mild traumatic brain injury (mTBI) frequently report symptoms associated with vestibular and/or oculomotor dysfunction (VOD) like dizziness, nausea, fatigue, brain fog, headache, gait and neurocognitive impairments which are associated with the development of chronic symptoms. The Vestibular/Ocular Motor Screening (VOMS) tool has been established as a reliable and clinically relevant complement to use alongside a battery of post-concussion tests to improve screening and referral for further evaluation and treatment of VOD. OBJECTIVES: This paper will review the pathoanatomy and symptomatology of common vestibular and oculomotor disorders after concussion, as well as the utility of the VOMS to assist in diagnosis, referral, and management. METHODS: Primary articles were identified using a search via PubMed, Google Scholar, OneSearch, and CINAHL. Search key terms were combinations of “mild traumatic brain injury” or “concussion” or “pursuit” or “accommodation” or “vergence” or “convergence insufficiency” or “saccades” or “vestibulo-ocular reflex” or “vestibular ocular motor screen” or “vestibular rehabilitation”, or “vision rehabilitation” including adult and pediatric populations that were published in print or electronically from 1989 to 2021 in English. Classic papers on anatomy of eye movements, vestibular system and pathological changes in mTBI were also included, regardless of publication date. RESULTS: Objective impairments are commonly found during testing of smooth pursuit, saccades, vergence, accommodation, vestibular ocular reflex, and visual motion sensitivity after mTBI. These deficits can be actively treated with vestibular physical therapy and oculomotor/neuro-optometric vision therapy. VOMS is an efficient and reliable tool that can be used by all healthcare and rehabilitation providers to aid in diagnosis of post-concussion VOD, to help facilitate the decision to refer for further evaluation and treatment to expedite symptomatic post-concussion recovery. CONCLUSIONS: VOD is common after concussion in acute, post-acute, and chronic phases. Once areas of impairments are identified through proper assessment, clinicians can maximize recovery by referring to vestibular physical therapy and/or neuro-optometry to design a targeted treatment program to address individual deficits.

Effects of Mild Traumatic Brain Injury on Resting State Brain Network Connectivity in Older Adults

Older age is associated with worsened outcome after mild traumatic brain injury (mTBI) and a higher risk of developing persistent post-traumatic complaints. However, the effects of mTBI sequelae on brain connectivity at older age and their association with post-traumatic complaints remain understudied.We analyzed multi-echo resting-state functional magnetic resonance imaging data from 25 older adults with mTBI (mean age: 68 years, SD: 5 years) in the subacute phase (mean injury to scan interval: 38 days, SD: 9 days) and 20 age-matched controls. Severity of complaints (e.g. fatigue, dizziness) was assessed using self-reported questionnaires. Group independent component analysis was used to identify intrinsic connectivity networks (ICNs). The effects of group and severity of complaints on ICNs were assessed using spatial maps intensity (SMI) as a measure of within-network connectivity, and (static) functional network connectivity (FNC) as a measure of between-network connectivity.Patients indicated a higher total severity of complaints than controls. Regarding SMI measures, we observed hyperconnectivity in left-mid temporal gyrus (cognitive-language network) and hypoconnectivity in the right-fusiform gyrus (visual-cerebellar network) that were associated with group. Additionally, we found interaction effects for SMI between severity of complaints and group in the visual(-cerebellar) domain. Regarding FNC measures, no significant effects were found.In older adults, changes in cognitive-language and visual(-cerebellar) networks are related to mTBI. Additionally, group-dependent associations between connectivity within visual(-cerebellar) networks and severity of complaints might indicate post-injury (mal)adaptive mechanisms, which could partly explain post-traumatic complaints (such as dizziness and balance disorders) that are common in older adults during the subacute phase.

Perception, knowledge, and attitude of medical doctors in Saudi Arabia about the role of physiotherapists in vestibular rehabilitation: a cross-sectional survey

Objectives

There is compelling scientific evidence about the role of physiotherapists in vestibular rehabilitation. However, patients with vestibular-associated dizziness and balance disturbances are seldom referred to physiotherapists in Saudi Arabia. Therefore, this study aims to achieve insight into perceptions, knowledge, attitudes, and referral practices among Saudi Arabian medical doctors relating to the role of physiotherapists in vestibular rehabilitation.

Methods

A sample of 381 medical doctors practicing in Saudi Arabia participated in this nationwide cross-sectional study. The sample was obtained from 226 hospitals across 13 provinces of Saudi Arabia by stratified sampling method. The 23-item questionnaire developed by a team of experts was emailed to medical doctors practicing in various hospitals across Saudi Arabia.

