A review on screening tests for vestibular disorders

Sensory Reweighting for Postural Control in Older Adults with Age-Related Hearing Loss

There is growing evidence linking hearing impairments and the deterioration of postural stability in older adults. To our knowledge, however, no study to date has investigated the effect of age-related hearing loss on the sensory reweighting process during postural control. In the absence of data, much is unknown about the possible mechanisms, both deleterious and compensatory, that could underly the deterioration of postural control following hearing loss in the elderly. The aim of this study was to empirically examine sensory reweighting for postural control in older adults with age-related hearing loss as compared to older adults with normal hearing. The center of pressure of all participants was recorded using a force platform and the modified clinical test of sensory interaction and balance protocol. The results suggest that individuals with age-related hearing loss displayed increased somatosensory reliance relative to normal hearing younger adults. This increased reliance on somatosensory input does not appear to be effective in mitigating the loss of postural control, probably due to the concomitant deterioration of tactile and proprioceptive sensitivity and acuity associated with aging. Beyond helping to further define the role of auditory perception in postural control, these results further the understanding of sensory-related mechanisms associated with postural instability in older adults.

Inertial Measurement Unit-Based Romberg Test for Assessing Adults With Vestibular Hypofunction

This work aims to explore the utility of wearable inertial measurement units (IMUs) for quantifying movement in Romberg tests and investigate the extent of movement in adults with vestibular hypofunction (VH). A cross-sectional study was conducted at an academic tertiary medical center between March 2021 and April 2022. Adults diagnosed with unilateral vestibular hypofunction (UVH) or bilateral vestibular hypofunction (BVH) were enrolled in the VH group. Healthy controls (HCs) were recruited from community or outpatient clinics. The IMU-based instrumented Romberg and tandem Romberg tests on the floor were applied to both groups. The primary outcomes were kinematic body metrics (maximum acceleration [ACC], mean ACC, root mean square [RMS] of ACC, and mean sway velocity [MV]) along the medio-lateral (ML), cranio-caudal (CC), and antero-posterior (AP) axes. A total of 31 VH participants (mean age, 33.48 [SD 7.68] years; 19 [61%] female) and 31 HCs (mean age, 30.65 [SD 5.89] years; 18 [58%] female) were recruited. During the eyes-closed portion of the Romberg test, VH participants demonstrated significantly higher maximum ACC and increased RMS of ACC in head movement, as well as higher maximum ACC in pelvic movement along the ML axis. In the same test condition, individuals with BVH exhibited notably higher maximum ACC and RMS of ACC along the ML axis in head and pelvic movements compared with HCs. Additionally, BVH participants exhibited markedly increased maximum ACC along the ML axis in head movement during the eyes-open portion of the tandem Romberg test. Conversely, no significant differences were found between UVH participants and HCs in the assessed parameters. The instrumented Romberg and tandem Romberg tests characterized the kinematic differences in head, pelvis, and ankle movement between VH and healthy adults. The findings suggest that these kinematic body metrics can be useful for screening BVH and can provide goals for vestibular rehabilitation.

Dispelling Mist That Obscures Positional Vertigo in Vestibular Migraine

(1) Background: Patients with vestibular migraine (VM) often present with positional vertigo. A portion of these patients have features of benign paroxysmal positional vertigo (BPPV). It is a challenge to rapidly identify the BPPV component of VM associated with positional vertigo. (2) Methods: Retrospective data collected from 60 VM and 47 VM + BPPV patients were used to build a diagnostic model, and then prospective data from 47 patients were used for the external validation. All patients had VM manifesting as positional vertigo, with or without accompanying BPPV. The clinical manifestations and the results of vestibular function tests were comprehensively analyzed using logistic regression. (3) Results: The univariate and multivariate analyses showed that the age, symptom duration, tinnitus, ear fullness, nausea, head shaking nystagmus, the direction of the Dix-Hallpike and roll tests, and horizontal gain could help differentiate between the two groups. A nomogram and an online calculator were generated. The C-index was 0.870. The diagnostic model showed good discriminative power and calibration performance during internal and external validation. (4) Conclusions: This study provided a new perspective for diagnosing VM with positional vertigo by identifying the BPPV component and, for the first time, offers a prediction model integrating multiple predictors.

Effectiveness of Balance Rehabilitation Unit (BRU) Posturography Versus Conventional Rehabilitation in Patients With Unilateral Peripheral Vestibular Dysfunction

BACKGROUND

Patients with unilateral peripheral vestibular deficit (UPVD) experience vertigo, dizziness, disability, negative influences on their quality of life, anxiety, and depression. In vestibular rehabilitation, virtual reality (VR) has proven to be effective. This investigation sought to evaluate the efficacy of the Balance Rehabilitation Unit (BRUTM) (MedicaaTM Montevideo, Uruguay, Balance Suite, version BRU 415) in patients with UPVD.

METHODS

A prospective, randomized, controlled study involved 38 patients from the Otoneurologic Service at the National Institute of Rehabilitation "Luis Guillermo Ibarra Ibarra" in Mexico. A physician specialist diagnosed the patients with UPVD and assigned them randomly to one of two groups. Group 1 (n = 19) received traditional vestibular rehabilitation, whereas Group 2 (n = 19) received BRUTM-supported vestibular rehabilitation. Both groups were monitored by medical professionals. Patients were evaluated with the Dizziness Handicap Inventory, static and dynamic balance assessments, the dynamic gait index, and the sensory organization test. The statistical analysis was conducted using the Student's t-test, with p 0.05 considered statistically significant.

