Treatment of dizziness: an interdisciplinary update

Association between screen time and self-reported balance disorders in middle-aged and older adults: national health and nutrition examination survey

BACKGROUND

Balance disorders can give rise to sensations of instability, lightheadedness, vertigo, disequilibrium, or syncope, ultimately leading to grave medical, physical, emotional, and societal ramifications. These conditions are highly prevalent among individuals aged 40 and above. Screen time encompasses activities associated with television viewing, video game playing, and non-work-related computer usage. Prolonged screen exposure may engender a spectrum of health issues and even elevate overall mortality rates. However, the available evidence on the potential link between excessive screen time and balance dysfunction remains limited.

AIMS

The primary aim of this study was to explore the possible association between prolonged screen exposure and impaired balance function.

METHODS

This cross-sectional study utilized data from participants who completed a comprehensive questionnaire in the NHANES database between 1999 and 2002, all of whom were aged over 40 and under 85 years. Participants' screen time was categorized into two groups (< 4 h/d and  ≥4 h/d) for subsequent data analysis. Logistic regression, combined with propensity score matching (PSM), was employed to investigate the correlation between screen time and balance disorders.

RESULTS

A total of 5176 participants were enrolled in this study, comprising 2,586 men and 2,590 women, with a prevalence rate of balance disorders at 25.7% (1331/5176). The incidence of balance disorders was found to be significantly higher among individuals who spent 4 hours or more per day on screen time compared to those with less screen time (P<0.001). Multivariate logistic analysis conducted on the unmatched cohort revealed a significant association between screen time and balance disorders, with an odds ratio (OR) 1.8 (95%CI 1.57 ∼ 2.05). These findings remained consistent even after adjusting for confounding factors, yielding an OR 1.43 (95%CI 1.24 ∼ 1.66). Moreover, the association persisted when employing various multivariate analyses such as propensity score matching adjusted model, standardized mortality ratio weighting model and pairwise algorithmic model; all resulting in ORs ranging from 1.38 to 1.43 and p-values < 0.001.

CONCLUSIONS

After controlling for all covariates, screen time (watching TV, playing video games, and using computers outside of work) was associated with balance dysfunction among middle-aged and older adults. This finding may offer a possible idea for the prevention of dizziness and balance disorders. Nevertheless, additional research is imperative to further validate these results.

Current definition, diagnosis, and treatment of canine and feline idiopathic vestibular syndrome

Idiopathic vestibular syndrome (IVS) is one of the most common neurological disorders in veterinary medicine. However, its diagnosis and treatment varies between publications. The aim of the current study was to gather experts' opinion about IVS definition, diagnosis, and treatment. An online-survey was used to assess neurology specialists' opinion about the definition, diagnosis and treatment of IVS. The study demonstrated that the definition, diagnosis, and treatment of IVS are largely consistent worldwide, with the EU prioritising less frequently advanced imaging and more often otoscopy to rule out other diseases. IVS was defined by most specialists as an acute to peracute, improving, non-painful peripheral vestibular disorder that often affects cats of any age and geriatric dogs. Regarding diagnosis, a detailed neurological examination and comprehensive blood tests, including thyroid values, blood pressure, and otoscopic examination, was seen as crucial. A thorough workup may also involve MRI and CSF analysis to rule out other causes of vestibular dysfunction. Treatment of IVS typically involved intravenous fluid therapy and the use of an antiemetic, with maropitant once daily being the preferred choice among specialists. Antinausea treatment was considered, however, only by a handful specialists. This survey-based study provides valuable insights from neurology experts and highlights areas that require further research to bridge the gap between theory and practice.

Central vestibular dysfunction: don't forget vestibular rehabilitation

INTRODUCTION

Vestibular rehabilitation (VR) is now a subject of active studies and has been shown to be effective for multiple vestibular disorders, peripheral or central. VR is a physical therapy that helps train the central nervous system to compensate for vestibular dysfunction. There is moderate to strong evidence that VR is safe and effective for the management of peripheral vestibular dysfunction. Nonetheless, the studies on how VR works on central vestibular dysfunction remains scanty.

