Measurement properties of the Dizziness Handicap Inventory by cross-sectional and longitudinal designs

Predictors of Chronic Dizziness in Acute Unilateral Vestibulopathy: A Longitudinal Prospective Cohort Study

OBJECTIVE

Chronic dizziness after acute unilateral vestibulopathy (AUVP) causes significant social and economic burdens. This study aims to identify predictors of chronic dizziness.

STUDY DESIGN

Prospective, longitudinal cohort study.

SETTING

ENT departments from secondary and tertiary hospitals.

METHODS

Participants meeting the Barany Society's diagnostic criteria for AUVP were included. Evaluations occurred within 0 to 21 days (T1), and at 4 (T2) and 10 weeks (T3) postonset. The primary outcome measure was the Dizziness Handicap Inventory (DHI) at 6 months, with a score >30 indicating chronic dizziness. Five clusters of predictors were assessed at T1-3: central vestibular compensation, visual dependence, movement exposure, psychological factors, and balance performance. Separate linear regression models for T1, T2, and T3 were constructed to explain the variability in the 6-month DHI score. Receiver operating characteristics analyses were conducted to predict chronic dizziness.

RESULTS

From June 2021 to January 2024, 103 participants (55.2 ± 16.6 years old, 49 women) were included. The regression models explained the variability in the 6-month DHI score by 33.0% at T1, 47.6% at T2, and 64.0% at T3 (P < .001), including psychological factors (T1, T2, T3), visual dependence (T2, T3), and static balance performance (T3). Cutoff values for the Vestibular Activities Avoidance Instrument (23/54), Visual Vertigo Analog Scale (33.5/100), and Hospital Anxiety and Depression Scale-Anxiety (7.5/21) at 10 weeks postonset predicted chronic dizziness.

CONCLUSION

Higher psychological burden, increased visual dependence, and poorer static balance performance were associated with chronic dizziness. Cutoff values were determined to identify individuals with AUVP at risk for chronic dizziness.

Psychometric Properties and Concurrent Validity of a 10-Item Questionnaire for Patients With Vestibular Disorders

OBJECTIVE

This study aimed to investigate the psychometric properties and concurrent validity of the Haukeland Dizziness Questionnaire (HDQ-10), a 10-item questionnaire designed for simplified assessment of symptom severity and emotional effects in patients with vestibular disorders.

STUDY DESIGN

Cross-sectional study.

SETTING

Secondary referral hospital.

METHODS

Out of 238 consecutive patients examined for suspected vestibular disease at an otolaryngology clinic, 201 completed the questionnaire. The psychometric properties of the HDQ-10 were examined by exploratory factor analysis and analysis of internal consistency. Concurrent validity was determined in comparison with the Dizziness Handicap Inventory (DHI), Vertigo Symptom Scale-Short Form (VSS-SF), and the Hospital Anxiety and Depression Scale.

RESULTS

The factor analysis revealed 3 subscales of the questionnaire covering "function," "unsteadiness," and "emotion." The examination of the total scale (α = .866) and its subscales indicated satisfactory psychometric properties. The HDQ-10 correlated highly with both DHI (r = .732. P < .001) and VSS-SF (r = .720. P < .001) indicating good concurrent validity.

CONCLUSION

The HDQ-10 is a 10-item questionnaire designed for simplified assessment of symptom severity and emotional effects in patients with vestibular disorders. It has satisfactory psychometric properties and good concurrent validity compared to existing dizziness questionnaires.

Walking and balance in older adults with age-related hearing loss: A cross-sectional study of cases and matched controls

BACKGROUND

Hearing loss (HL) is prevalent in older individuals. It is suggested that there is an association between age-related HL, walking and balance, leading to poorer function and increased risk of falls in older individuals.

RESEARCH QUESTION

Is HL associated with physical performance, gait variability, and postural sway in older adults, and will additional dizziness moderate the effect of HL on balance?

METHODS

In this cross-sectional study we examined 100 older individuals (age ≥70 years, 60 % females), divided in two groups, with or without age-related HL. Physical function and balance were evaluated by the Short Physical Performance Battery (SPPB), postural sway measured on a force platform (posturography), and balance in walking (gait variability) measured with a body-worn sensor. Multiple linear regression was used to examine the relationships between the variables, with physical function and balance as outcomes and HL as a dichotomous exposure (>30 dB). For all analyses, we further tested if associations were modified by self-reported dizziness.

RESULTS

Multiple regression analysis with HL, age, sex, education, diabetes, and cardiovascular disease revealed a significant association between reduced SPPB and HL. Multiple linear regression analysis also showed that HL was associated with increased postural sway on firm surface with eyes open and closed after adjusting for age, sex, education, diabetes, and cardiovascular disease. There was significant association between HL and increased gait variability during dual task walking in all directions after adjusting for age, sex, education, diabetes, and cardiovascular disease. Further, we found that the association between HL and SPPB was significantly stronger in those with dizziness compared with those without dizziness. Dizziness also modified the association of HL with the other SPPB sub-scores but not for the other outcomes of postural sway or gait variability.

SIGNIFICANCE

In this study, age-related HL was associated with worse physical performance as measured by SPPB, postural sway, and gait variability. This relationship illustrates the importance of assessing physical performance in people with HL to prevent risk of falls and disability.

Long-Term Epidural Patching Outcomes and Predictors of Benefit in Patients With Suspected CSF Leak Nonconforming to ICHD-3 Criteria

BACKGROUND AND OBJECTIVES

Spinal CSF leaks lead to spontaneous intracranial hypotension (SIH). While International Classification of Headache Disorders, Third Edition (ICHD-3) criteria necessitate imaging confirmation or low opening pressure (OP) for SIH diagnosis, their sensitivity may be limited. We offered epidural blood patches (EBPs) to patients with symptoms suggestive of SIH, with and without a documented low OP or confirmed leak on imaging. This study evaluates the efficacy of this strategy.

METHODS

We conducted a prospective cohort study with a nested case-control design including all patients who presented to a tertiary headache clinic with clinical symptoms of SIH who completed study measures both before and after receiving an EBP between August 2016 and November 2018.

RESULTS

The mean duration of symptoms was 8.7 ± 8.1 years. Of 85 patients assessed, 69 did not meet ICHD-3 criteria for SIH. At an average of 521 days after the initial EBP, this ICHD-3-negative subgroup experienced significant improvements in Patient-Reported Outcomes Measurement Information System (PROMIS) Global Physical Health score of +3.3 (95% CI 1.5-5.1), PROMIS Global Mental Health score of +1.8 (95% CI 0.0-3.5), Headache Impact Test (HIT)-6 head pain score of -3.8 (95% CI -5.7 to -1.8), Neck Disability Index of -4.8 (95% CI -9.0 to -0.6) and PROMIS Fatigue of -2.3 (95% CI -4.1 to -0.6). Fifty-four percent of ICHD-3-negative patients achieved clinically meaningful improvements in PROMIS Global Physical Health and 45% in HIT-6 scores. Pain relief following lying flat prior to treatment was strongly associated with sustained clinically meaningful improvement in global physical health at an average of 521 days (odds ratio 1.39, 95% CI 1.1-1.79; p < 0.003). ICHD-3-positive patients showed high rates of response and previously unreported, treatable levels of fatigue and cognitive deficits.

DISCUSSION

Patients who did not conform to the ICHD-3 criteria for SIH showed moderate rates of sustained, clinically meaningful improvements in global physical health, global mental health, neck pain, fatigue, and head pain after EBP therapy. Pre-treatment improvement in head pain when flat was associated with later, sustained improvement after EBP therapy among patients who did not meet the ICHD-3 criteria.

CLASSIFICATION OF EVIDENCE

This study provides Class IV evidence that epidural blood patch is an effective treatment of suspected CSF leak not conforming to ICHD-3 criteria for SIH.

The effect of neck-specific exercise and prescribed physical activity on headache and dizziness in individuals with cervical radiculopathy: Further analyses of a randomized study with a 1-year follow-up

OBJECTIVE

To evaluate the effect of neck-specific exercise (NSE) compared to prescribed physical activity (PPA) on headache and dizziness in individuals with cervical radiculopathy (CR). Also, to investigate associations between headache or dizziness and pain, neck muscle endurance (NME), neck mobility, physical activity, and fear avoidance beliefs.

METHODS

Individuals randomized to either NSE or PPA were selected to a headache subgroup (n = 59) and/or a dizziness subgroup (n = 73). Data were evaluated, according to headache and/or dizziness outcomes at baseline and at 3, 6, and 12-month follow-ups.

RESULTS

No significant between-group differences were found between NSE and PPA in either subgroup. In the headache subgroup, significant within-group improvements were seen at all follow-ups for NSE (p < .001) and from baseline to 3 (p = .037) and 12 (p = .003) months for PPA. For dizziness, significant within-group improvements were seen from baseline to 3 months for NSE (p = .021) and from baseline to 3 (p = .001) and 6 (p = .044) months for PPA. Multiple regression models showed significant associations at baseline between headache intensity and neck pain (adjusted R-square = 0.35, p < .001), and for dizziness with neck pain and dorsal NME (adjusted R-square = 0.34, p < .001).

CONCLUSION

NSE and PPA show similar improvements in headache intensity and dizziness in individuals with CR. Headache intensity is associated with neck pain, and dizziness with neck pain and dorsal NME, highlighting the importance of these factors when evaluating headache and dizziness.

Postural impairments in unilateral and bilateral vestibulopathy

Chronic imbalance is a major complaint of patients suffering from bilateral vestibulopathy (BV) and is often reported by patients with chronic unilateral vestibulopathy (UV), leading to increased risk of falling. We used the Central SensoriMotor Integration (CSMI) test, which evaluates sensory integration, time delay, and motor activation contributions to standing balance control, to determine whether CSMI measures could distinguish between healthy control (HC), UV, and BV subjects and to characterize vestibular, proprioceptive, and visual contributions expressed as sensory weights. We also hypothesized that sensory weight values would be associated with the results of vestibular assessments (vestibulo ocular reflex tests and Dizziness Handicap Inventory scores). Twenty HCs, 15 UVs and 17 BVs performed three CSMI conditions evoking sway in response to pseudorandom (1) surface tilts with eyes open or, (2) surface tilts with eyes closed, and (3) visual surround tilts. Proprioceptive weights were identified in surface tilt conditions and visual weights were identified in the visual tilt condition. BVs relied significantly more on proprioception. There was no overlap in proprioceptive weights between BV and HC subjects and minimal overlap between UV and BV subjects in the eyes-closed surface-tilt condition. Additionally, visual sensory weights were greater in BVs and were similarly able to distinguish BV from HC and UV subjects. We found no significant correlations between sensory weights and the results of vestibular assessments. Sensory weights from CSMI testing could provide a useful measure for diagnosing and for objectively evaluating the effectiveness of rehabilitation efforts and future treatments designed to restore vestibular function such as hair cell regeneration and vestibular implants.

Item Level Psychometrics of the Dizziness Handicap Inventory in Vestibular Migraine and Meniere's Disease

OBJECTIVES

Evaluate the measurement properties of the Dizziness Handicap Inventory (DHI) using item response theory in patients diagnosed with vestibular migraine (VM) and Meniere's disease (MD).