RESULTS

The difference in mean age between the conventional therapy and BRUTM groups was not statistically significant. Both conventional vestibular rehabilitation and the BRUTM led to statistically significant improvements in all assessed parameters, with no statistically significant differences between the two groups.

CONCLUSION

Balance, mobility, and quality of life were enhanced similarly in UPVD patients by BRUTM-supported vestibular rehabilitation and conventional vestibular rehabilitation. In addition, BRUTM facilitated patient motivation, exercise feedback, and confidence enhancement.

Development and Application of a Stability Index Estimation Algorithm Based on Machine Learning for Elderly Balance Ability Diagnosis in Daily Life

BACKGROUND

The stability index estimation algorithm was derived and applied to develop and implement a balance ability diagnosis system that can be used in daily life.

METHODS

The system integrated an approach based on sensory function interaction, called the clinical test of sensory interaction with balance. A capacitance and resistance sensing type force mat was fabricated, and a stability index prediction algorithm was developed and applied using the center of pressure variables. The stability index prediction algorithm derived a center of pressure variable for 103 elderly people by Nintendo Wii Balance Board to predict the stability index of the balance system (Biodex SD), and the accuracy of this approach was confirmed.

RESULTS

As a result of testing with the test set, the linear regression model confirmed that the r-value ranged between 0.943 and 0.983. To confirm the similarity between the WBB and the flexible force mat, each measured center of pressure value was inputted and calculated in the developed regression model, and the result of the correlation coefficient validation confirmed an r-value of 0.96.

CONCLUSION

The system developed in this study will be applicable to daily life in the home in the form of a floor mat.

Application of machine learning in the diagnosis of vestibular disease

Machine learning is considered a potential aid to support human decision making in disease prediction. In this study, we determined the utility of various machine learning algorithms in classifying peripheral vestibular (PV) and non-PV diseases based on the results of equilibrium function tests. A total of 1009 patients who had undergone our standardized neuro-otological examinations were recruited. We applied five supervised machine learning algorithms (random forest, adaboost, gradient boosting, support vector machine, and logistic regression). After preprocessing the data, optimizing the hyperparameters using GridSearchCV, and performing a final evaluation on the test set using scikit-learn, we evaluated the predictive capability using various performance metrics, namely, accuracy, F1-score, area under the receiver operating characteristic curve, precision, recall, and Matthews correlation coefficient (MCC). All five machine learning algorithms yielded satisfactory results; the accuracy of the algorithms ranged from 76 to 79%, with the support vector machine classifier having the highest accuracy. In cases where the predictions of the five models were consistent, the accuracy of the PV diagnostic results was improved to 83%, whereas it increased to 85% for the non-PV diagnostic results. Future research should increase the number of patients and optimize the classification methods to obtain the highest diagnostic accuracy.

The Vestibular/Ocular Motor Screening-Child (VOMS-C) tool for concussion evaluation in 5- to 9-year-old pediatric patients: preliminary evidence

OBJECTIVE

Vestibular and ocular motor dysfunction occurs in an estimated 60%-90% of concussion patients. The Vestibular/Ocular Motor Screening (VOMS) tool is validated for use in concussion patients older than 9 years. The goal of the current study was to adapt the current VOMS tool for a pediatric sample of children aged 5-9 years and establish its clinical utility in this patient population.

METHODS

In this case-control study, 80 symptomatic concussion patients (n = 33 [41%] female) aged 5-9 years (mean age 7.40 ± 1.09 years) and 40 (n = 18 [45%] female) age- and sex-matched uninjured controls (mean age 7.10 ± 1.26 years) completed the VOMS-Child (VOMS-C), a version of the VOMS adapted for younger patients. Differences in binary "yes" or "no" symptom provocation for headache, dizziness, and nausea/"tummy ache" across the 7 items of the VOMS-C, and near point of convergence (NPC) distance, were examined. Logistic regression (LR) models were built to classify concussion and controls. Predicted probabilities were generated from the LR model and entered into receiver operating characteristic (ROC) curve models to generate area under the curve (AUC) values.

RESULTS

VOMS-C item provocation ranged from 13% to 30% for concussed patients and 3% to 20% for controls. The LR model distinguished concussed participants from controls (R2 = 0.39; p < 0.001), with significant predictors being smooth pursuits, family depression history, and NPC distance. The ROC analysis had an AUC of 0.81 (95% CI 0.73-0.89; p < 0.001) in the good range.

CONCLUSIONS

Accurate diagnosis of concussion in the clinic setting requires comprehensive evaluation in multiple domains, including detailed clinical interview, neurocognitive testing, and vestibular/ocular motor assessment, regardless of patient age. Our results provide preliminary support for the VOMS-C as a developmentally appropriate tool for concussion management.