AREAS COVERED

This article addressed the rehabilitation strategies and possible mechanisms, including how central vestibular function might improve upon rehabilitation. In addition, it provides some examples concerning the effect of VR on central vestibular dysfunction.

EXPERT OPINION

VR works on the vestibular system through repetition of specific physical exercises that activate central neuroplastic mechanisms to achieve adaptive compensation of the impaired functions. VR has become a mainstay in the management of patients with dizziness and balance dysfunction. Individualized VR programs are a safe and effective treatment option for a large percentage of patients with central vestibular disease reporting imbalance and dizziness. Exploration of various treatment strategies and possible mechanisms will help develop the best and personalized VR treatment for patients with central vestibular dysfunction.

Cervicogenic dizziness alleviation after coblation discoplasty: a retrospective study

OBJECTIVE

Little is known about the therapeutic relationship between coblation discoplasty and cervicogenic dizziness (CGD). CGD can be caused by abnormal proprioceptive inputs from compressed nerve roots, intradiscal mechanoreceptors and nociceptors to the vestibulospinal nucleus in the degenerative cervical disc. The aim was to analyze the efficacy of coblation discoplasty in CGD through intradiscal nerve ablation and disc decompression in a 12-month follow-up retrospective study.

METHODS

From 2015 to 2019, 42 CGD patients who received coblation discolplasty were recruited as the surgery group, and 22 CGD patients who rejected surgery were recruited as the conservative group. Using intent-to-treat (ITT) analysis, we retrospectively analyzed the CGD visual analogue scale (VAS), neck pain VAS, CGD frequency score, and the CGD alleviation rating throughout a 12-month follow-up period.

RESULTS

Compared with conservative intervention, coblation discoplasty revealed a better recovery trend with effect sizes of 1.76, 2.15, 0.92, 0.78 and 0.81 in CGD VAS, and effect sizes of 1.32, 1.54, 0.93, 0.86 and 0.76in neck pain VAS at post-operative 1 week, and 1, 3, 6, 12 months, respectively. The lower CGD frequency score indicated fewer attacks of dizziness until postoperative 3 months (p < 0.01). At post-operative 12 months, the coblation procedure showed increased satisfactory outcomes of CGD alleviation rating (p < .001, -1.00 of effect size).

CONCLUSIONS

Coblation discoplasty significantly improves the severity and frequency of CGD, which is important inbridging unresponsive conservative intervention and open surgery.Key messagesThere is a correlation between the degenerative cervical disc and cervicogenic dizziness (CGD).CGD can be caused by abnormal proprioceptive inputs from a compressed nerve root and intradiscal mechanoreceptors and nociceptors to the vestibulospinal nucleus in the degenerative cervical disc.Cervical coblation discoplasty can alleviate CGD through ablating intradiscal nerve endings and decompressing the nerve root.

Changing Paradigm for Vertigo/Dizziness Patients: a Retrospective Before-After Study from Tertiary Hospitals in Northwestern China

BACKGROUND

Single disciplinary management of patients with vertigo and dizziness is an important challenge for most physicians in China.

OBJECTIVE

To assess the impact of a new paradigm of practice (Clinic for Vertigo and Dizziness, CVD) performed by a multidisciplinary team (MDT) on diagnostic spectrum, medical costs, and patient satisfaction.

DESIGN

Retrospective before-after study.

PARTICIPANTS

Sample of 29,793 patients with vertigo/dizziness as primary complaint.

MEASURES

Changes in diagnostic spectrum, medical costs, and patient satisfaction before and after the establishment of a CVD based on a 4-year database in three tertiary hospitals in northwestern China.

KEY RESULTS

The most common diagnoses of patients with vertigo and dizziness were Meniere's disease (25.77%), cervical disease (25.00%), cerebral vascular disease (13.96%), vestibular syndrome (10.57%), and other etiologies (6.34%) before the CVD establishment. In contrast, after the CVD establishment, the most common diagnoses were BPPV (23.92%), vestibular migraine (15.83%), Meniere's disease (14.22%), CSD/PPPD (11.61%), and cerebral vascular diseases (4.45%). Extended implementation of a structured questionnaire for vertigo/dizziness and vestibular-oriented examinations (nystagmus, positional tests, HINTS) at the CVD resulted in a remarkable decline in the utility of CT/MRI and X-ray examination (p < 0.001). Meanwhile, medical costs in patients with vertigo/dizziness dropped by 11.5% (p < 0.001), with a significant improvement in patient satisfaction after the establishment of CVD (p < 0.001).