DESIGN

One hundred twenty-five patients diagnosed with VM and 169 patients diagnosed with MD by a vestibular neurotologist according to the Bárány Society criteria in two tertiary multidisciplinary vestibular clinics and who completed the DHI at their initial visit, were included in the study. The DHI (total score and individual items) was analyzed using the Rasch Rating Scale model for patients in each subgroup, VM and MD, and as a whole group. The following categories were assessed: rating-scale structure, unidimensionality, item and person fit, item difficulty hierarchy, person-item match, and separation index, standard error of measurement, and minimal detectable change (MDC).

RESULTS

Patients were predominantly female (80% of the VM subgroup and 68% of the MD subgroup) with a mean age of 49.9 ± 16.5 years and 54.1 ± 14.2 years, respectively. The mean total DHI score for the VM group was 51.9 ± 22.3 and for the MD group was 48.5 ± 26.6 ( p > 0.05). While neither all items nor the separate constructs met all criteria for unidimensionality (i.e., items measuring a single construct), post hoc analysis showed that the all-item analysis supported a single construct. All analyses met the criterion for showing a sound rating scale and acceptable Cronbach's alpha (≥0.69). The all-item analysis showed the most precision, separating the samples into three to four significant strata. The separate-construct analyses (physical, emotional, and functional) showed the least precision, separated the samples into less than three significant strata. Regarding MDC, the MDC remained consistent across the analyses of the different samples; approximately 18 points for the full analyses and approximately 10 points for the separate construct (physical, emotional, and functional).

CONCLUSIONS

Our evaluation of the DHI using item response theory shows that the instrument is psychometrically sound and reliable. The all-item instrument fulfills criteria for essential unidimensionality but does seem to measure multiple latent constructs in patients with VM and MD, which has been reported in other balance and mobility instruments. The current subscales did not show acceptable psychometrics, which is in line with multiple recent studies favoring the use of the total score. The study also shows that the DHI is adaptable to episodic recurrent vestibulopathies. The total score shows better precision and separation of subjects in up to four strata compared to the separate construct that separate subjects into less than three strata. The measurement error smallest detectable change was found in our analysis to be 18 points, which means any change in the DHI of less than 18 points is not likely to be clinically significant. The minimal clinically important difference remains indeterminate.

Psychometric Properties of the Persian Dizziness Handicap Inventory - Screening Version

OBJECTIVES

The Dizziness Handicap Inventory (DHI) is the most popular and widely used questionnaire in evaluating patients with vertigo. This questionnaire has a screening version with a high correlation with DHI. This study aimed to assess the psychometric properties of the Persian DHI - Screening version (DHI-S).

METHODS

This cross-sectional and methodological study was conducted on 300 patients at the central vestibular clinic in Mashhad, Iran, from 2020 to 2021. First, the DHI-S was translated into Persian using the backward-forward translation method. Subsequently, the following types of validity and reliability were examined: content validity based on content validity index and content validity ratio, face validity based on impact score, construct validity based on confirmatory factor analysis, internal consistency based on Cronbach's α and Ω, and test-retest stability based on intraclass correlation coefficient and smallest detectable change.

RESULTS

The DHI-S had high content and face validity. Score 8 was selected for the cutoff point between patients and the normal group with a sensitivity of 63.67% and specificity of 96.08%. The construct validity indicated that the questionnaire is one-dimensional. The Cronbach's α and Ω for internal consistency were 0.855 and 0.851, respectively. The intraclass correlation coefficient was 0.981 and the smallest detectable change was 5.521.

CONCLUSIONS

The DHI-S in the Persian language has high and acceptable psychometric properties. This questionnaire can be used in research and clinical settings.

Persistent Postural-Perceptual Dizziness (PPPD) and quality of life: a cross-sectional study

PURPOSE

To determine if Persistent Postural-Perceptual Dizziness (PPPD) is associated with increased burden of dizziness and quality of life. Secondly, if this association is present, to determine if it can be explained by differences in anxiety and/or depression between patients with PPPD and dizzy patients without PPPD.

METHODS

Cross-sectional study performed in an outpatient otolaryngology clinic, including patients 18-67 years referred from primary care for suspected vestibular disease with chronic dizziness. Patients underwent clinical examination and completed the following questionnaires: Dizziness Handicap Inventory (DHI), RAND-12 Health Status Inventory and Hospital Anxiety and Depression Scale (HADS). Scores in DHI and RAND-12 were compared between patients diagnosed with PPPD and patients without PPPD.

RESULTS

202 patients were included. 150 (74%) were women and 37 (18%) were diagnosed with PPPD. Patients in the PPPD group had increased burden of dizziness and reduced quality of life (QoL) as shown by a higher mean DHI score (49.2 vs. 30.8; p < 0.001) and reduced mean RAND-12 physical score (39.0 vs. 44.6; p = 0.004). After adjusting for age, gender and HADS, PPPD was associated with a 15.3 (p < 0.001) points increase in DHI score, and a 4.0 (p = 0.020) points decrease in RAND-12 physical score.

CONCLUSION

Patients with PPPD have a higher burden of dizziness and a lower physical health-related quality of life (HRQoL) compared to other dizzy patients. The difference was evident also after adjusting for anxiety and depression, illustrating how PPPD is a different entity than these common psychiatric conditions.

Optimizing vestibular neuritis management with modular strategies

Objective

This study proposes a "modular management" approach for vestibular neuritis (VN) to reduce chronicization and improve patient prognosis. The approach involves multi-factor grading and hierarchical intervention and was found to be more effective than traditional treatment strategies.

Methods

This retrospective analysis compared two groups of VN patients from two medical institutions. The intervention group of 52 patients received "modular management," while the control group of 51 patients did not receive this kind of management. Analyzed the early treatment strategies, 6-month prognosis, and other indicators of the two groups of patients, compared and analyzed their overall prognosis, and identified the risk factors affecting the chronicization.

Results

The modular management group had lower dizziness severity, better balance, lower anxiety, and higher video head impulse testing (v-HIT) gain after 6 months of onset. Analysis of factors related to persistent postural-perceptual dizziness (PPPD) in patients with VN showed positive correlations between the time from onset to diagnosis and PPPD, and Vertigo Symptom Scale (VSS), Dizziness Handicap Inventory (DHI), anxiety, and depression. Normalized vestibular rehabilitation was negatively correlated with PPPD, while gender, age, and early steroid use had no significant correlation. The multi-factor logistic regression model correctly classified 93.20% of the study subjects with a sensitivity of 87.50% and specificity of 94.90%.

Conclusion

The proposed "modular management" scheme for VN is a comprehensive and dynamic approach that includes health education, assessment, rehabilitation, therapy, evaluation, and prevention. It can significantly improve patient prognosis and reduce chronicization by shifting from simple acute treatment to continuous management.

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.

Sub-symptom threshold aerobic exercise for patients with persisting post-concussion symptoms and exercise intolerance after mild traumatic brain injury - a study protocol with a nested feasibility study for a randomized controlled trial

BACKGROUND

Persistent post-concussion symptoms (PPCS) affect between 34 and 46% after a mild traumatic brain injury (mTBI). Many also experience exercise intolerance. Sub-symptom threshold aerobic exercise, SSTAE (exercise at an intensity level that does not increase symptoms) is proposed as a treatment to both reduce the symptom burden and increase the exercise tolerance after the injury. It is unclear if this also applies in a more chronic phase after mTBI.

MAIN PURPOSE

The main purpose of this study is to evaluate whether SSTAE in addition to ordinary rehabilitation will lead to clinically meaningful improvement of symptom burden, normalize exercise tolerance, increase physical activity, improve health-related quality of life, and reduce patient-specific activity limitations compared to a control group that only receives ordinary rehabilitation.

DESIGN

Randomized, controlled, single-blind parallel-group study with three measurement times; T0 at baseline, T1 after the intervention and T2 six months after T1.

METHODS

Patients between the ages of 18 and 60 with exercise intolerance and persistent PPCS (> 3 months) will be recruited to the study and randomized to two groups. All patients will receive follow-up at the outpatient TBI clinic. The intervention group will in addition receive SSTAE for 12 weeks with exercise diaries and a retest every 3 weeks for optimal dosage and progression. The Rivermead post-concussion symptoms questionnaire will be the main outcome measure. The secondary outcome measure will be a test of exercise tolerance-the Buffalo Concussion Treadmill Test. Other outcome measures include the patient-specific functional scale that measures patient-specific activity limitations, as well as outcome measures for diagnosis-specific health-related quality of life, anxiety and depression, specific symptoms such as dizziness, headache and fatigue, and physical activity.

DISCUSSION

This study will add knowledge about the effect of SSTAE and whether it should be implemented in rehabilitation for the adult population with persistent PPCS after mTBI. The nested feasibility trial showed that the SSTAE intervention was safe and that the study procedures and delivery of the intervention overall were feasible. However, minor amendments to the study protocol were made prior to the commencement of the RCT.

TRIAL REGISTRATION

Clinical Trials.gov, NCT05086419. Registered on September 5th, 2021.

Non-pharmacological interventions for prophylaxis of vestibular migraine

BACKGROUND

Vestibular migraine is a form of migraine where one of the main features is recurrent attacks of vertigo. These episodes are often associated with other features of migraine, including headache and sensitivity to light or sound. These unpredictable and severe attacks of vertigo can lead to a considerable reduction in quality of life. The condition is estimated to affect just under 1% of the population, although many people remain undiagnosed. A number of interventions have been used, or proposed to be used, as prophylaxis for this condition, to help reduce the frequency of the attacks. Many of these interventions include dietary, lifestyle or behavioural changes, rather than medication.  OBJECTIVES: To assess the benefits and harms of non-pharmacological treatments used for prophylaxis of vestibular migraine.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 23 September 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs in adults with definite or probable vestibular migraine comparing dietary modifications, sleep improvement techniques, vitamin and mineral supplements, herbal supplements, talking therapies, mind-body interventions or vestibular rehabilitation with either placebo or no treatment. We excluded studies with a cross-over design, unless data from the first phase of the study could be identified.  DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were: 1) improvement in vertigo (assessed as a dichotomous outcome - improved or not improved), 2) change in vertigo (assessed as a continuous outcome, with a score on a numerical scale) and 3) serious adverse events. Our secondary outcomes were: 4) disease-specific health-related quality of life, 5) improvement in headache, 6) improvement in other migrainous symptoms and 7) other adverse effects. We considered outcomes reported at three time points: < 3 months, 3 to < 6 months, > 6 to 12 months. We used GRADE to assess the certainty of evidence for each outcome.  MAIN RESULTS: We included three studies in this review with a total of 319 participants. Each study addressed a different comparison and these are outlined below. We did not identify any evidence for the remaining comparisons of interest in this review.   Dietary interventions (probiotics) versus placebo We identified one study with 218 participants (85% female). The use of a probiotic supplement was compared to a placebo and participants were followed up for two years. Some data were reported on the change in vertigo frequency and severity over the duration of the study. However, there were no data regarding improvement of vertigo or serious adverse events. Cognitive behavioural therapy (CBT) versus no intervention One study compared CBT to no treatment in 61 participants (72% female). Participants were followed up for eight weeks. Data were reported on the change in vertigo over the course of the study, but no information was reported on the proportion of people whose vertigo improved, or on the occurrence of serious adverse events.  Vestibular rehabilitation versus no intervention The third study compared the use of vestibular rehabilitation to no treatment in a group of 40 participants (90% female) and participants were followed up for six months. Again, this study reported some data on change in the frequency of vertigo during the study, but no information on the proportion of participants who experienced an improvement in vertigo or the number who experienced serious adverse events.  We are unable to draw meaningful conclusions from the numerical results of these studies, as the data for each comparison of interest come from single, small studies and the certainty of the evidence was low or very low.  AUTHORS' CONCLUSIONS: There is a paucity of evidence for non-pharmacological interventions that may be used for prophylaxis of vestibular migraine. Only a limited number of interventions have been assessed by comparing them to no intervention or a placebo treatment, and the evidence from these studies is all of low or very low certainty. We are therefore unsure whether any of these interventions may be effective at reducing the symptoms of vestibular migraine and we are also unsure whether they have the potential to cause harm.