Automatic ML-based vestibular gait classification: examining the effects of IMU placement and gait task selection

BACKGROUND

Vestibular deficits can impair an individual's ability to maintain postural and/or gaze stability. Characterizing gait abnormalities among individuals affected by vestibular deficits could help identify patients at high risk of falling and inform rehabilitation programs. Commonly used gait assessment tools rely on simple measures such as timing and visual observations of path deviations by clinicians. These simple measures may not capture subtle changes in gait kinematics. Therefore, we investigated the use of wearable inertial measurement units (IMUs) and machine learning (ML) approaches to automatically discriminate between gait patterns of individuals with vestibular deficits and age-matched controls. The goal of this study was to examine the effects of IMU placement and gait task selection on the performance of automatic vestibular gait classifiers.

METHODS

Thirty study participants (15 with vestibular deficits and 15 age-matched controls) participated in a single-session gait study during which they performed seven gait tasks while donning a full-body set of IMUs. Classification performance was reported in terms of area under the receiver operating characteristic curve (AUROC) scores for Random Forest models trained on data from each IMU placement for each gait task.

RESULTS

Several models were able to classify vestibular gait better than random (AUROC > 0.5), but their performance varied according to IMU placement and gait task selection. Results indicated that a single IMU placed on the left arm when walking with eyes closed resulted in the highest AUROC score for a single IMU (AUROC = 0.88 [0.84, 0.89]). Feature permutation results indicated that participants with vestibular deficits reduced their arm swing compared to age-matched controls while they walked with eyes closed.

CONCLUSIONS

These findings highlighted differences in upper extremity kinematics during walking with eyes closed that were characteristic of vestibular deficits and showed evidence of the discriminative ability of IMU-based automated screening for vestibular deficits. Further research should explore the mechanisms driving arm swing differences in the vestibular population.

[The occurrence and evaluation methods of horizontal semicircular canal dysfunction in patients with common vestibular diseases]

Objective:To understand the occurrence of horizontal semicircular canal functional impairment in patients with common vestibular diseases and to explore the characteristics and clinical value of different evaluation methods of horizontal semicircular canal. Methods:From July 2013 to December 2016, patients who attended the vertigo clinic of the First Affiliated Hospital of Dalian Medical University and completed more than three horizontal semicircular canal function tests were retrospectively analyzed. A total of 396 patients diagnosed as vestibular migraine （VM）, Ménière's disease （MD）, benign paroxysmal positional vertigo （BPPV）, vestibular neuritis （VN） and 104 patients with unknown diagnosis were enrolled. The results of caloric test （CT）, rotation test （RT）, head-shaking nystagmus test （HSN） and video head impulse test （vHIT） were collected and the abnormal detection rates of different detection methods were calculated. The sensitivity, specificity and coincidence rate of various detection methods were statistically analyzed using CT as the gold standard. Results:①The abnormal rates of the four evaluation methods from high to low were HSN, CT, RT, vHIT （51.20%, 50.80%, 25.76%, 19.74%, respectively）; ②Taking CT as the gold standard, among these four common vestibular diseases, the sensitivity and specificity of vHIT were 0.13-0.41 and 0.69-1.00, the sensitivity and specificity of HSN were 0.44-0.76 and 0.29-0.69, and the sensitivity and specificity of RT were 0.25-0.45 and 0.50-0.84;③According to statistical analysis, only HSN and CT results showed no statistically significant difference in the 4 diseases. There was no significant difference between RT and CT in VM and BPPV, and vHIT and CT in BPPV. Conclusion:The abnormal rate of HSN results in common vestibular diseases is highest, and it could be recommended as a routine vestibular function screening item. The specificity of vHIT is highest and worthy of promotion. CT is still an irreplaceable method to evaluate the function of horizontal semicircular canal.

Immediate Improvement in Subjective Visual Vertical and Disequilibrium Predicts Resolution of Benign Paroxysmal Positional Vertigo Following Single Canalith Repositioning Maneuver

Objective

To evaluate whether immediate post-canalith repositioning maneuver (CRM) vestibular changes are predictive of benign paroxysmal positional vertigo (BPPV) resolution.

Study Design

Retrospective cohort study.

Setting

Tertiary referral center.

Patients

Adults (n = 27) with posterior canal BPPV.

Interventions

Single CRM with Frenzel goggles.

Main Outcome Measures

The Visual Analog Scale (VAS) for disequilibrium, the subjective visual vertical (SVV), the subjective visual horizontal (SVH), and the Modified Clinical Test of Sensory Interaction on Balance (mCTSIB) were administered pre- and immediately following single CRM. Dix-Hallpike was performed 1-3 weeks after CRM to assess for BPPV resolution. Pre- and post-treatment vestibular assessments were compared between groups to determine if post-CRM vestibular changes could predict BPPV resolution.

Results

The change in VAS score following CRM treatment was statistically different between patients who responded to CRM treatment (n = 15) and those who did not (n = 12), (-0.07 points versus -2.40 points, respectively; P = 0.03). Likewise, a significantly greater improvement in SVV score was observed for CRM responders compared with CRM nonresponders (0.92° versus -0.06°, respectively; P = 0.02). Change in SVH and mCTSIB scores did not differ significantly between groups. Additionally, patient age was found to predict outcome of CRM treatment, with older patients more likely to experience persistent BPPV (P ≤ 0.01).

Conclusions

Immediate improvement in VAS and SVV scores following CRM may be useful in predicting resolution of BPPV and may assist in directing the timing and need for future interventions. Younger age may have a favorable predictive value for improvement following single CRM.