Results

Out of 1,231 medical doctors invited, 381 medical doctors responded, giving a response rate of 30.9%. One hundred ninety-three (50.6%) medical doctors reported managing patients with vestibular rehabilitation. The most preferred specialist for managing patients with vestibular disorders was an Ear Nose Throat (ENT) specialist (n = 173, 89.6%). Related Sample Cochran's Q test showed statistically significant difference between preferred specialist for managing patients with vestibular disorders (ENT specialists, physiotherapists, nurses, occupational therapists and audiologists) (χ2(4) = 482.476, p = 0.001). Out of 193 medical doctors, 153 (79.2%) reported no role of the physiotherapist in vestibular rehabilitation. One hundred forty-five (75.1%) of medical doctors reported that they were not aware of the role of physiotherapists in vestibular rehabilitation. Only 27 (15.5%) medical doctors reported referring patients with vestibular disorders to physiotherapists.

Conclusion

The study reports that physiotherapy services are underutilized in vestibular rehabilitation due to limited referral from Saudi Arabian medical doctors. Therefore, there is a need to increase the awareness among Saudi Arabian doctors about the physiotherapist's role in vestibular rehabilitation.

Vestibular Rehabilitation Therapy for the Treatment of Vestibular Migraine, and the Impact of Traumatic Brain Injury on Outcome: A Retrospective Study

INTRODUCTION

Vestibular migraine (VM) is a common condition; individuals experience dizziness with migraine symptoms. Vestibular rehabilitation therapy (VRT) has been reported as an effective treatment for VM, however, evidence is limited. VM and traumatic brain injury (TBI) can co-occur, and some suggest that TBI can induce VM. There is limited evidence on the effect a history of TBI has on VRT in patients with VM.

METHODS

Retrospective case series of 93 (f = 63, m = 30) participants with VM and underwent VRT (mean age 48.62; SD 15.92). Pre- and post-treatment self-reported outcome measures and functional gait assessment were extracted from the participants health records and evaluated. The impact of TBI on VRT outcome in participants with VM was analyzed. Individuals with TBI and no history of migraine (n = 40) were also extracted to act as a control.

RESULTS

VRT significantly improved self-reported dizziness on the Dizziness Handicap Inventory (DHI), with a mean change of -18 points (p < 0.000) and +5 points on the functional gait assessment (FGA) (p < 0.000) in patients with VM. A history of TBI significantly impacted outcome on the DHI (p = 0.018) in patients with VM.VRT significantly improved all outcome measures for individuals with TBI, with a mean change of -16 points on the DHI (p = 0.001) and +5 points on the FGA (p < 0.000). VM presence significantly impacted outcome.

CONCLUSION

VRT should be considered as a treatment option to reduce dizziness and the risk of falls in individuals with VM. TBI may negatively impact VRT outcomes in individuals with VM.

Vestibular/Ocular Motor Screening is Independently Associated With Concussion Symptom Severity in Youths

OBJECTIVE

To examine the independent contributions of the Vestibular/Ocular Motor Screening (VOMS) to concussion symptom severity in youths while controlling for computerized neurocognitive screening performance, demographics, and medical history.

STUDY DESIGN

Cross-sectional.

SETTING

Concussion specialty clinic.

PARTICIPANTS

A retrospective review of 278 concussed youths clinical charts resulted in a total of 158 participants (16.5 ± 2.8 years, 46.8% women, 4.3 ± 3.3 days post-injury) when exclusionary criteria (ie, neurological or substance use disorders, age >21, >14 days since injury, and missing/incomplete data) were applied.

INDEPENDENT VARIABLES

Vestibular/Ocular Motor Screening items and computerized neurocognitive test scores.

MAIN OUTCOME MEASURES

Standardized postconcussion symptom scale scores.

RESULTS

At the univariate level, all VOMS items were positively associated with concussion symptom severity at small to medium effect sizes (r range 0.26-0.42). Women and individuals with a concussion history and/or Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder diagnosis reported higher VOMS item scores (Ps < 0.10). In a multiple hierarchical regression, the contribution of VOMS item scores was significant and explained 9.6% of the variance in concussion symptom severity after adjustment for sex, baseline VOMS symptom ratings, and ImPACT scores [F(6, 141) = 3.90, P = 0.001]. Vertical saccades (b = 2.22, P = 0.003) and vertical vestibulo-ocular reflex (VOR; b = -1.46, P = 0.004) VOMS items significantly contributed to concussion symptom severity in the multivariable model.