Pharmacological interventions for prophylaxis of vestibular migraine

BACKGROUND

Vestibular migraine is a form of migraine where one of the main features is recurrent attacks of vertigo. These episodes are often associated with other features of migraine, including headache and sensitivity to light or sound. These unpredictable and severe attacks of vertigo can lead to a considerable reduction in quality of life. The condition is estimated to affect just under 1% of the population, although many people remain undiagnosed. A number of pharmacological interventions have been used or proposed to be used as prophylaxis for this condition, to help reduce the frequency of the attacks. These are predominantly based on treatments that are in use for headache migraine, with the belief that the underlying pathophysiology of these conditions is similar.

OBJECTIVES

To assess the benefits and harms of pharmacological treatments used for prophylaxis of vestibular migraine.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 23 September 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs in adults with definite or probable vestibular migraine comparing beta-blockers, calcium channel blockers, antiepileptics, antidepressants, diuretics, monoclonal antibodies against calcitonin gene-related peptide (or its receptor), botulinum toxin or hormonal modification with either placebo or no treatment. We excluded studies with a cross-over design, unless data from the first phase of the study could be identified.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were: 1) improvement in vertigo (assessed as a dichotomous outcome - improved or not improved), 2) change in vertigo (assessed as a continuous outcome, with a score on a numerical scale) and 3) serious adverse events. Our secondary outcomes were: 4) disease-specific health-related quality of life, 5) improvement in headache, 6) improvement in other migrainous symptoms and 7) other adverse effects. We considered outcomes reported at three time points: < 3 months, 3 to < 6 months, > 6 to 12 months. We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

We included three studies with a total of 209 participants. One evaluated beta-blockers and the other two evaluated calcium channel blockers. We did not identify any evidence for the remaining interventions of interest. Beta-blockers versus placebo One study (including 130 participants, 61% female) evaluated the use of 95 mg metoprolol once daily for six months, compared to placebo. The proportion of people who reported improvement in vertigo was not assessed in this study. Some data were reported on the frequency of vertigo attacks at six months and the occurrence of serious adverse effects. However, this is a single, small study and for all outcomes the certainty of evidence was low or very low. We are unable to draw meaningful conclusions from the numerical results. Calcium channel blockers versus no treatment Two studies, which included a total of 79 participants (72% female), assessed the use of 10 mg flunarizine once daily for three months, compared to no intervention. All of the evidence for this comparison was of very low certainty. Most of our outcomes were only reported by a single study, therefore we were unable to conduct any meta-analysis. Some data were reported on improvement in vertigo and change in vertigo, but no information was available regarding serious adverse events. We are unable to draw meaningful conclusions from the numerical results, as these data come from single, small studies and the certainty of the evidence was very low.

AUTHORS CONCLUSIONS

There is very limited evidence from placebo-controlled randomised trials regarding the efficacy and potential harms of pharmacological interventions for prophylaxis of vestibular migraine. We only identified evidence for two of our interventions of interest (beta-blockers and calcium channel blockers) and all evidence was of low or very low certainty. Further research is necessary to identify whether these treatments are effective at improving symptoms and whether there are any harms associated with their use.

Non-pharmacological interventions for persistent postural-perceptual dizziness (PPPD)

BACKGROUND

Persistent postural-perceptual dizziness (PPPD) is a chronic balance disorder, which is characterised by subjective unsteadiness or dizziness that is worse on standing and with visual stimulation. The condition was only recently defined and therefore the prevalence is currently unknown. However, it is likely to include a considerable number of people with chronic balance problems. The symptoms can be debilitating and have a profound impact on quality of life. At present, little is known about the optimal way to treat this condition. A variety of medications may be used, as well as other treatments, such as vestibular rehabilitation.  OBJECTIVES: To assess the benefits and harms of non-pharmacological interventions for persistent postural-perceptual dizziness (PPPD).  SEARCH METHODS: The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 21 November 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs in adults with PPPD, which compared any non-pharmacological intervention with either placebo or no treatment. We excluded studies that did not use the Bárány Society criteria to diagnose PPPD, and studies that followed up participants for less than three months.  DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were: 1) improvement in vestibular symptoms (assessed as a dichotomous outcome - improved or not improved), 2) change in vestibular symptoms (assessed as a continuous outcome, with a score on a numerical scale) and 3) serious adverse events. Our secondary outcomes were: 4) disease-specific health-related quality of life, 5) generic health-related quality of life and 6) other adverse effects. We considered outcomes reported at three time points: 3 to < 6 months, 6 to ≤ 12 months and > 12 months. We planned to use GRADE to assess the certainty of evidence for each outcome.  MAIN RESULTS: Few randomised controlled trials have been conducted to assess the efficacy of different treatments for PPPD compared to no treatment (or placebo). Of the few studies we identified, only one followed up participants for at least three months, therefore most were not eligible for inclusion in this review.  We identified one study from South Korea that compared the use of transcranial direct current stimulation to a sham procedure in 24 people with PPPD. This is a technique that involves electrical stimulation of the brain with a weak current, through electrodes that are placed onto the scalp. This study provided some information on the occurrence of adverse effects, and also on disease-specific quality of life at three months of follow-up. The other outcomes of interest in this review were not assessed. As this is a single, small study we cannot draw any meaningful conclusions from the numeric results.  AUTHORS' CONCLUSIONS: Further work is necessary to determine whether any non-pharmacological interventions may be effective for the treatment of PPPD and to assess whether they are associated with any potential harms. As this is a chronic disease, future trials should follow up participants for a sufficient period of time to assess whether there is a persisting impact on the severity of the disease, rather than only observing short-term effects.

Musculoskeletal pain patterns and association between dizziness symptoms and pain in patients with long term dizziness - a cross-sectional study

BACKGROUND

The impact of long-term dizziness is considerable both on the personal level and in society and may lead to self-imposed restrictions in daily activities and social relations due to fear of triggering the symptoms. Musculoskeletal complaints seem to be common in persons with dizziness, but studies addressing these complaints as a widespread occurrence, are scarce. This study aimed to examine the occurrence of widespread pain in patients with long-term dizziness and investigate the associations between pain and dizziness symptoms. Further, to explore whether diagnostic belonging is related to the occurrence of pain.

METHODS

This cross-sectional study was conducted in an otorhinolaryngology clinic and included 150 patients with persistent dizziness. The patients were categorized into three groups: episodic vestibular syndromes, chronic vestibular syndromes, and non-vestibular group. The patients completed questionnaires on dizziness symptoms, catastrophic thinking, and musculoskeletal pain when entering the study. Descriptive statistics were used to describe the population, and associations between pain and dizziness were investigated by linear regression.

RESULTS

Pain was reported by 94.5% of the patients. A significantly higher prevalence of pain was reported in all the ten pain sites examined compared to the general population. Number of pain sites and pain intensity were associated with the dizziness severity. Number of pain sites was also associated with dizziness-related handicap, but not with catastrophic thinking. There was no association between pain intensity and dizziness-related handicap or catastrophic thinking. Pain was equally distributed in the diagnostic groups.

CONCLUSION

Patients with long-term dizziness have a considerably higher prevalence of pain and number of pain sites than the general population. Pain co-exists with dizziness and is associated with dizziness severity. These findings may indicate that pain should be systematically assessed and treated in patients with persisting dizziness.

Systemic pharmacological interventions for Ménière's disease

BACKGROUND

Ménière's disease is a condition that causes recurrent episodes of vertigo, associated with hearing loss and tinnitus. A number of pharmacological interventions have been used in the management of this condition, including betahistine, diuretics, antiviral medications and corticosteroids. The underlying cause of Ménière's disease is unknown, as is the way in which these treatments may work. The efficacy of these different interventions at preventing vertigo attacks, and their associated symptoms, is currently unclear.

OBJECTIVES

To evaluate the benefits and harms of systemic pharmacological interventions versus placebo or no treatment in people with Ménière's disease.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 14 September 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs in adults with definite or probable Ménière's disease comparing betahistine, diuretics, antihistamines, antivirals or systemic corticosteroids with either placebo or no treatment. We excluded studies with follow-up of less than three months, or with a cross-over design (unless data from the first phase of the study could be identified).  DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were: 1) improvement in vertigo (assessed as a dichotomous outcome - improved or not improved), 2) change in vertigo (assessed as a continuous outcome, with a score on a numerical scale) and 3) serious adverse events. Our secondary outcomes were: 4) disease-specific health-related quality of life, 5) change in hearing, 6) change in tinnitus and 7) other adverse effects. We considered outcomes reported at three time points: 3 to < 6 months, 6 to ≤ 12 months and > 12 months. We used GRADE to assess the certainty of evidence for each outcome.  MAIN RESULTS: We included 10 studies with a total of 848 participants. The studies evaluated the following interventions: betahistine, diuretics, antivirals and corticosteroids. We did not identify any evidence on antihistamines.  Betahistine Seven RCTs (548 participants) addressed this comparison. However, we were unable to conduct any meta-analyses for our primary outcomes as not all outcomes were considered by every study, and studies that did report the same outcome used different time points for follow-up, or assessed the outcome using different methods. Therefore, we were unable to draw meaningful conclusions from the numerical results. Some data were available for each of our primary outcomes, but the evidence was low- or very low-certainty throughout. One study reported on the outcome 'improvement in vertigo' at 6 to ≤ 12 months, and another study reported this outcome at > 12 months. Four studies reported on the change in vertigo, but again all used different methods of assessment (vertigo frequency, or a global score of vertigo severity) or different time points. A single study reported on serious adverse events.  Diuretics Two RCTs addressed this comparison. One considered the use of isosorbide (220 participants), and the other used a combination of amiloride hydrochloride and hydrochlorothiazide (80 participants). Again, we were unable to conduct any meta-analyses for our primary outcomes, as only one study reported on the outcome 'improvement in vertigo' (at 6 to ≤ 12 months), one study reported on change in vertigo (at 3 to < 6 months) and neither study assessed serious adverse events. Therefore, we were unable to draw meaningful conclusions from the numerical results. The evidence was all very low-certainty.  Other pharmacological interventions We also identified one study that assessed antivirals (24 participants), and one study that assessed corticosteroids (16 participants). The evidence for these interventions was all very low-certainty. Again, serious adverse events were not considered by either study.