The Relationship between Meniere's Disease and Acute Low-Tone Sensorineural Hearing Loss

Objective

To analyse the vestibular function characteristics of patients with Meniere's disease and acute hypophonic sensorineural hearing loss in order to find more reliable and objective ancillary tests that will reduce misdiagnosis and missed diagnoses.

Methods

From January 2021 to December 2021, 60 healthy adults who underwent physical examination in our hospital were included in the control group, 60 patients with Meniere's disease were included in Study Group A, and 60 patients with acute low-tone sensorineural hearing loss were recruited in Study Group B. All participants underwent the caloric test (CT), video-head impulse test (vHIT), headshaking test (HST), and vestibular-evoked myogenic potential (VEMP) testing, which includes ocular vestibular-evoked myogenic potential (oVEMP) and cervical vestibular-evoked myogenic potential (cVEMP).

Results

Statistical analyses of unilateral weakness and directional preponderance (DP) in the two groups of patients found no significant differences between the two groups (P > 0.05). There was no statistically significant difference in the abnormal rate of vHIT and HST results between the two study groups (P > 0.05). There was no significant difference in the wave latencies, interwave intervals, and amplitudes of cVEMP and oVEMP, among the three groups (P > 0.05).

Conclusion

This study found that factors affecting CT, vHIT, HST, and VEMP results included age, head posture and position during testing, stimulus type, manipulation method, and control of muscle tone, and also those that are related to the testing instrument, statistical software, and manipulation procedures, resulting in different excitation rates and testing parameters. The small sample size prevented a comprehensive assessment of the differences in vestibular function between patients with Meniere's disease and acute hypotonic sensorineural hearing loss, and a larger sample size will be investigated in the future to provide useful insight into the diagnosis, treatment and differentiation of Meniere's disease, and acute hypotonic sensorineural hearing loss.

Validity and Reliability of Smartphone App for Evaluating Postural Adjustments during Step Initiation

The evaluation of anticipatory postural adjustments (APAs) requires high-cost and complex handling systems, only available at research laboratories. New alternative methods are being developed in this field, on the other hand, to solve this issue and allow applicability in clinic, sport and hospital environments. The objective of this study was to validate an app for mobile devices to measure the APAs during gait initiation by comparing the signals obtained from cell phones using the Momentum app with measurements made by a kinematic system. The center-of-mass accelerations of a total of 20 healthy subjects were measured by the above app, which read the inertial sensors of the smartphones, and by kinematics, with a reflective marker positioned on their lumbar spine. The subjects took a step forward after hearing a command from an experimenter. The variables of the anticipatory phase, prior to the heel-off and the step phase, were measured. In the anticipatory phase, the linear correlation of all variables measured by the two measurement techniques was significant and indicated a high correlation between the devices (APAonset: r = 0.95, p < 0.0001; APAamp: r = 0.71, p = 0.003, and PEAKtime: r = 0.95, p < 0.0001). The linear correlation between the two measurement techniques for the step phase variables measured by ques was also significant (STEPinterval: r = 0.56, p = 0.008; STEPpeak1: r = 0.79, p < 0.0001; and STEPpeak2: r = 0.64, p < 0.0001). The Bland−Altman graphs indicated agreement between instruments with similar behavior as well as subjects within confidence limits and low dispersion. Thus, using the Momentum cell phone application is valid for the assessment of APAs during gait initiation compared to the gold standard instrument (kinematics), proving to be a useful, less complex, and less costly alternative for the assessment of healthy individuals.

Acoustic Environmental Conditions (Do Not?) Affect the Static Posturography Diagnostic Accuracy: A Test-Retest Reliability Study

Static posturography assessed with force platforms is a procedure used to obtain objective estimates related to postural adjustments. However, controlling multiple intrinsic and extrinsic factors influencing the diagnostic accuracy is essential to obtain reliable measurements and recommend its use with clinical or research purposes. We aimed to analyze how different environmental acoustic conditions affect the test−retest reliability and to analyze the most appropriate number of trials to calculate a valid mean average score. A diagnostic accuracy study was conducted enrolling 27 healthy volunteers. All procedures were taken considering consistent device settings, posture, feet position, recording time, and illumination of the room. Three trials were recorded in a silent environment (35−40 dB) and three trials were recorded in a noisy environment (85−90 dB). Results showed comparable reliability estimates for both acoustic conditions (ICC = 0.453−0.962 and 0.621−0.952), but silent conditions demonstrated better sensitivity to changes (MDC = 13.6−76%). Mean average calculations from 2 and 3 trials showed no statistically significant differences (p > 0.05). Cross-sectional studies can be conducted under noisy or silent conditions as no significantly different scores were obtained (p > 0.05) and ICC were comparable (except oscillation area). However, longitudinal studies should consider silent conditions as they demonstrated better sensitivity to real changes not derived from measurement errors.