CONCLUSIONS

Findings from this study provide support for the independent contributions of the VOMS items, particularly vertical saccades and vertical VOR, to acute concussion symptom severity in youths. Further work is warranted for a comparison of the VOMS to the full gold standard of concussion testing (ie, clinical interview, physical examination, balance testing, and neurocognitive assessment).

Normative data for ages 18-45 for ocular motor and vestibular testing using eye tracking

OBJECTIVE

Eye tracking technology has been employed in assessing ocular motor and vestibular function following vestibular and neurologic conditions, including traumatic brain injury (TBI). Assessments include tests that provide visual and motion (rotation) stimuli while recording horizontal, vertical, and torsional eye movements. While some of these tests have shown diagnostic promise in previous studies, their use in clinical practice is limited by the lack of normative data. The goal of this study was to construct normative reference ranges to be used when comparing patients' results.

METHODS

Optokinetic response, subjective visual horizontal and vertical, and rotation tests were administered to male and female volunteers, ages 18-45, who were free from neurological, vestibular disorders, or other head injuries. Tests were administered using either a rotatory chair or a portable virtual reality-like goggle equipped with video-oculography.

RESULTS

Reference values for eye movements in response to different patterns of stimuli were analyzed from 290 to 449 participants. Analysis of gender (self-reported) or age when grouped as pediatric (late adolescent; 18-21 years of age) and adult (21-45 years of age) revealed no effects on the test metrics. Data were pooled and presented for each test metric as the 95% reference interval (RI) with 90% confidence intervals (CI) on upper and lower limits of the RI.

CONCLUSIONS

This normative database can serve as a tool to aid in diagnosis, treatment, and/or rehabilitation protocols for vestibular and neurological conditions, including mild TBI (mTBI). This database has been cleared by the FDA for use in clinical practice (K192186).

LEVEL OF EVIDENCE

2b.

Long-Term Presentation of Postconcussion Symptoms and Associated Factors: Analysis of Latent Class Modeling

OBJECTIVE

Postconcussion symptoms (PCS) are commonly reported by patients with mild traumatic brain injury (MTBI). Although PCS significantly recovered by 3-month postinjury, a number of patients still experienced persistent PCS for >1 year. As few researchers investigated long-term PCS endorsement, the present study thus aims to show the latent structure of long-term PCS and further uncover its associating factors.

METHODS

In total, 110 patients with MTBI and 32 healthy participants were prospectively enrolled. PCS was evaluated at 2 weeks and long-term evaluations (mean = 2.90 years) after MTBI. In addition, cognitive functions, which include memory, executive function, and information processing, and emotional disturbances, which include depression, anxiety, and irritability, were also examined at 2-week postinjury.

RESULTS

Patients reported significantly more PCS at 2-week postinjury than healthy participants did, but PCS significantly improved at long-term evaluations when comparing with PCS at acute stage after MTBI. Both of PCS at 2 weeks and long-term evaluations can be further subdivided into subgroups based on the severity of PCS, in which specific PCS (e.g., fatigue, loss of energy, insomnia, slowness of information processing, irritability, and blurred vision) can be well differentiated among subgroups at long-term evaluations.

CONCLUSIONS

This study directly showed the characteristics of long-term PCS and associating factors. It further evidenced that specific physical, cognitive, and emotional symptoms might be determinant to identify the subgroups of patients with long-term PCS endorsement.

Vestibular Assessment in Patients with Persistent Symptoms of Mild Traumatic Brain Injury

Aim

The estimated worldwide incidence of TBI is 10 million cases per year. Dizziness and imbalance are two common symptoms in mild TBI (mTBI). In about 10-15% of TBI patients, these symptoms remain for a long time and may show no recovery. These persistent symptoms may relate to different factors including vestibular abnormalities. The aim of this study is a vestibular assessment of patients with persistent symptoms of mTBI by different tests including computerized dynamic posturography.

Materials and Methods

21 patients with mTBI evaluated in this study. Patients were civilians with persistent symptoms. TBI did cause by blunt force trauma (mainly from falling) in the past 6 months. They had normal neurologic and musculoskeletal assessments and no temporal bone fracture. Several auditory and vestibular evaluations were performed for each patient. They included: case history, otoscopy, pure tone and speech audiometry, tympanometry, vestibular bedside examination (spontaneous nystagmus, gaze, saccade, pursuit, Dix-Hallpike maneuver, side-lying maneuver, roll, and Romberg test), cervical Vestibular Myogenic Evoked Potential (c-VEMP), Computerized Dynamic Posturography (CDP) and Dizziness Handicap Inventory (DHI).