AUTHORS' CONCLUSIONS

The evidence for systemic pharmacological interventions for Ménière's disease is very uncertain. There are few RCTs that compare these interventions to placebo or no treatment, and the evidence that is currently available from these studies is of low or very low certainty. This means that we have very low confidence that the effects reported are accurate estimates of the true effect of these interventions. Consensus on the appropriate outcomes to measure in studies of Ménière's disease is needed (i.e. a core outcome set) in order to guide future studies in this area and enable meta-analyses of the results. This must include appropriate consideration of the potential harms of treatment, as well as the benefits.

Vestibular Complaints Impact on the Long-Term Quality of Life of Vestibular Schwannoma Patients

OBJECTIVE

To analyze the effect of dizziness-related symptoms on the long-term quality of life (QoL) of patients with unilateral vestibular schwannoma.

METHODS

In this cross-sectional study, patients with a unilateral vestibular schwannoma diagnosed between 2004 and 2013 completed a disease-specific QoL questionnaire (Penn Acoustic Neuroma Quality of Life [PANQOL]) and the Dizziness Handicap Inventory (DHI) in 2020. Linear regression was performed to assess the correlation between QoL and the DHI total score, and the scores of the DHI functional, emotional, and physical subdomains. Potential confounders such as age, sex, tumor size at baseline, and treatment modality (active surveillance, surgery, or radiotherapy) were included in the model.

RESULTS

In total, 287 of 479 patients (59%) experienced dizziness with a median follow-up of 10 years. The DHI total score was significantly associated with the PANQOL total score. On average, we found a reduction of 0.7 points on the PANQOL for each additional point on the DHI. The DHI emotional subdomain was the most prominent determinant of poorer QoL. Each point on the DHI emotional subscale was associated with a reduction of 1.3 on the PANQOL score. Treatment modality did not have a clinically relevant effect on dizziness-related QoL.

CONCLUSIONS

Even mild dizziness can have a significant and clinically relevant effect on the QoL of patients with unilateral vestibular schwannoma in the long term. This holds true for all treatment modalities. Addressing the vestibular problems may improve QoL in vestibular schwannoma patients, and DHI subscale analysis may help tailor the optimal vestibular intervention.

The Dizziness Handicap Inventory and sickness absence: a cross-sectional study

PURPOSE

The aim of this study was to examine the association between the Dizziness Handicap Inventory (DHI) and sickness absence from work in patients with dizziness.

MATERIAL AND METHODS

This was a cross-sectional study conducted at an otolaryngology clinic with 238 patients referred for a suspected vestibular disorder during a 1-year period. The association between sickness absence over the last 30 days and DHI was examined with binary and ordinal logistic regression. The Hospital Anxiety and Depression scale (HADS), health-related quality of life (RAND-12), duration of dizziness, diagnosis, age and gender were used as adjustments variables.

RESULTS

The adjusted analysis showed that a 10-point increase on DHI was associated with an increased risk of sickness absence (yes/no) (OR: 1.50, 95% CI: 1.25-1.90, p < 0.001). In addition, a 10-point increase in DHI-score was associated with a higher degree of sickness absence (OR: 1.50, 95% CI: 1.25-1.80, p < 0.001).

CONCLUSION

A higher DHI-score was associated with sickness absence in addition to the duration of absence the previous month. These results indicate the relevance and clinical usefulness of the DHI as a possible indicator of sickness absence from work in patients with dizziness regardless of diagnosis.IMPLICATIONS FOR REHABILITATIONApproximately half of patients referred to a dizziness clinic have sickness absence.A higher score on The Dizziness Handicap Inventory is associated with longer duration of sickness absence.A vestibular diagnosis was not associated with sickness absence.The results indicate that the Dizziness Handicap Inventory may be a clinically useful tool for identifying patients with a high risk of sickness absence.

Effect of Interventional Therapy Unexplained Dizziness and Relationship Between Dizziness Handicap Inventory and Right-to-Left Shunt Grading

Objective

Unexplained dizziness remains a clinical challenge. Our previous studies have shown that unexplained dizziness may be related to patent foramen ovale (PFO). This study aims to explore whether the degree of shunt is correlated with the degree of unexplained dizziness and looking for the possible clinical intervention for patients with unexplained dizziness.

Methods

This study was a large single-center, prospective, controlled study. From March 2019 to March 2022, patients with unexplained dizziness and explained dizziness and healthy controls were recruited. Contrast-enhanced transcranial Doppler sonography (c-TCD) was performed to detect the existence of right-to-left shunt (RLS) and shunt grading. The dizziness handicap inventory (DHI) was completed to evaluate the dizziness. Unexplained dizziness patients with large amount of PFO were volunteered to receive medication treatment and transcatheter PFO closure and followed up six months.

Results

A total of 387 patients (132 unexplained, 123 explained and 132 controls) were enrolled. There was a statistical difference in the RLS grading with three groups (p < 0.001). The Spearman correlation coefficient of RLS grading and DHI scores in unexplained dizziness patients (r=0.122, p=0.163) and explained dizziness patients (r=0.067, p=0.460). In the unexplained group, there were 49 cases with massive grading RLS. Of which 25 patients received percutaneous PFO closure treatment and 24 cases received medication treatment. Followed up six months after treatment, the amount of DHI scores change in patients who received the percutaneous PFO closure was significantly higher than that in the medication treatment group (p < 0.001).

Conclusion

RLS may play an important role in unexplained dizziness. For unexplained dizziness patients, PFO closure may contribute to better outcomes. In the future, large-scale randomized controlled studies are still needed.

Accelerated Cognitive Decline Associated With Hearing Loss and Bilateral Vestibulopathy: Insights From a Prospective Cross-Sectional Study Using the Repeatable Battery for the Assessment of Neuropsychological Status Adjusted for the Hearing Impaired in the DFNA9 Population

BACKGROUND

DeaFNess Autosomal dominant 9 (DFNA9) is a hereditary disorder known to affect both hearing and vestibular function in its carriers. Its phenotype is characterized by progressive sensorineural hearing loss (SNHL) and vestibular dysfunction evolving towards bilateral vestibulopathy (BV) by the 3rd to 5th life decade. Recent studies have identified the impact of hearing loss and vestibular dysfunction on cognitive functioning.

OBJECTIVE

The main objective of this study was to investigate how the cognitive functioning of carriers of the p.Pro51Ser variant in the COCH gene is affected by the disease and compare these results with a matched healthy control group.

STUDY DESIGN

Forty-six carriers of the pathogenic p.Pro51Ser variant in the COCH gene were included in this study, of which 38 met the Bárány Society criteria and were thus diagnosed with BV. All subjects were between the age of 22 and 72 years old. Each control was individually matched based on age, gender, and education level. A cognitive, vestibular, and hearing assessment was performed in all subjects. All participants completed the Repeatable Battery for the Assessment of Neuropsychological Status, adjusted for the Hearing Impaired (RBANS-H), a cognitive test battery that includes subtests probing Immediate and Delayed Memory, Visuospatial/Constructional, Language, and Attention.

RESULTS

Overall, the DFNA9 patients demonstrated significantly lower scores on the Immediate Memory subscale and lower Total Scale scores than their healthy matched controls. The total sample was divided into two groups: age <55 years old and age ≥55 years old. The DFNA9 group aged ≥55 years old obtained significantly lower scores on the Attention subscale and lower Total Scale scores than their matched controls. Cognition of DFNA9 patients aged <55 years old no longer differed significantly from their matched controls.

CONCLUSION

This cross-sectional study found that DFNA9 patients demonstrated cognitive deficits in comparison with their healthy matched controls. The DFNA9 group aged ≥ 55 years old obtained significantly lower scores on the Total Scale and Attention subscale. This finding; however, was not observed for the age group younger than 55 years old. Further research is needed on the individual trajectory of SNHL and vestibular function, and how hearing rehabilitation affects cognitive functioning.

Central sensorimotor integration assessment reveals deficits in standing balance control in people with chronic mild traumatic brain injury

Imbalance is common following mild Traumatic Brain Injury (mTBI) and can persist months after the initial injury. To determine if mTBI subjects with chronic imbalance differed from healthy age- and sex-matched controls (HCs) we used both the Central SensoriMotor Integration (CSMI) test, which evaluates sensory integration, time delay, and motor activation properties and the standard Sensory Organization Test (SOT). Four CSMI conditions evoked center-of-mass sway in response to: surface tilts with eyes closed (SS/EC), surface tilts with eyes open viewing a fixed visual surround (SS/EO), visual surround tilts with eyes open standing on a fixed surface (VS/EO), and combined surface and visual tilts with eyes open (SS+VS/EO). The mTBI participants relied significantly more on visual cues during the VS/EO condition compared to HCs but had similar reliance on combinations of vestibular, visual, and proprioceptive cues for balance during SS/EC, SS/EO, and SS+VS/EO conditions. The mTBI participants had significantly longer time delays across all conditions and significantly decreased motor activation relative to HCs across conditions that included surface-tilt stimuli with a sizeable subgroup having a prominent increase in time delay coupled with reduced motor activation while demonstrating no vestibular sensory weighting deficits. Decreased motor activation compensates for increased time delay to maintain stability of the balance system but has the adverse consequence that sensitivity to both internal (e.g., sensory noise) and external disturbances is increased. Consistent with this increased sensitivity, SOT results for mTBI subjects showed increased sway across all SOT conditions relative to HCs with about 45% of mTBI subjects classified as having an “Aphysiologic” pattern based on published criteria. Thus, CSMI results provided a plausible physiological explanation for the aphysiologic SOT pattern. Overall results suggest that rehabilitation that focuses solely on sensory systems may be incomplete and may benefit from therapy aimed at enhancing rapid and vigorous responses to balance perturbations.

The effects of augmenting traditional rehabilitation with audio biofeedback in people with persistent imbalance following mild traumatic brain injury

Complaints of non-resolving imbalance are common in individuals with chronic mild traumatic brain injury (mTBI). Vestibular rehabilitation therapy may be beneficial for this population. Additionally, wearable sensors can enable biofeedback, specifically audio biofeedback (ABF), and aid in retraining balance control mechanisms in people with balance impairments. In this study, we described the effectiveness of vestibular rehabilitation therapy with and without ABF to improve balance in people with chronic mTBI. Participants (n = 31; females = 22; mean age = 40.9 ± 11 y) with chronic (>3 months) mTBI symptoms of self-reported imbalance were randomized into vestibular rehabilitation with ABF (n = 16) or without ABF (n = 15). The intervention was a standard vestibular rehabilitation, with or without ABF, for 45 min biweekly for 6 weeks. The ABF intervention involved a smartphone that provided auditory feedback when postural sway was outside of predetermined equilibrium parameters. Participant's completed the Post-Concussion Symptom Scale (PCSS). Balance was assessed with the sensory organization test (SOT) and the Central Sensorimotor Integration test which measured sensory weighting, motor activation, and time delay with sway evoked by surface and/or visual surround tilts. Effect sizes (Hedge's G) were calculated on the change between pre-and post-rehabilitation scores. Both groups demonstrated similar medium effect-sized decreases in PCSS and large increases in SOT composite scores after rehabilitation. Effect sizes were minimal for increasing sensory weighting for both groups. The with ABF group showed a trend of larger effect sizes in increasing motor activation (with ABF = 0.75, without ABF = 0.22) and in decreasing time delay (with ABF = −0.77, without ABF = −0.52) relative to the without ABF group. Current clinical practice focuses primarily on sensory weighting. However, the evaluation and utilization of motor activation factors in vestibular rehabilitation, potentially with ABF, may provide a more complete assessment of recovery and improve outcomes.