Utility of the Novel MediPost Mobile Posturography Device in the Assessment of Patients with a Unilateral Vestibular Disorder

Balance disorders are a growing problem worldwide. Thus, there is an increasing need to provide an inexpensive and feasible alternative to standard posturographic platforms (SP) used for the assessment of balance and to provide a possible solution for telemonitoring of patients. A novel mobile posturography (MP) MediPost device was developed to address these issues. This prospective study used a Modified Clinical Test of Sensory Interaction on Balance to evaluate healthy individuals and patients with a unilateral vestibular disorder through SP and MP simultaneously. The control group included 65 healthy volunteers, while the study group included 38 patients diagnosed with a unilateral vestibular deficit. The angular velocity values obtained from both methods were compared by intraclass correlation coefficients (ICC) and Bland−Altman plot analysis. Diagnostic capabilities were measured in terms of sensitivity and specificity. The ICC between the two methods for conditions 2−4 was indicative of excellent reliability, with the ICC > 0.9 (p < 0.001), except for Condition 1 (standing stance, eyes open) ICC = 0.685, p < 0.001, which is indicative of moderate reliability. ROC curve analysis of angular velocity for condition 4 represents the most accurate differentiating factor with AUC values of 0.939 for SP and 0.953 for MP. This condition also reported the highest sensitivity, specificity, PPV, and NPV values with 86.4%, 87.7%, 80%, and 90.5% for SP, and 92.1%, 84.6%, 77.8%, and 94.8% for MP, respectively. The newly developed MediPost device has high sensitivity and specificity in distinguishing between healthy individuals and patients with a unilateral vestibular deficit.

The Fukuda Stepping Test Is Influenced by a Concurrent Cognitive Task and Step Height in Healthy Young Adults: A Descriptive Study

Purpose: The Fukuda stepping test assesses spatial orientation in people with vestibular disorders. To standardize the test, it is important to know which factors influence the outcome. This study investigated the impact of two factors, a concurrent cognitive task and step height, on the Fukuda stepping test in healthy individuals. Method: A total of 16 young adults participated and completed 20 trials of the 50-step Fukuda stepping test in four conditions: comfortable and high step height and with and without a cognitive task. Body kinematics were collected using the three-dimensional motion analysis Vicon system. The cognitive task was to listen to a sequence of three-digit numbers and identify the total number of times that one pre-determined digit was presented. Results: All participants slowly turned and drifted forward during the test. The concurrent cognitive task yielded significantly shorter forward displacement and lateral deviation and lower stepping height, and high stepping produced significantly greater body rotation and lateral deviation. Conclusions: Performance on the Fukuda stepping test in healthy young individuals is influenced by a concurrent cognitive task and by step height. Clinicians and researchers must instruct people to use a comfortable step height during the test, and they must be aware that a concurrent cognitive task may improve test performance, at least among young adults.

Passive stretching decreases muscle efficiency in balance tasks

The current study aimed to verify whether or not passive static stretching affects balance control capacity. Thirty-eight participants (19 women and 19 men) underwent a passive static stretching session, involving the knee extensor/flexor and dorsi/plantarflexor muscles, and a control session (no stretching, CTRL). Before (PRE), immediately after (POST), after 15 (POST15) and 30 min (POST30) from stretching (or rest in CTRL), balance control was evaluated under static and dynamic conditions, with open/closed eyes, and with/without somatosensory perturbation (foam under the feet). During tests, centre of pressure (CoP) sway area and perimeter and antero-posterior and medio-lateral sway mean speed were computed. Surface electromyography root mean square (sEMG RMS) was calculated from the vastus lateralis, biceps femoris, gastrocnemius medialis, and tibialis anterior muscles during MVC and during the balance tests. Hip flexion/extension and dorsi/plantarflexion range of motion (ROM), maximum voluntary contraction (MVC) and sEMG RMS during MVC were measured at the same time points. After stretching, ROM increased (≈6.5%; P<0.05), while MVC and sEMG RMS decreased (≈9% and ≈7.5%, respectively; P<0.05). Regardless of the testing condition, CoP sway area and the perimeter remained similar, while antero-posterior and medio-lateral sway mean speed decreased by ≈8% and ≈12%, respectively (P<0.05). sEMG RMS during the balance tests increased in all muscles in POST (≈7%, P<0.05). All variables recovered in POST30. No changes occurred in CTRL. Passive static stretching did not affect the overall balance control ability. However, greater muscle activation was required to maintain similar CoP sway, thus suggesting a decrease in muscle efficiency.

Age-Related Changes in the Cochlea and Vestibule: Shared Patterns and Processes

Both age-related hearing loss (ARHL) and age-related loss in vestibular function (ARVL) are prevalent conditions with deleterious consequences on the health and quality of life. Age-related changes in the inner ear are key contributors to both conditions. The auditory and vestibular systems rely on a shared sensory organ - the inner ear - and, like other sensory organs, the inner ear is susceptible to the effects of aging. Despite involvement of the same sensory structure, ARHL and ARVL are often considered separately. Insight essential for the development of improved diagnostics and treatments for both ARHL and ARVL can be gained by careful examination of their shared and unique pathophysiology in the auditory and vestibular end organs of the inner ear. To this end, this review begins by comparing the prevalence patterns of ARHL and ARVL. Next, the normal and age-related changes in the structure and function of the auditory and vestibular end organs are compared. Then, the contributions of various molecular mechanisms, notably inflammaging, oxidative stress, and genetic factors, are evaluated as possible common culprits that interrelate pathophysiology in the cochlea and vestibular end organs as part of ARHL and ARVL. A careful comparison of these changes reveals that the patterns of pathophysiology show similarities but also differences both between the cochlea and vestibular end organs and among the vestibular end organs. Future progress will depend on the development and application of new research strategies and the integrated investigation of ARHL and ARVL using both clinical and animal models.