Results

Patients showed hearing loss in 10 (47.6%) and tinnitus in 4 (19.0%) cases. In ocular motor tests, patients had the most abnormal results in the pursuit test. 6 patients also had Benign Paroxysmal Positional Vertigo (BPPV) in the posterior canal. c-VEMP showed abnormal saccular function in 14 patients. In CDP, the composite scores were decreased relative to normal populations.

Conclusion

vestibular tests showed abnormal results in most patients. Vestibular abnormality could relate to persisting symptoms of mTBI patients.

Vestibular and Balance Dysfunction Following Sport-Related Concussion

Purpose

Sport-related concussion is a significant public health concern that requires a multidisciplinary team to appropriately manage. Athletes often report dizziness and imbalance following concussion, and these symptoms can predict increased time to recover. Vestibular diagnostic evaluations provide important information regarding the athlete's oculomotor, gaze stability, and balance function in order to identify deficits for rehabilitation. These measures also describe objective function helpful for determining when an athlete is ready to return to play. The purpose of this clinical focus article is to provide background on the current understanding of the effects of concussion on the peripheral and central vestibular system, as well as information on a protocol that can be used for acute concussion assessment. Case studies describing 3 common postconcussion presentations will highlight the usefulness of this protocol.

Conclusion

Sport-related concussion is a highly visible disorder with many symptoms that may be evaluated in the vestibular clinic. A thoughtful protocol evaluating the typical presentation of these patients may help guide the multidisciplinary team in determining appropriate management and clearance for return to sport.

Neck pain associated with clinical symptoms in dizzy patients-A cross-sectional study

OBJECTIVE

Many patients suffer from concurrent neck pain and dizziness. The aim of this study was to describe the clinical symptoms and physical findings in patients with concurrent neck pain and dizziness and to examine whether they differ from patients with dizziness alone.

METHODS

Consecutive patients with dizziness and neck pain were recruited from an ear-nose-throat department and a spine clinic. They were divided into three groups: patients with dizziness only (n = 100), patients with dizziness as their primary complaint and additional neck pain (n = 138) and finally, patients with neck pain as their primary complaint accompanied by additional dizziness (n = 55). The patients filled in questionnaires regarding their symptom quality, time-course, triggers of dizziness and the Vertigo Symptom Scale Short Form. The physical examination included Cervical Range of Motion, American College of Rheumatology (ACR) Tender Points, Cervical Pressure Pain Thresholds and Global Physiotherapy Examination 52-Flexibility.

RESULTS

Both neck pain groups were more likely to have a gradual onset of dizziness symptoms, more light-headedness, visual disturbances, autonomic/anxiety symptoms, decreased cervical range of motion, decreased neck and shoulder flexibility and increased number of ACR tender points compared with patients with dizziness alone. The group having dizziness as their primary complaint and also reporting neck pain had the highest symptom severity and tended to report rocking vertigo and increased neck tenderness. The group with neck pain as their primary complaint was more likely to report headache.

CONCLUSION

Neck pain is associated with certain dizziness characteristics, increased severity of dizziness and increased physical impairment when compared with dizzy patients without neck pain.

Vestibular Rehabilitation for Children

This article focuses on vestibular rehabilitation (VR) for children. Reports of the presence of vestibular dysfunction in infants, young children, and adolescents have increased over the past decade. In addition to being a comorbidity of sensorineural hearing loss, vestibular dysfunction has been noted in children with cytomegalovirus, late prematurity, and concussion, to name a few. Despite ample evidence and reports of VR for adults, the selection and provision of exercises to be included in the VR protocol for children vary, depending on the nature of the lesion, impairments identified, age at the time of lesion, and developmental factors such as critical periods of development and intermodality interdependence. Unlike adults, children with loss of function or hypofunction of the vestibular apparatus since or shortly after birth present with a developmental delay that is progressive. Very young children may not be able to describe symptoms but rather only avoid activities or cry. This report provides a review of vestibular-related impairments in children, determinants of the symptoms and functional impairments of vestibular dysfunction, the mechanisms of recovery in children, the challenges of VR for children, and a summary of research on the efficacy for VR for children.

The effects of vestibular rehabilitation on dizziness and balance problems in patients after traumatic brain injury: a randomized controlled trial

OBJECTIVE:

To investigate the effects of group-based vestibular rehabilitation in patients with traumatic brain injury.