Self-Reported Measures Have a Stronger Association With Dizziness-Related Handicap Compared With Physical Tests in Persons With Persistent Dizziness

Background

Associations between dizziness-related handicap and a variety of self-reported measures have been reported. However, research regarding associations between dizziness-related handicap and aspects of functioning that includes both physical tests and self-reported measures is scarce.

Objective

The purpose of the study was to describe the variations in signs and symptoms in people with persistent dizziness using physical tests and self-reported outcomes across three severity levels of the Dizziness Handicap Inventory (DHI) and investigate their associations with the DHI.

Method

Participants with persistent dizziness (n = 107) were included in this cross-sectional study. The participants underwent (1) physical tests (gait tests, grip strength, body flexibility, and movement-induced dizziness) and completed questionnaires regarding (2) psychological measures (Mobility Inventory of Agoraphobia, Body Sensation Questionnaire, Agoraphobic Cognitions Questionnaire, and Hospital Depression and Anxiety Questionnaire), and (3) fatigue, dizziness severity, and quality of life (Chalders Fatigue Scale, Vertigo Symptom Scale-Short Form, and EQ visual analog scale), in addition to the DHI. Data were presented by descriptive statistics for three DHI severity levels (mild, moderate, and severe). A multiple linear backward regression analysis was conducted for each group of measures in relation to the DHI total score, with additional analyses adjusting for age and sex. Based on these results, significant associations were tested in a final regression model.

Results

With increasing severity levels of DHI, the participants demonstrated worse performance on most of the physical tests (preferred and fast gait velocity, dizziness intensity after head movements), presented with worse scores on the self-reported measures (avoidance behavior, fear of bodily sensation, fear of fear itself, psychological distress, fatigue, dizziness severity, quality of life). After adjusting for age and sex, significant associations were found between total DHI and avoidance behavior, psychological distress, dizziness severity, and quality of life, but not with any of the physical tests, explaining almost 56% of the variance of the DHI total score.

Conclusion

There was a trend toward worse scores on physical tests and self-reported measurements with increasing DHI severity level. The DHI seems to be a valuable tool in relation to several self-reported outcomes; however, several signs and symptoms may not be detected by the DHI, and thus, a combination of outcomes should be utilized when examining patients with persistent dizziness.

Dizziness, Psychosocial Function, and Postural Stability Following Sport-Related Concussion

OBJECTIVE

To examine if self-reported dizziness is associated with concussion symptoms, depression and/or anxiety symptoms, or gait performance within 2 weeks of postconcussion.

DESIGN

Cross-sectional study.

SETTING

Research laboratory.

PARTICIPANTS

Participants were diagnosed with a concussion within 14 days of initial testing (N = 40). Participants were divided into 2 groups based on their Dizziness Handicap Inventory (DHI) score: 36 to 100 = moderate/severe dizziness and 0 to 35 = mild/no dizziness.

INTERVENTIONS

Participants were tested on a single occasion and completed the DHI, hospital anxiety and depression scale (HADS), Patient Health Questionnaire-9 (PHQ-9), and Post-Concussion Symptom Inventory (PCSI). Three different postural control tests were use: modified Balance Error Scoring System, single-/dual-task tandem gait, and a single-/dual-task instrumented steady-state gait analysis.

MAIN OUTCOME MEASURES

Comparison of patient-reported outcomes and postural control outcomes between moderate/severe (DHI ≥ 36) and mild/no (DHI < 36) dizziness groups.

RESULTS

Participants with moderate/severe dizziness (n = 19; age = 17.1 ± 2.4 years; 63% female) reported significantly higher symptom burden (PSCI: 43.0 ± 20.6 vs 22.8 ± 15.7; P = 0.001) and had higher median HADS anxiety (6 vs 2; P < 0.001) and depression (6 vs 1; P = 0.001) symptom severity than those with no/minimal dizziness (n = 21; age = 16.5 ± 1.9; 38% female). During steady-state gait, moderate/severe dizziness group walked with significantly slower single-task cadence (mean difference = 4.8 steps/minute; 95% confidence interval = 0.8, 8.8; P = 0.02) and dual-task cadence (mean difference = 7.4 steps/minute; 95% confidence interval = 0.7, 14.0; P = 0.04) than no/mild dizziness group.

CONCLUSION

Participants who reported moderate/severe dizziness reported higher concussion symptom burden, higher anxiety scores, and higher depression scores than those with no/mild dizziness. Cadence during gait was also associated with the level of dizziness reported.

The Non-Concordance of Self-Reported and Performance-Based Measures of Vestibular Dysfunction in Military and Civilian Populations Following TBI

As a predominately young, physically active, and generally healthy population, service members (SMs) with vestibular dysfunction (VD) following a TBI may not be accurately represented by the current civilian reference ranges on assessments of VD. This study enrolled SMs who were referred for vestibular rehabilitation following a mild/moderate TBI. The participants self-reported VD using the Activities-specific Balance Confidence (ABC) scale and the Dizziness Handicap Inventory (DHI) followed by evaluation of vestibular performance using computerized dynamic posturography sensory organizational test (CDP−SOT). Retrospective analysis of these outcomes comparing the study sample of SMs to the reported civilian samples revealed SMs self-reported lower VD with significantly higher balance confidence (ABC: 77.11 ± 14.61, p < 0.05) and lower dizziness (DHI: 37.75 ± 11.74, p < 0.05) than civilians. However, the SMs underperformed in performance-based evaluations compared to civilians with significantly lower CDP−SOT composite and ratio scores (COMP: 68.46 ± 13.46, p < 0.05; VIS: 81.36 ± 14.03, p < 0.01; VEST: 55.63 ± 22.28, p < 0.05; SOM: 90.46 ± 10.17, p < 0.05). Correlational analyses identified significant relationships between the ABC and CDP−SOT composite (r = 0.380, p < 0.01) and ratio scores (VIS: r = 0.266, p < 0.05; VEST: r = 0.352, p < 0.01). These results highlight the importance of recognizing and understanding nuances in assessing VD in SMs to ensure they have access to adequate care and rehabilitation prior to returning to duty.

Migraine and balance impairment: Influence of subdiagnosis, otoneurological function, falls, and psychosocial factors

OBJECTIVE

To assess the balance sensory organization among patients with migraine, considering the influence of migraine subdiagnosis, otoneurological function, falls, and psychosocial factors.

BACKGROUND

Migraine has been associated with vestibular symptoms and balance dysfunction; however, neither comprehensive balance assessment nor associated factors for greater impairment have been addressed thus far.

METHODS

Patients from a tertiary headache clinic with a diagnosis of episodic migraine with aura (MWA), without aura (MWoA), and chronic migraine (CM) were included for this cross-sectional study (30 patients per group). Thirty headache-free controls (CG) were recruited. Participants underwent a comprehensive evaluation protocol, including the Sensory Organization Test (SOT) and otoneurological examination. Questionnaires about fear of falls, dizziness disability, and kinesiophobia were administered.

RESULTS

All migraine groups presented lower composite SOT scores than controls (CG: 82.4 [95% confidence interval (CI): 79.5-85.3], MWoA: 76.5 [95% CI: 73.6-79.3], MWA: 66.5 [95% CI: 63.6-69.3], CM: 69.1 [95% CI: 66.3-72.0]; p < 0.0001). Compared to controls and to MWoA, MWA and CM groups exhibited greater vestibular (CG: 75.9 [95% CI: 71.3-80.4], MWoA: 67.3 [95% CI: 62.7-71.8], MWA: 55.7 [95% CI: 51.2-60.3], CM: 58.4 [95% CI: 53.8-63.0]; p < 0.0001) and visual functional impairment (CG: 89.6 [95% CI: 84.2-94.9], MWoA: 83.2 [95% CI: 77.9-88.6], MWA: 68.6 [95% CI: 63.3-74.0], CM: 71.9 [95% CI: 66.5-77.2], p < 0.0001). Fall events during the assessment were documented more often among patients with migraine (CG: 0.0, interquartile range [IQR], 0.0, 0.0); MWoA: 1.0 [IQR: 1.0, 1.0], MWA: 2.0 [IQR: 1.8, 4.3], CM: 1.0 [IQR: 1.0, 2.0]; p = 0.001). The SOT scores correlated with fear of falls (r = -0.44), dizziness disability (r = -0.37), kinesiophobia (r = -0.38), and migraine frequency (r = -0.38). There was no significant influence of the vestibular migraine diagnosis in the study outcomes when used as a covariate in the analysis (composite score [F = 3.33, p = 0.070], visual score [F = 2.11, p = 0.149], vestibular score [F = 1.88, p = 0.172], somatosensory score [F = 0.00, p = 0.993]).

CONCLUSIONS

Aura and greater migraine frequency were related to falls and balance impairment with sensory input manipulation, although no otoneurological alterations were detected. The diagnosis of vestibular migraine does not influence the balance performance. The vestibular/visual systems should be considered in the clinical examination and treatment of patients with migraine.

Balance Training With Vibrotactile Neurofeedback and Ginkgo Biloba Extract in Age-Related Vertigo

Background: Balance training with vibrotactile neurofeedback (VNF) can improve balance and subjective impairment in age-related vertigo and dizziness. Ginkgo biloba dry extract EGb 761 has been shown to improve subjective impairment in chronic vertigo and the efficacy of conventional balance training. The combination was expected to work synergistically in this difficult-to-treat population.

Objectives: To demonstrate the efficacy of VNF added to EGb 761 for age-related vertigo and dizziness.

Design: Multicenter, prospective, controlled, randomized, single-blind, two-arm trial (German Clinical Trials Register https://www.drks.de No. DRKS00007633).

Setting: Specialist offices and tertiary care outpatient department.

Participants: One hundred and twenty subjects aged 60+ years with chronic dizziness for over 3 months, a Dizziness Handicap Inventory (DHI) Sum Score &gt;25 and fall risk in balance-related situations as measured by the geriatric Standard Balance Deficit Test Composite Score (gSBDT-CS)&gt;40. Patients with other distinct vestibular pathology (e.g., Meniére's disease, stroke, BPPV) were excluded.

Intervention: EGb 761 (80 mg twice daily for 12 weeks) plus 10 days of individually adapted balance training with VNF, randomized 1:1 to sensitive (active) or non-sensitive (sham) neurofeedback.

Measurements: The change in gSBDT-CS after 6 weeks (primary), other gSBDT outcomes, DHI, cognition, hearing, and safety.

Results: One hundred nine of 120 enrolled subjects received both treatments at least once. Over 12 weeks, the gSBDT-CS improved by 6.7 (active) vs. 4.5 (sham). There was a difference in favor of the active treatment of −2.4 (95% CI −5.4; 0.6) after 6 weeks. Under active treatment, more pronounced effects occurred in all secondary analyses and in nearly all secondary endpoints. The DHI sum score decreased from 44.1 to 31.1 in the total sample with a treatment group difference after 6 weeks of −3.1, 95% CI (−7.1; 0.9). No safety issues were reported.

Conclusion: Over 12 weeks, the combination of balance training with VNF and Ginkgo biloba dry extract EGb 761 reached a clinically relevant improvement of age-related vertigo and dizziness with a good pharmacological safety profile.