Effect of Dual Task on Step Variability during Stepping in Place without Vision

Stepping in place without vision is a spatial orientation task that is associated with unperceived foot displacements. This study was aimed at determining whether foot displacement variability is modified by a concurrent cognitive task. Fourteen young adults stepped for 50 steps with their vision blocked and performed a continuous mental counting task. 3-D Kinematic data from both feet (heel and big toe) was recorded. The variability of foot displacements was either unchanged or slightly lower in dual task, while the foot displacements were significantly shorter (p < 0.05) in dual task than without the cognitive task. The results suggest that the concurrent cognitive task might have allowed a better control of the repetitive lower limb movements.

Visual and Vestibular Impairment and Idiopathic Scoliosis – are They Related?

Scoliosis is a tri-dimensional lateral curvature of the spine of 10° or more, with a rotational component. The most common form of scoliosis in the population is adolescent idiopathic scoliosis (AIS). As its name states, it has no known direct cause, even if, over time some evidence for multiple linked causes has been provided

There is some evidence accumulated pointing to an association between AIS and posture control, where vision and vestibular systems are both involved

We analysed the links between the curvature of the spine, its evolution and possible visual and vestibular impairment on 44 children with scoliosis.

A postural aetiology of scoliosis in the visually and vestibular impaired population could be implied, since all the cases that could be defined as scoliosis and not as a scoliotic attitude (Cobb > 10º) were positive for the Fukuda Stepping Test and more than 60% of the patients that had a Cobb angle value higher than 15º had a type of visual impairment (myopia).

Perspectives: Evaluation of Older Adult Cochlear Implant Candidates for Fall Risk in a Developing Country Setting

Dizziness, vertigo, and falls are common in older adults. Data suggest that cochlear implant candidates are no different and could be argued to be at elevated risk due to the presence of hearing loss and likely vestibular involvement. Perspectives contextualizes current testing and screening paradigms for vestibular deficits and fall risk and suggests a protocol suitable for use in developing country settings.

Normal values for cervical and ocular vestibular-evoked myogenic potentials using EMG scaling: effect of body position and electrode montage

BACKGROUND

The clinical utility of cervical and ocular vestibular-evoked myogenic potential (cVEMP and oVEMP) is limited by variability of testing protocols and a dearth of normative data using contemporary methods for amplitude scaling.

AIMS/OBJECTIVES

To investigate the effect of body position and electrode montage on VEMP responses and to establish normative values.

MATERIAL AND METHODS

This is a repeated measures study of 44 healthy young adult subjects (22 men and 22 women).

RESULTS

The highest response rate (99%) for cVEMP was achieved in the supine position with the head elevated and turned. For oVEMP, the highest response rate (90%) was achieved using nasal alar electrode montage with the subject in a sitting position. Scaled peak-to-peak amplitude was higher in males than in females for both cVEMP and oVEMP.

CONCLUSION

Normative data for 44 young healthy adults was successfully collected for two body positions for cVEMP and two head positions and two electrode montages for oVEMP.

SIGNIFICANCE

Our findings describe VEMP protocols that efficiently detect VEMP responses, and we provide normative VEMP response data for young healthy subjects. We describe a potential difference in response between males and females, which may be clinically important.

Vestibular Impairments on Objective Diagnostic Tests in HIV+ Women and Control Men and Women

OBJECTIVE

To describe the value of two vestibular test batteries across ages in healthy men and women for detecting vestibular disorders and to compare the occurrence of vestibular disorders in the healthy adult population and women with human immunodeficiency virus (HIV) disease.

STUDY DESIGN

Two groups were tested on the battery of objective diagnostic tests of the vestibular system.

SETTING

Two tertiary care centers.

SUBJECTS

Healthy controls (284 women and 105 men) and women (63) with HIV/AIDS (HIV+) who are being followed up in a longitudinal study of HIV. They were tested on objective diagnostic tests of the vestibular system.

RESULTS

In all age decades, healthy controls had evidence of vestibular impairment, significantly more in older adults. HIV+ subjects, all females, did not differ from healthy control females.

CONCLUSION

These data suggest that at all ages, people do have decreased vestibular function, even young, asymptomatic, and apparently healthy adults. HIV disease, itself, does not cause an increased prevalence of peripheral vestibular disorders when HIV is controlled on antiretroviral medication.

LEVEL OF EVIDENCE

2 Laryngoscope, 131:E2318-E2322, 2021.

Co-morbidities to Vestibular Impairments-Some Concomitant Disorders in Young and Older Adults