CONCLUSIONS AND RELEVANCE

Our study suggested that the MDT paradigm of CVD practice may facilitate the medical management of patients with vertigo/dizziness and improve patient satisfaction.

Development of a complex intervention to improve mobility and participation of older people with vertigo, dizziness and balance disorders in primary care: a mixed methods study

BACKGROUND

Vertigo, dizziness and balance disorders (VDB) are common in older people and cause restrictions in mobility and social participation. Due to a multifactorial aetiology, health care is often overutilised, but many patients are also treated insufficiently in primary care. The purpose of this study was to develop a care pathway as a complex intervention to improve mobility and participation in older people with VDB in primary care.

METHODS

The development process followed the UK Medical Research Council guidance using a mixed-methods design with individual and group interviews carried out with patients, physical therapists (PTs), general practitioners (GPs), nurses working in community care and a multi-professional expert panel to create a first draft of a care pathway (CPW) and implementation strategy using the Consolidated Framework of Implementation Research and the Expert recommendations for Implementing Change. Subsequently, small expert group modelling of specific components of the CPW was carried out, with GPs, medical specialists and PTs. The Behaviour Change Wheel was applied to design the intervention´s approach to behaviour change. To derive theoretical assumptions, we adopted Kellogg´s Logic Model to consolidate the hypothesized chain of causes leading to patient-relevant outcomes.

RESULTS

Individual interviews with patients showed that VDB symptoms need to be taken more seriously by GPs. Patients demanded age-specific treatment offers, group sessions or a continuous mentoring by a PT. GPs required a specific guideline for diagnostics and treatment options including psychosocial interventions. Specific assignment to and a standardized approach during physical therapy were desired by PTs. Nurses favoured a multi-professional documentation system. The structured three-day expert workshop resulted in a first draft of CPW and potential implementation strategies. Subsequent modelling resulted in a CPW with components and appropriate training materials for involved health professionals. A specific implementation strategy is now available.

CONCLUSION

A mixed-methods design was suggested to be a suitable approach to develop a complex intervention and its implementation strategy. We will subsequently test the intervention for its acceptability and feasibility in a feasibility study accompanied by a comprehensive process evaluation to inform a subsequent effectiveness trial.

TRIAL REGISTRATION

The research project is registered in "Projektdatenbank Versorgungsforschung Deutschland" (Project-ID: VfD_MobilE-PHY_17_003910; date of registration: 30.11.2017).

The Treatment of Vestibular Migraine: A Narrative Review

Vestibular migraine (VM) is one of the most debilitating chronic diseases that is currently underdiagnosed and undertreated. The treatment of VM is a dynamic and rapidly advancing area of research. New developments in this field have the potential to improve the diagnosis and provide more individualized treatments for this condition. In this review, we discussed the progress of evidence-based treatment of VM, including pharmacotherapy and nonmedical methods. A search of the literature was conducted up to September 2019. In order to control or cure VM, patients should follow three steps. First, patients should comply with diet and behavioral medication; Second, during the attack of VM, patients should take medicine to control the symptoms. These acute attack treatment of VM consists of antiemetic medications (e.g., dimenhydrinate and benzodiazepines), anti-vertigo medicine, and analgesics (e.g. triptans). Third, prophylactic medicine (e.g., propranolol, topiramate, valproic aid, lamotrigine, and flunarizine) can be used to reduce the frequency and severity of VM attack. Also, vestibular rehabilitation (VR) treatment should be considered for all VM. Meanwhile, we also propose to establish a culture of prevention which is essential for reducing the personal, social and economic burden of VM.