Feasibility and safety of an immersive virtual reality-based vestibular rehabilitation programme in people with multiple sclerosis experiencing vestibular impairment: a protocol for a pilot randomised controlled trial

INTRODUCTION

Vestibular system damage in patients with multiple sclerosis (MS) may have a central and/or peripheral origin. Subsequent vestibular impairments may contribute to dizziness, balance disorders and fatigue in this population. Vestibular rehabilitation targeting vestibular impairments may improve these symptoms. Furthermore, as a successful tool in neurological rehabilitation, immersive virtual reality (VRi) could also be implemented within a vestibular rehabilitation intervention.

METHODS AND ANALYSIS

This protocol describes a parallel-arm, pilot randomised controlled trial, with blinded assessments, in 30 patients with MS with vestibular impairment (Dizziness Handicap Inventory ≥16). The experimental group will receive a VRi vestibular rehabilitation intervention based on the conventional Cawthorne-Cooksey protocol; the control group will perform the conventional protocol. The duration of the intervention in both groups will be 7 weeks (20 sessions, 3 sessions/week). The primary outcomes are the feasibility and safety of the vestibular VRi intervention in patients with MS. Secondary outcome measures are dizziness symptoms, balance performance, fatigue and quality of life. Quantitative assessment will be carried out at baseline (T0), immediately after intervention (T1), and after a follow-up period of 3 and 6 months (T2 and T3). Additionally, in order to further examine the feasibility of the intervention, a qualitative assessment will be performed at T1.

ETHICS AND DISSEMINATION

The study was approved by the Andalusian Review Board and Ethics Committee, Virgen Macarena-Virgen del Rocio Hospitals (ID 2148-N-19, 25 March 2020). Informed consent will be collected from participants who wish to participate in the research. The results of this research will be disseminated by publication in peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT04497025.

Translation and Validation of the Dizziness Handicap Inventory into Thai Language

OBJECTIVE

To translate and evaluate psychometric properties of Thai version of the Dizziness Handicap Inventory (DHI-TH).

STUDY DESIGN

A cross-sectional study.

SETTING

Ambulatory.

PATIENTS

Fifty patients with dizziness at a vestibular clinic.

MAIN OUTCOME MEASURES

Translation and cross-cultural adaptation of the original English version of the DHI was performed according to published guidelines. Psychometric evaluation included internal consistency, content validity, test-retest reliability, convergent validity, discriminant ability, and responsiveness. Responsiveness was examined in 28 patients with vestibular dysfunction who received vestibular rehabilitation for 6 to 8 weeks.

RESULTS

There were no floor and ceiling effects. The Cronbach's alpha was good for the total score (0.87) and subscale scores (0.70 physical, 0.73 emotional, and 0.71 functional). Excellent test-retest reliability was demonstrated for the total and subscales (ICC ranged from 0.91 to 0.97, p < 0.001). The SEM was 3.50 and the MDC was 9.68. The total and subscales of DHI-TH were moderately correlated with the SF-36-TH scores (r ranged from -0.40 to -0.63). An optimal cut-off point for detection of dizziness was 21 points (98% sensitivity, 94% specificity). Responsiveness of the DHI-TH was excellent. The ES and SRM were large (1.25 and 1.59, respectively). The DHI-TH discriminated well between patients with self-perceived improved dizziness versus unchanged dizziness (AUC = 0.87). The MCID was 17 points (82.0% sensitivity, 82.0% specificity).

CONCLUSION

The DHI-TH demonstrated good psychometric properties for patients with dizziness. The DHI-TH is a valid and reliable instrument recommended as a measure of disability and quality of life in Thai patients with dizziness.

An upper cervical spine treatment protocol for cervicogenic dizziness: a randomized controlled trial

INTRODUCTION

Physiotherapy is a common treatment used for cervicogenic dizziness (CD). Treatment of the cervical spine using manual therapy techniques shows moderate evidence in favor of its use. International criteria for the treatment of the cervical spine have been described. Detecting patients' contraindications is the most important safety consideration. International criteria and recommendations for treatment of the cervical spine have been described, as well as safety criteria. A safe traction-manipulation intervention protocol is therefore possible. However, the effects of this protocol on dizziness intensity and dizziness-related disability have not been studied.

OBJECTIVE

To analyze the effects of a traction-manipulation protocol in patients with CD.

METHODS

The patients were referred by an otoneurologist, and after inclusion were randomly divided into a control group and an intervention group. The intervention was based on the application of a traction-manipulation protocol in the resting position. Dizziness intensity, self-reported disability, and cervical range of motion with and without a fixed gaze were assessed. All data were collected beforehand and at two days and four weeks after intervention.

RESULTS

At the two-days follow-up, statistically significant differences in favor of the intervention were observed between groups in the primary outcomes of dizziness intensity (p < .001) and Dizziness Handicap Inventory (p < .001), and at the four-week follow-up in dizziness intensity (p < .001) and Dizziness Handicap Inventory (p < .001).

CONCLUSIONS

The traction-manipulation protocol reduces the intensity of dizziness, the patient's self-perceived disability, and improves cervical mobility with and without fixed gaze.

Dizziness and localized pain are often concurrent in patients with balance or psychological disorders

Background and aims Symptoms of dizziness and pain are both common complaints and the two symptoms often seem to coincide. When symptoms appear concomitant for sustained periods of time the symptoms might maintain and even exacerbate each other, sometimes leading to psychological distress. In order to evaluate such comorbidity we studied patients referred to a vestibular unit and to a psychiatric outpatient clinic with respectively balance disorders and psychological issues. Methods Consecutive patients referred to a vestibular unit (n = 49) and a psychiatric outpatient clinic (n = 62) answered the Dizziness Handicap Inventory (DHI) questionnaire and a questionnaire detailing occurrence of dizziness and pain. Results The experience of dizziness and pain often coincided within individuals across both clinical populations, especially if the pain was located to the neck/shoulder or the back (p = 0.006). Patients who reported dizziness had significantly more often pain (p = 0.024); in the head (p = 0.002), neck/shoulders (p = 0.003) and feet (p = 0.043). Moreover, patients who reported dizziness stated significantly higher scoring on emotional (p < 0.001) and functional (p < 0.001) DHI sub-scales. Furthermore, patients who reported an accident in their history suffered significantly more often from dizziness (p = 0.039) and pain (p < 0.001); in the head (p < 0.001), neck/shoulders (p < 0.001) and arms (p = 0.045) and they scored higher on the emotional (p = 0.004) and functional (p = 0.002) DHI sub-scales. Conclusions The findings suggest comorbidity to exist between dizziness and neck/shoulder or back pain in patients seeking health care for balance disorders or psychological issues. Patients suffering from dizziness and pain, or with both symptoms, also reported higher emotional and functional strain. Thus, healthcare professionals should consider comorbidity when determining diagnosis and consequent measures. Implications Clinicians need to have a broader "receptive scope" in both history and clinical examinations, and ask for all symptoms. Although the patients in this study visited a vestibular unit respectively a psychological clinic, they commonly reported pain conditions when explicitly asked for this symptom. A multimodal approach is thus to favor, especially when the symptoms persist, for the best clinical management.

Does time since injury and duration matter in the benefits of physical therapy treatment for concussion?

Objective

To determine if there are differences in post-concussion symptom levels depending on 1) when physical therapy treatment is begun after the concussion and 2) the length of treatment.

Method

Retrospective chart review yielded 202 patients who sustained concussions and were referred for physical therapy. Participants/patients were assigned to independent groups based on time elapsed between concussion and physical therapy (0–14, 15–30, 31–60, 61–120, 121–365 days), and on months spent in treatment (1–4). Pre- and post- treatment scores were documented for the following measures: Sport Concussion Assessment Tool (SCAT), Convergence Insufficiency Symptom Survey (CISS), Dizziness Handicap Inventory (DHI), and Modified Clinical Test of Sensory Interaction on Balance (mCTSIB) using ANOVAs, with a Bonferroni-corrected p-value of p < .005.

Results

All patients demonstrated improvements with treatment, with no significant differences in outcomes for time elapsed since injury (SCAT Symptom Score ( p = .80), SCAT Symptom Severity Score ( p = .97), CISS ( p = .61), DHI ( p = .65), mCTSIB ( p = .13)); or for months in treatment (SCAT Symptom Score ( p = .23), SCAT Symptom Severity Score ( p = .04), CISS ( p = .41), DHI ( p = .37), mCTSIB ( p = .50)).

Conclusions

Improvements were similar for all patients receiving post-concussive physical therapy, regardless of time between injury and treatment onset, and regardless of time spent in treatment. These results may have implications for clinical decision-making and for third party payors’ coverage of post-concussion treatment. Longer periods of treatment may not necessarily be of greater benefit and application of treatment if delayed may also be beneficial. Limitations to the study, such as its retrospective nature, lack of randomization, and convenience sample size are discussed.

Exploring persistent complaints of imbalance after mTBI: Oculomotor, peripheral vestibular and central sensory integration function

BACKGROUND

Little is known on the peripheral and central sensory contributions to persistent dizziness and imbalance following mild traumatic brain injury (mTBI).

OBJECTIVE

To identify peripheral vestibular, central integrative, and oculomotor causes for chronic symptoms following mTBI.

METHODS

Individuals with chronic mTBI symptoms and healthy controls (HC) completed a battery of oculomotor, peripheral vestibular and instrumented posturography evaluations and rated subjective symptoms on validated questionnaires. We defined abnormal oculomotor, peripheral vestibular, and central sensory integration for balance measures among mTBI participants as falling outside a 10-percentile cutoff determined from HC data. A X-squared test associated the proportion of normal and abnormal responses in each group. Partial Spearman's rank correlations evaluated the relationships between chronic symptoms and measures of oculomotor, peripheral vestibular, and central function for balance control.

RESULTS

The mTBI group (n = 58) had more abnormal measures of central sensory integration for balance than the HC (n = 61) group (mTBI: 41% -61%; HC: 10%, p's <  0.001), but no differences on oculomotor and peripheral vestibular function (p >  0.113). Symptom severities were negatively correlated with central sensory integration for balance scores (p's <  0.048).

CONCLUSIONS

Ongoing balance complaints in people with chronic mTBI are explained more by central sensory integration dysfunction rather than peripheral vestibular or oculomotor dysfunction.

Epley manoeuvre for posterior semicircular canal benign paroxysmal positional vertigo in people with multiple sclerosis: protocol of a randomised controlled trial

INTRODUCTION

Vestibular disorders in multiple sclerosis (MS) could have central or peripheral origin. Although the central aetiology is the most expected in MS, peripheral damage is also significant in this disease. The most prevalent effect of vestibular peripheral damage is benign paroxysmal positional vertigo (BPPV). Impairments of the posterior semicircular canals represent 60%-90% of cases of BPPV. The standard gold treatment for this syndrome is the Epley manoeuvre (EM), the effectiveness of which has been poorly studied in patients with MS. Only one retrospective research study and a case study have reported encouraging results for EM with regard to resolution of posterior semicircular canal BPPV. The aim of this future randomised controlled trial (RCT) is to assess the effectiveness of EM for BPPV in participants with MS compared with a sham manoeuvre.