Background: Dizziness and pain are common complaints that often appear concomitantly, with or without a causal relationship. However, these symptoms might maintain and exacerbate each other and other co-morbidities. Therefore, adequate rehabilitation may have to include an expanded focus on other deficits and preconditions, especially in older adults and in patients. Objective: To understand how frequently vestibular dysfunction coincided with medical conditions and aging, we studied two categories: Study 1: patients referred to a vestibular unit and Study 2: senior members in a fitness association. Method: Study 1: 49 patients [34 females/15 males; mean age 52 years (SEM 2.0)] seeking health care for balance disorders and vestibular deficits were asked in questionnaires about their perception of dizziness and pain, and emotional and functional strains. Study 2: 101 senior members in a fitness association [91 females/10 males; mean age 75 years (SEM 0.6)], were assessed for vestibular and balance deficits and for any co-morbidities. The participants were monitored for falls for 12 months after the initial assessments. Result: Study 1: Co-morbidity often existed between dizziness and pain (65%). The patients reported high emotional and functional strain related to their dizziness and pain. Patients older than 60 years reported longer durations of pain (p ≤ 0.028) but less emotional strain (p = 0.036), compared to younger patients. Study 2: 84% of the participants had a vestibular impairment, often without noticing any symptoms. Furthermore, 40% reported cardiovascular illnesses, 12% musculoskeletal disorders, and 63% reported other medical conditions. Forty-two percent experienced falls within 1 year after the initial assessments (thereof 42% in the group with vestibular deficits and 38% in the group without vestibular deficits). Conclusion: To enhance and preserve postural control, both in patients with vestibular deficits and in older adults, we suggest an expanded clinical perspective. Hence, we recommend detailed examinations of the vestibular system but simultaneously probing for possible co-morbidities. Since aging often entails deterioration of multimodal processes related to maintained mobility and postural stability, our results add focus on the importance of addressing balance disorders together with additional medical conditions.

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

OBJECTIVE

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

DESIGN

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

SETTING

Ambulatory clinic, tertiary referral center.

PARTICIPANTS

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

MAIN OUTCOME AND MEASURE(S)

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

RESULTS

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

CONCLUSIONS AND RELEVANCE

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

Functional Gait Assessment scale in the rehabilitation of patients after vestibular tumor surgery in an acute hospital

BACKGROUND

Patients in the acute phase of rehabilitation after vestibular tumor surgery are dysfunctional in basic daily activities. Balance, gait impairments, and falls are prevalent with vestibular loss.

AIM

To determine the degree of balance disorders after vestibular tumor surgery, the susceptibility to falls and to assess motor tasks using the Functional Gait Assessment (FGA) scale for functional gait, as part of the vestibular rehabilitation program during hospital stay.

METHODS

Patients who achieved a score higher than 25 points on the Mini-Mental State Examination and higher than 8 points on the Barthel index were included in the study. They were evaluated with the Berg Balance Scale the second day after surgery, during their hospital stay, at discharge, and three months after surgery. Throughout their hospitalization, patients took part in the vestibular rehabilitation program, focusing on multiple motor tasks included in the FGA.

RESULTS

All patients progressed clinically and statistically significant differences in functional activities of daily living were observed during hospitalization, before discharge to the home environment (median = 11; P = 0.0059) and three months after vestibular tumor surgery (median = 8; P = 0.0058). After discharge from hospital, four patients were at risk of falls, and two patients were at risk at three months.

CONCLUSION

Our study showed a positive effect of the use of FGA tasks as part of a rehabilitation program on functional activities of daily living in patients after vestibular tumor surgery. Nevertheless, we suggest further research to include a larger sample and a control group to overcome the deficiencies of our study.

Internal Carotid Artery Dissection Presenting as Partial Horner's Syndrome and Vertigo

Distinguishing between central and peripheral causes of vertigo can be challenging not only in an acute setting but also in chronic settings. A thorough review of systems and physical exam can assist providers in differentiating central versus peripheral etiologies and the need for urgent imaging. In this case, a 47-year-old man presented with vertigo, right-sided hearing loss, right-sided headache, and right-sided facial pain that began 4 weeks before while the patient was on a cruise ship. His physical exam findings were notable for anisocoria with right pupil 3.5 and left pupil 4.5, mild ptosis on the right side, positive Romberg test to the right, and Fakuda test with deviation to the right. Urgent magnetic resonance imaging revealed dissection of the right cervical internal carotid artery with a nonocclusive intramural hematoma. This case illustrates the importance of imaging in vertigo patients in which a central etiology is suspected. It further demonstrates that isolated partial Horner's or unilateral headache may indeed be the only presenting sign in a carotid dissection.

Clinical Balance Testing to Screen for Patients With Vestibular Disorders: A Retrospective Case-control Study

OBJECTIVE

Identify clinical screening tests to proficiently screen for patients with vestibular disorders.

STUDY DESIGN

Retrospective case-control study.

SETTING

Tertiary referral center.

PATIENTS

318 healthy individuals and 331 subjects with vestibular disorders.

INTERVENTIONS

All subjects performed Romberg and Jendrassic maneuver with eyes closed (ROMJec), standing on foam with eyes open (SOFeo) and eyes closed (SOFec), Tandem Romberg with eyes open (TReo) and eyes closed (TRec), single leg stance with eyes open (SLSeo) and eyes closed (SLSec), Tandem gait (TG) and Timed Up and Go (TUG).

MAIN OUTCOME MEASURES

Significant differences in performance on the balance tests.

RESULTS

For the age-group <40 years, TUG >6 seconds (OR 102.4; p <0.0001) and SLSec <30 seconds (OR 48.0; p <0.0001) proved to be the most predictive combination of testing (AUC 0.9; LR+ 15.8; LR- 0.2), with a positive predictive value (PPV) of 88.4%. For the age-group 40-60, TUG >7 seconds (OR 4.0; p = 0.0107) and TRec <30 seconds (OR 63.1; p < 0.0001) was the most predictive combination of tests (AUC 0.9 LR+ 6.0; LR- 0.1), with a PPV of 93.8%. For the age-group >60 the combination of TUG >8 seconds (OR 17.4; p < 0.0001) and SOFec <30 seconds (OR 10.4; p < 0.0001) was the most predictive (AUC 0.9 LR+ 6.3; LR- 0.2), with a PPV of 84.8%.