DESIGN:

A single-blind randomized controlled trial.

SETTING:

University Hospital (recruitment and baseline assessments) and Metropolitan University (experimental intervention).

SUBJECTS:

A total of 65 patients (45 women) with mild-to-moderate traumatic brain injury (mean age 39.4 ± 13.0 years) were randomly assigned to intervention ( n = 33) or control group ( n = 32).

INTERVENTION:

Group-based vestibular rehabilitation for eight weeks. Participants were tested at baseline (3.5 ± 2.1 months after injury) and at two post-intervention follow-ups (2.7 ± 0.8 and 4.4 ± 1.0 months after baseline testing).

MAIN MEASURES:

Primary outcome: Dizziness Handicap Inventory. Secondary outcome: High-Level Mobility Assessment Tool. Other outcomes: Vertigo Symptom Scale; Rivermead Post-concussion Symptoms Questionnaire; Hospital Anxiety and Depression Scale; and Balance Error Scoring System. Between-group differences were analyzed with a linear mixed-model analysis for repeated measurements.

RESULTS:

At baseline, no group differences were revealed (personal factors, clinical characteristics and outcome measures). At the first follow-up, statistically significant mean differences in favor of the intervention were found in the primary (-8.7, 95% confidence interval (CI): -16.6 to -0.9) and secondary outcomes (3.7 points, 95% CI: 1.4-6.0). At the second follow-up, no significant between-group differences were found. No significant between-group differences in the other outcomes were found at the two follow-ups.

CONCLUSION:

The intervention appeared to speed up recovery for patients with dizziness and balance problems after traumatic brain injury. However, the benefits had dissipated two months after the end of the intervention.

Assessment and rehabilitation of central sensory impairments for balance in mTBI using auditory biofeedback: a randomized clinical trial

Background

Complaints of imbalance are common non-resolving signs in individuals with post-concussive syndrome. Yet, there is no consensus rehabilitation for non-resolving balance complaints following mild traumatic brain injury (mTBI). The heterogeneity of balance deficits and varied rates of recovery suggest varied etiologies and a need for interventions that address the underlying causes of poor balance function. Our central hypothesis is that most chronic balance deficits after mTBI result from impairments in central sensorimotor integration that may be helped by rehabilitation. Two studies are described to 1) characterize balance deficits in people with mTBI who have chronic, non-resolving balance deficits compared to healthy control subjects, and 2) determine the efficacy of an augmented vestibular rehabilitation program using auditory biofeedback to improve central sensorimotor integration, static and dynamic balance, and functional activity in patients with chronic mTBI.

Methods

Two studies are described. Study 1 is a cross-sectional study to take place jointly at Oregon Health and Science University and the VA Portland Health Care System. The study participants will be individuals with non-resolving complaints of balance following mTBI and age- and gender-matched controls who meet all inclusion criteria. The primary outcome will be measures of central sensorimotor integration derived from a novel central sensorimotor integration test. Study 2 is a randomized controlled intervention to take place at Oregon Health & Science University. In this study, participants from Study 1 with mTBI and abnormal central sensorimotor integration will be randomized into two rehabilitation interventions. The interventions will be 6 weeks of vestibular rehabilitation 1) with or 2) without the use of an auditory biofeedback device. The primary outcome measure is the daily activity of the participants measured using an inertial sensor.

Discussion

The results of these two studies will improve our understanding of the nature of balance deficits in people with mTBI by providing quantitative metrics of central sensorimotor integration, balance, and vestibular and ocular motor function. Study 2 will examine the potential for augmented rehabilitation interventions to improve central sensorimotor integration.

Trial registration

This trial is registered at clinicaltrials.gov (NCT02748109)

Treatment of persistent post-concussion syndrome due to mild traumatic brain injury: current status and future directions

Persistent post-concussion syndrome caused by mild traumatic brain injury has become a major cause of morbidity and poor quality of life. Unlike the acute care of concussion, there is no consensus for treatment of chronic symptoms. Moreover, most of the pharmacologic and non-pharmacologic treatments have failed to demonstrate significant efficacy on both the clinical symptoms as well as the pathophysiologic cascade responsible for the permanent brain injury. This article reviews the pathophysiology of PCS, the diagnostic tools and criteria, the current available treatments including pharmacotherapy and different cognitive rehabilitation programs, and promising new treatment directions. A most promising new direction is the use of hyperbaric oxygen therapy, which targets the basic pathological processes responsible for post-concussion symptoms; it is discussed here in depth.