METHODS AND ANALYSIS

The current protocol describes an RCT with two-arm, parallel-group design. Randomisation, concealed allocation and double-blinding will be conducted to reduce possible bias. Participants and evaluators will be blinded to group allocation. At least 80 participants who meet all eligibility criteria will be recruited. Participants will have the EM or sham manoeuvre performed within the experimental or control group, respectively. The primary outcome of the study is changes in the Dix Hallpike test. The secondary outcome will be changes in self-perceived scales: Dizziness Handicap Inventory and Vestibular Disorders Activities of Daily Living Scale. The sample will be evaluated at baseline, immediately after the intervention and 48 hours postintervention.

ETHICS AND DISSEMINATION

The study was approved by the Andalusian Review Board and Ethics Committee of Virgen Macarena-Virgen del Rocio Hospitals (ID 0107-N-20, 23 July 2020). The results of the research will be disseminated by the investigators to peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04578262.

Dizziness Handicap Inventory in Clinical Evaluation of Dizzy Patients

(1) Objectives: The evaluation of dizzy patients is difficult due to nonspecific symptoms that require a multi-specialist approach. The Dizziness Handicap Inventory (DHI) is widely used in the assessment of dizziness-related disability, but its clinical efficacy needs further expansion. The aim of this study was to identify the subscales of DHI that may correlate with some vestibular or nonvestibular dysfunctions. (2) Material and methods: This observational study included 343 dizzy patients with one of the following clinical conditions: Vestibular impairment noncompensated or compensated, central or bilateral, benign paroxysmal positional vertigo (BPPV), migraine and psychogenic dizziness. Principal component analysis was used to examine the factorial structure of the questionnaire. (3) Results: The DHI questionnaire total scoring and its vestibular subscale distinguished between patients with compensated and uncompensated vestibular dysfunction with positive predictive values of 76% and 79%, respectively. The DHI items composing the F3 (positional) subscale revealed the highest scoring in the BPPV group with 75% sensitivity and 92% negative predictive value (NPV) in reference to Dix–Hallpike tests. The DHI total score and the subscales scores correlated with anxiety-depression, and the highest correlation coefficients were calculated for vestibular (F2 0.56) and anxiety (F5 0.51) subscales. (4) Conclusions: Our analysis revealed that the DHI vestibular subscale distinguishes between patients with compensated and uncompensated vestibular dysfunction. The positional subscale showed the highest scoring in the BPPV group with high sensitivity and low specificity of the test. The DHI is highly correlated with patients’ psychological status.

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.

Short-term effects of the traction-manipulation protocol in dizziness intensity and disability in cervicogenic dizziness: a randomized controlled trial

PURPOSE

Analyse the short-term effects of traction-manipulation protocol in dizziness and pain intensity and disability, cervical mobility and postural instability.

MATERIALS AND METHODS

Randomized controlled assessor-blind clinical trial. The traction-manipulation protocol was carried out in the intervention group and compared with a control group where the subjects were kept supine. The intervention protocol follows the IFOMPT safety recommendations. Dizziness and pain intensity, Dizziness Handicap Inventory (DHI), cervical mobility and balance were measured after 48 h and a one-month follow-up.

RESULTS

Forty subjects with cervicogenic dizziness were randomly assigned to an intervention or control group. Significant differences were found in favour of the intervention protocol group in: dizziness intensity (p < 0.001; d = 1.31), DHI (p < 0.001; d = 0.76) pain intensity (p < 0.007; d = 0.92), upper cervical flexion (p < 0.032; d = 0.30) and extension (p < 0.012; d = 0.80) at 48 h follow up. At one-month follow up there were significant differences in favour of the intervention group in: dizziness intensity (p < 0.001; d = 0.95), DHI (p < 0.001; d = 0.0.92) pain intensity (p < 0.001; d = 1.38) and upper cervical extension (p < 0.005; d = 0.92). Postural instability improved in mediolateral displacement static with eyes closed (p < 0.032; d = 0.79) and in dynamic with eyes open (p = 0.003; d = 0.55) at one-month follow-up in the intervention group.

CONCLUSION

The traction-manipulation protocol reduces the dizziness and pain intensity, ameliorates disability and improves upper cervical mobility and postural instability.IMPLICATIONS FOR REHABILITATIONThe intervention protocol reduces the dizziness and pain intensity, and improves self-perceived disability in patients with cervicogenic dizziness.Manual therapy improves the cervical range of motion and the postural instability in the cervicogenic dizziness.The intervention protocol follows the safety recommendations of the International Federation of Orthopaedic Manipulative Physical Therapists.

Upper cervical spine dysfunction and dizziness

Although various causes of dizziness have been identified, many patients suffer from dizziness of unknown etiology and continue to visit hospitals to resolve their symptoms. Problems that occur in the ligaments or muscles of the upper cervical spine can cause confusion in proprioception. These changes can convey misinformation to the vestibular nucleus, resulting in abnormal reactions that can lead to cervicogenic dizziness (CGD). Though CGD remains controversial, it should be considered while diagnosing patients with dizziness. Understanding CGD can help create treatment strategies for them. This article suggested a relationship between the structure and function of the upper cervical spine and dizziness, and presented evaluations and treatments for the same.

Treatment success of internet-based vestibular rehabilitation in general practice: development and internal validation of a prediction model

OBJECTIVES

To develop and internally validate prediction models to assess treatment success of both stand-alone and blended online vestibular rehabilitation (VR) in patients with chronic vestibular syndrome.

DESIGN

Secondary analysis of a randomised controlled trial.

SETTING

59 general practices in The Netherlands.

PARTICIPANTS

202 adults, aged 50 years and older with a chronic vestibular syndrome who received either stand-alone VR (98) or blended VR (104). Stand-alone VR consisted of a 6-week, internet-based intervention with weekly online sessions and daily exercises. In blended VR, the same intervention was supplemented with physiotherapy support.

MAIN OUTCOME MEASURES

Successful treatment was defined as: clinically relevant improvement of (1) vestibular symptoms (≥3 points improvement Vertigo Symptom Scale-Short Form); (2) vestibular-related disability (>11 points improvement Dizziness Handicap Inventory); and (3) both vestibular symptoms and vestibular-related disability. We assessed performance of the predictive models by applying calibration plots, Hosmer-Lemeshow statistics, area under the receiver operating characteristic curves (AUC) and applied internal validation.

RESULTS

Improvement of vestibular symptoms, vestibular-related disability or both was seen in 121, 81 and 64 participants, respectively. We generated predictive models for each outcome, resulting in different predictors in the final models. Calibration for all models was adequate with non-significant Hosmer-Lemeshow statistics, but the discriminative ability of the final predictive models was poor (AUC 0.54 to 0.61). None of the identified models are therefore suitable for use in daily general practice to predict treatment success of online VR.

CONCLUSION

It is difficult to predict treatment success of internet-based VR and it remains unclear who should be treated with stand-alone VR or blended VR. Because we were unable to develop a useful prediction model, the decision to offer stand-alone or blended VR should for now be based on availability, cost effectiveness and patient preference.

TRIAL REGISTRATION NUMBER

The Netherlands Trial Register NTR5712.

Cost-effectiveness of internet-based vestibular rehabilitation with and without physiotherapy support for adults aged 50 and older with a chronic vestibular syndrome in general practice

OBJECTIVES

To evaluate the cost-effectiveness of stand-alone and blended internet-based vestibular rehabilitation (VR) in comparison with usual care (UC) for chronic vestibular syndromes in general practice.

DESIGN

Economic evaluation alongside a three-armed, individually randomised controlled trial.

SETTING

59 Dutch general practices.

PARTICIPANTS

322 adults, aged 50 years and older with a chronic vestibular syndrome.

INTERVENTIONS

Stand-alone VR consisted of a 6-week, internet-based intervention with weekly online sessions and daily exercises. In blended VR, this intervention was supplemented with face-to-face physiotherapy support. UC group participants received usual general practice care without restrictions.

MAIN OUTCOME MEASURES

Societal costs, quality-adjusted life years (QALYs), Vertigo Symptom Scale-Short Form (VSS-SF), clinically relevant response (≥3 points VSS-SF improvement).

RESULTS

Mean societal costs in both the stand-alone and blended VR groups were statistically non-significantly higher than in the UC group (mean difference (MD) €504, 95% CI -1082 to 2268; and €916, 95% CI -663 to 2596). Both stand-alone and blended VR groups reported non-significantly more QALYs than the UC group (MD 0.02, 95% CI -0.00 to 0.04; and 0.01, 95% CI -0.01 to 0.03), and significantly better VSS-SF Scores (MD 3.8 points, 95% CI 1.7 to 6.0; and 3.3 points, 95% CI 1.3 to 5.2). For stand-alone VR compared with UC, the probability of cost-effectiveness was 0.95 at a willingness-to-pay ratio of €24 161/QALY, €600/point improvement in VSS-SF and €8000/clinically relevant responder in VSS-SF. For blended VR versus UC, the probability of cost-effectiveness was 0.95 at a willingness-to-pay ratio of €123 335/QALY, €900/point improvement in VSS-SF and €24 000/clinically relevant responder in VSS-SF.

CONCLUSION

Stand-alone and blended internet-based VR non-significantly increased QALYs and significantly reduced vestibular symptoms compared with UC, while costs in both groups were non-significantly higher. Stand-alone VR has the highest probability to be cost-effective compared with UC.

TRIAL REGISTRATION NUMBER

The Netherlands Trial Register NTR5712.

Measurement Properties of the Dizziness Handicap Inventory-Children and Adolescents for Children and Adolescents Postconcussion

PURPOSE

The purpose of this study was to examine and report the construct validity, internal consistency, and item structure of the Dizziness Handicap Inventory-Children and Adolescents (DHI-CA) in postconcussion children and adolescents.

METHODS

A retrospective chart review was conducted for 132 participants. Data were extracted on the DHI-CA, Sports Concussion Assessment Tool-III symptom inventory, and Vestibulo-ocular Motor Screening. The DHI-CA was examined for validity, internal consistency, and factor structure.

RESULTS

The DHI-CA had fair convergent validity (rs = 0.30-0.40), but discriminant validity findings were inconclusive. The functional subscale demonstrated least consistent loadings and 4 items had cross-loading. Reliability analysis indicated possible item redundancy given that the overall Cronbach α was higher than the subscales.

CONCLUSION

Despite demonstrating convergent validity, structural inconsistencies and possible item redundancy warrant further exploration and restructuring of the DHI-CA. Caution is recommended while making clinical decisions based on the DHI-CA results alone.

VIDEO ABSTRACT

For more insights from the authors, see Supplemental Digital Content 1, available at: http://links.lww.com/PPT/A303.

Treatment of horizontal canal BPPV-a randomized sham-controlled trial comparing two therapeutic maneuvers of different speeds

OBJECTIVES

To compare the effect of a high-speed barbecue maneuver with the modified Lempert maneuver and sham in patients with benign paroxysmal positional vertigo (BPPV) of the horizontal canal.

METHODS

Randomized sham-controlled, single blinded multicenter clinical trial in two university hospitals investigating consecutive patients with horizontal canal BPPV.Patients were randomly assigned to high-speed barbecue (HSB), modified Lempert maneuver (ML), or sham maneuver (SM). All treatments were performed in a biaxial rotational chair with weekly follow-up to a maximum of three treatment sessions. The final follow-up was 3 months after the last treatment.