CONCLUSIONS

Combinations of clinical tests are proposed to promptly screen for vestibular disorders in specific age groups. To interpret the results for the individual patient, the physician must take the history and the general examination into consideration.

Quantitative Evaluation of a New Posturo-Locomotor Phenotype in a Rodent Model of Acute Unilateral Vestibulopathy

Vestibular pathologies are difficult to diagnose. Existing devices make it possible to quantify and follow the evolution of posturo-locomotor symptoms following vestibular loss in static conditions. However, today, there are no diagnostic tools allowing the quantitative and spontaneous analysis of these symptoms in dynamic situations. With this in mind, we used an open-field video tracking test aiming at identifying specific posturo-locomotor markers in a rodent model of vestibular pathology. Using Ethovision XT 14 software (Noldus), we identified and quantified several behavioral parameters typical of unilateral vestibular lesions in a rat model of vestibular pathology. The unilateral vestibular neurectomy (UVN) rat model reproduces the symptoms of acute unilateral peripheral vestibulopathy in humans. Our data show deficits in locomotion velocity, distance traveled and animal mobility in the first day after the injury. We also highlighted alterations in several parameters, such as head and body acceleration, locomotor pattern, and position of the body, as well as “circling” behavior after vestibular loss. Here, we provide an enriched posturo-locomotor phenotype specific to full and irreversible unilateral vestibular loss. This test helps to strengthen the quantitative evaluation of vestibular disorders in unilateral vestibular lesion rat model. It may also be useful for testing pharmacological compounds promoting the restoration of balance. Transfer of these novel evaluation parameters to human pathology may improve the diagnosis of acute unilateral vestibulopathies and could better follow the evolution of the symptoms upon pharmacological and physical rehabilitation.

Is postural dysfunction related to sarcopenia? A population-based study

Postural dysfunction is one of the most common community health symptoms and frequent chief complaints in hospitals. Sarcopenia is a syndrome characterized by degenerative loss of skeletal muscle mass, muscle quality, and muscle strength, and is the main contributor to musculoskeletal impairment in the elderly. Previous studies reported that loss of muscle mass is associated with a loss of diverse functional abilities. Meanwhile, there have been limited studies concerning postural dysfunction among older adults with sarcopenia. Although sarcopenia is primarily a disease of the elderly, its development may be associated with conditions that are not exclusively seen in older persons. Also, recent studies recognize that sarcopenia may begin to develop earlier in life. The objective of this paper was to investigate the association between the prevalence of sarcopenia and postural dysfunction in a wide age range of adults using data from a nationally representative cohort study in Korea. Korean National Health & Nutrition Exhibition Survey V (KNHANES V, 2010–2012) data from the fifth cross-sectional survey of the South Korean population performed by the Korean Ministry of Health and Welfare were used. Appendicular skeletal muscle mass (ASM)/height (ht)² was used to define sarcopenia, and the Modified Romberg test using a foam pad (“foam balance test”) was performed to evaluate postural dysfunction. ASM/ht² was lower in women and significantly decreased with age in men. Subjects with sarcopenia were significantly more likely to fail the foam balance test, regardless of sex and age. Regression analysis showed a significant relationship between sarcopenia and postural dysfunction (OR: 2.544, 95% CI: 1.683–3.846, p<0.001). Multivariate regression analysis revealed that sarcopenia (OR: 1.747, 95% CI: 1.120–2.720, p = 0.014) and age (OR: 1.131, 95% CI: 1.105–1.158, p<0.001) are independent risk factors for postural instability. In middle age subjects, the adjusted OR for sarcopenia was 3.344 (95% CI: 1.350–8.285) (p = 0.009). The prevalence of postural dysfunction is higher in sarcopenia patients, independent of sex and age.

Impaired Balance in Patients with Fibromyalgia Syndrome: Predictors of the Impact of This Disorder and Balance Confidence

Patients with fibromyalgia syndrome (FMS) have a nonspecific postural balance disorder and a greater prevalence of falls. Objective: to clarify which aspects of maintaining balance are associated with the impact of the disorder and with balance confidence. Methods: A total of 182 persons with FMS agreed to participate in this study. After re-evaluation, 57 fully met inclusion criteria: age 40–70 years and moderate-severe impact of the illness according to the Fibromyalgia Impact Questionnaire (FIQ). All participants underwent a posture control analysis with a stabilometric platform, an evaluation of the perception of verticality and an exploration of the vestibular system via functional tests. Additionally, they self-completed questionnaires about balance confidence, central sensitization, pain catastrophizing, kinesiophobia, dizziness and days with episodes of instability. Results: The FIQ was associated with central sensitization and dizziness, which explained 56% of its variance (AdjR2 = 0.566), while days with instability, kinesiophobia and dizziness also explained more than half of the variance of the balance confidence scale (AdjR2 = 0.527). A high percentage of positive responses was found for functional tests (>50%) and a high dispersion in the stabilometric parameters. Conclusion: the detection of factors susceptible to intervention, such as disability due to dizziness, takes on special relevance in patients with FMS.