RESULTS

Primary outcome: 2-week recovery rate per protocol. Secondary outcome: Cumulative recovery rate and Dizziness Handicap Inventory (DHI) scores after 3 months per protocol (HSB and ML) and intention to treat (all groups).Fifty-four patients were analyzed after 2 weeks (HSB = 17; ML = 20; SM = 17). Two-week recovery rate was 14/17 after HSB, 11/20 after ML, and 4/17 after SM, with significantly better recovery in HSB [OR 15.17, 95% CI (1.85, 124.63), P = .001] using sham as base level. Recovery rate after 3 months was 15/17 after HSB and 15/19 after ML. Cumulative recovery rate showed no significant differences between the two treatment groups [95% CI (0.30, 13.14), P = .46] in cure rate DHI [95% CI (-16.56, 15.02), P = .92]. No unexpected adverse events were observed.

CONCLUSION

Velocity change in horizontal canal BPPV treatment gives a faster initial recovery. Rapid recovery could reduce the disease burden.

TRIAL REGISTRATION

Clinicaltrials.gov. Identifier: NCT01905800.

LEVEL OF EVIDENCE

1b.

The 25-item Dizziness Handicap Inventory was shortened for use in general practice by 60 percent

OBJECTIVES

The 25-item Dizziness Handicap Inventory (DHI) is the most used questionnaire to assess vestibular symptoms. However, the abbreviated 10-item DHI-S is more suitable for daily practice. The objective of this study was to assess validity, reliability, responsiveness, optimal cutoff point for substantial impairment, and minimally important change (MIC) of the DHI-S in general practice.

STUDY DESIGN AND SETTING

We performed a psychometric questionnaire evaluation in general practice. In a prospective cohort study, 415 adults with vestibular symptoms filled out the DHI at baseline, and 1-week, 6-month, and 10-year follow-up. DHI answers were used to calculate DHI-S scores. We assessed validity by criterion validity (Pearson's r) at each measurement. We used longitudinal measurements for test-retest reliability (intraclass correlation coefficient (ICC)) and responsiveness (r). We determined optimal DHI-S cutoff points for substantial impairment (≥30 DHI) and MIC (>11 DHI) with receiver operating characteristic (ROC) curve analyses.

RESULTS

DHI-S demonstrated excellent criterion validity (r = 0.93-0.96), test-retest reliability (ICC = 0.86), and responsiveness (r = 0.89). DHI-S reliably distinguished substantial impairment and identified MIC, with optimal DHI-S cutoff scores of ≥12 points and >5 points, respectively.

CONCLUSION

The DHI-S is a valid, reliable, and responsive questionnaire that could replace the DHI in general practice.

The Component Structure of the Dizziness Handicap Inventory (DHI): A Reappraisal

OBJECTIVE

The Dizziness Handicap Inventory (DHI) is a 25-item self-report questionnaire developed to measure the disabling and handicapping impact of dizziness. The present investigation was conducted in an effort to re-assess the factor structure of the DHI.

STUDY DESIGN

Retrospective study.

SETTING

Tertiary care center.

PATIENTS

Subjects were 1,991 patients who were evaluated in the Mayo Clinic-Rochester Vestibular and Balance Laboratory.

MAIN OUTCOME MEASURES

Exploratory factor analysis: an exploratory bifactor analysis (EFA) with bifactor rotation was used to analyze a random sample of 999 patients. Analyses were used to determine the dominance of the general factor (i.e., total score) relative to the group factor (i.e., subscales). Confirmatory factor analysis: a confirmatory bifactor graded response model was fit with appropriate item-to-group relationships that was discovered by our exploratory analyses. To validate the bifactor model that was identified with the exploratory analyses, a bifactor model with three grouping factors (i.e., Physical manifestations, Catastrophic impact of dizziness, and the Emotional impact of dizziness) were fit to a different random sample of 992 patients using the new item-to-group factor specifications.

RESULTS

In the confirmatory analyses, all items had a positive factor loading on the general factor. There were 14 items that loaded on the general factor only. The rest of the items (n = 11) loaded on both the general factor and one of three group factors.

CONCLUSIONS

Conclusions of the study revealed several findings: 1) reporting the result as a total score (i.e., a single general factor) is warranted, and, 2) there is statistical support for the existence of three subscales representing: the Physical manifestations, Catastrophic impact, and Emotional impact of dizziness and vertigo.

Validation and Factor Analysis of the Lithuanian Version of the Dizziness Handicap Inventory

OBJECTIVES

This study aimed to validate the Lithuanian version of the Dizziness Handicap Inventory (DHI-L), investigate its reliability, and perform factor analysis.

MATERIALS AND METHODS

A standard protocol of translation was followed for psychometric instruments. A total of 108 patients (75.9% women), mean age 51.9 years, with peripheral or central dizziness and vertigo participated in our cross-sectional study. The internal consistency was measured by Cronbach's alpha coefficient and corrected item-total correlations (CI-TCs). After a week, 65 of the recruited patients were again asked to fill out Dizziness Handicap Inventory (DHI)-L to ascertain test-retest reliability (intraclass correlation, ICC). Concurrent validation was performed using Pearson correlation between the total score and subscales of DHI-L and the eight scales of Short Form-36 Health Survey (SF-36). Finally, the factor structure of the DHI was assessed by principal component analysis (PCA).

RESULTS

The Cronbach's alpha coefficient was very high (0.91). CI-TCs for DHI-L total scale ranged from 0.33 to 0.67. The correlations between DHI and SF-36 were high to weak. The ICC was excellent for the total score and its subscales. Our proposed two-factor model explained 44.5% of the variance. The first factor indicated disability in daily activities and psychological effect of handicap. The second factor comprised of items that pertained to postural instability.

CONCLUSION

The DHI-L has shown good reliability and validity. Results did not support the original subscale structure of the DHI. As more studies need to be done to restructure DHI, we recommend only using the total DHI score as a measure of dizziness handicap.

Comparing the measurement properties and relationship to gait speed recovery of the Mini-Balance Evaluation Systems Test and the Berg Balance Scale in ambulatory individuals with subacute stroke

OBJECTIVES

Although the Mini-Balance Evaluation Systems Test (Mini-BESTest) is known to be a reliable and valid measure of balance in individuals with stroke, the utility of this tool in relation to subacute stroke walking speed and the recovery of gait ability has not been explored. Here, we compared the measurement properties and their relationship to gait speed on the Mini-BESTest and the Berg Balance Scale (BBS) in middle and older ambulatory individuals with subacute stroke, and we investigated which balance assessment tool is more likely to capture the status of the recovery of gait speed.

METHODS

We retrospectively analyzed the cases of 88 individuals 50 years or older with stroke who had been evaluated using the Mini-BESTest by using the BBS and by assessing their comfortable walking speed (CWS). The proportion of subjects who showed improvement was calculated for 34 stroke survivors from data obtained at admission to and discharge from the hospital.

RESULTS

Compared with the BBS, the Mini-BESTest showed a better distribution of total scores without a ceiling effect. The two scales showed correlations with gait speed (Mini-BESTest: r=0.702; BBS: r=0.592) and discrimination between fast and slow walkers. The responsiveness of the Mini-BESTest was excellent, with an area under the curve of 0.894, thus discriminating between gait speed improvement versus non-improvement.

CONCLUSIONS

These results indicate that the Mini-BESTest is more useful than the BBS in terms of its measurement properties and ability to measure gait recovery in middle and older ambulatory individuals with subacute stroke.

Prospective cohort study on the predictors of fall risk in 119 patients with bilateral vestibulopathy

OBJECTIVES

To identify predictive factors for falls in patients with bilateral vestibulopathy (BV). Specific variables contributing to the general work-up of a vestibular patient were compared between BV patients experiencing falls and those who did not.

DESIGN

Prospective multi-centric cohort study.

SETTING

Department of Otorhinolaryngology & Head and Neck Surgery at two tertiary referral centers: Antwerp University Hospital and Maastricht University Medical Center.

PARTICIPANTS

In total, 119 BV patients were included. BV diagnosis was defined in accordance with the diagnostic BV criteria, established by the Bárány Society in 2017.

MAIN OUTCOME MEASURES

Patients were divided into fallers and non-fallers, depending on the experience of one or more falls in the preceding 12 months. Residual vestibular function on caloric testing, rotatory chair testing, video head impulse test (vHIT) and cervical vestibular evoked myogenic potentials (cVEMP) was evaluated as a predictive factor for falls. Furthermore, hearing function (speech perception in noise (SPIN)), sound localization performance, etiology, disease duration, sport practice, scores on the Dizziness Handicap Inventory (DHI) and the Oscillopsia Severity Questionnaire (OSQ) were compared between fallers and non-fallers.

RESULTS

Forty-five (39%) patients reported falls. In a sub-analysis in the patients recruited at UZA (n = 69), 20% experienced three or more falls and three patients (4%) suffered from severe fall-related injuries. The DHI score and the OSQ score were significantly higher in fallers. Residual vestibular function, SPIN, sound localization performance, etiology, disease duration, age and sport practice did not differ between fallers and non-fallers.

CONCLUSIONS

Falls and (severe) fall-related injuries are frequent among BV patients. A DHI score > 47 and an OSQ score > 27.5 might be indicative for BV patients at risk for falls, with a sensitivity of 70% and specificity of 60%. Residual vestibular function captured by single vestibular tests (vHIT, calorics, rotatory chair, cVEMP) or by overall vestibular function defined as the number of impaired vestibular sensors are not suitable to distinguish fallers and non-fallers in a BV population.

Prognosis and Survival of Older Patients With Dizziness in Primary Care: A 10-Year Prospective Cohort Study

PURPOSE

The prognosis of older patients with dizziness in primary care is unknown. Our objective was to determine the prognosis and survival of patients with different subtypes and causes of dizziness.

METHODS

In a primary care prospective cohort study, 417 older adults with dizziness (mean age 79 years) received a full diagnostic workup in 2006-2008. A panel of physicians classified the subtype and primary cause of dizziness. Main outcome measures were mortality and dizziness-related impairment assessed at 10-year follow-up.

RESULTS

At 10-year follow-up 169 patients (40.5%) had died. Presyncope was the most common dizziness subtype (69.1%), followed by vertigo (41.0%), disequilibrium (39.8%), and other dizziness (1.7%). The most common primary causes of dizziness were cardiovascular disease (56.8%) and peripheral vestibular disease (14.4%). Multivariable adjusted Cox models showed a lower mortality rate for patients with the subtype vertigo compared with other subtypes (hazard ratio [HR] = 0.62; 95% CI, 0.40-0.96), and for peripheral vestibular disease vs cardiovascular disease as primary cause of dizziness (HR = 0.46; 95% CI, 0.25-0.84). After 10 years, 47.7% of patients who filled out the follow-up measurement experienced substantial dizziness-related impairment. No significant difference in substantial impairment was seen between different subtypes and primary causes of dizziness.

CONCLUSIONS

The 10-year mortality rate was lower for the dizziness subtype vertigo compared with other subtypes. Patients with dizziness primarily caused by peripheral vestibular disease had a lower mortality rate than patients with cardiovascular disease. Substantial dizziness-related impairment in older patients with dizziness 10 years later is high, and indicates that current treatment strategies by family physicians may be suboptimal.