[Clinical diagnosis and treatment of chronic dizziness]

Chronic dizziness is defined as a complex of symptoms lasting months or years, including oscillopsia, nystagmus, and postural instability. Diagnostic search includes peripheral vestibulopathy - chronic unilateral vestibulopathy resulting from vestibular neuronitis, schwannoma of the 8th pair of cranial nerves, medical or surgical ablation of the labyrinth, and bilateral vestibulopathy; central vestibulopathy - syndromes accompanied by central vertical nystagmus, small vessel disease in patients with chronic cerebral ischemia; general somatic diseases, peripheral polyneuropathy, side-effects of medications as well as persistent postural-perceptual dizziness. Often, when collecting an anamnesis, it is not possible to identify specific features of dizziness and instability, therefore, clinical and instrumental examination of the patient is of particular importance. In the otoneurological examination, the greatest attention is paid to static/coordination tests, oculomotor tests aimed at identifying signs of damage to the vestibulo-ocular reflex. The principles of treatment depend on the diagnosed cause of dizziness and instability and can, to varying degrees, combine pharmacotherapy, vestibular rehabilitation and psychotherapy, as well as correction of therapy for the underlying disease that caused vestibulopathy.

Physical therapy interventions for older people with vertigo, dizziness and balance disorders addressing mobility and participation: a systematic review

BACKGROUND

Vertigo, dizziness and balance disorders (VDB) are among the most relevant contributors to the burden of disability among older adults living in the community and associated with immobility, limitations of activities of daily living and decreased participation. The aim of this study was to identify the quality of evidence of physical therapy interventions that address mobility and participation in older patients with VDB and to characterize the used primary and secondary outcomes.

METHODS

A systematic search via MEDLINE (PubMed), Cochrane Library, CINAHL, PEDro, forward citation tracing and hand search was conducted initially in 11/2017 and updated in 7/2019. We included individual and cluster-randomized controlled trials and trials with quasi-experimental design, published between 2007 and 2017/2019 and including individuals ≥65 years with VDB. Physical therapy and related interventions were reviewed with no restrictions to outcome measurement. Screening of titles, abstracts and full texts, data extraction and critical appraisal was conducted by two independent researchers. The included studies were heterogeneous in terms of interventions and outcome measures. Therefore, a narrative synthesis was conducted.

RESULTS

A total of 20 randomized and 2 non-randomized controlled trials with 1876 patients met the inclusion criteria. The included studies were heterogeneous in terms of complexity of interventions, outcome measures and methodological quality. Vestibular rehabilitation (VR) was examined in twelve studies, computer-assisted VR (CAVR) in five, Tai Chi as VR (TCVR) in three, canal repositioning manoeuvres (CRM) in one and manual therapy (MT) in one study. Mixed effects were found regarding body structure/function and activities/participation. Quality of life and/or falls were assessed, with no differences between groups. VR is with moderate quality of evidence superior to usual care to improve balance, mobility and symptoms.

CONCLUSION

To treat older individuals with VDB, VR in any variation and in addition to CRMs seems to be effective. High-quality randomized trials need to be conducted to inform clinical decision making.

TRIAL REGISTRATION

PROSPERO 2017 CRD42017080291 .

[Qualitative Study on the Experience of Patients with Meniere Disease]

PURPOSE

The purpose of this study was to understand and describe the experiences of patients with Meniere disease.

METHODS

Data were collected from February 19, 2019, to February 5, 2020, through individual in-depth interviews with 13 Meniere patients. Verbatim transcripts were analyzed using Colaizzi's phenomenological analysis.

RESULTS

The experiences of patients with Meniere disease were clustered into the following four themes from 22 meaning units: 1) Complex unfamiliar symptoms that shatter both balance of the body and peace of the heart; 2) A disease that health professionals and medical treatment cannot cure; 3) Suffering hardships that cannot be understood by non-Meniere's sufferers; and 4) Making daily efforts to become healthier. Meniere's symptoms are life-shattering and depressing because they are neither visible nor easily curable. Over time, as they accepted the reality of living with the disease, the participants would shift their focus from complete symptomatic cure to leading a healthy and more balanced life.

CONCLUSION

This study shows that Meniere disease has a pervasive impact on all aspects of the patients' lives. Patients are prone to experiencing restrictions in their social functioning and activities. They also experience psychosocial problems due to the unseen nature of their symptoms. This study elucidates the experiences of Meniere patients and the need for nursing intervention to help improve their quality of life and ability to self-manage. Lastly, this study shows the need for a coordinated interdisciplinary approach to raising public awareness of the disease.

A review on the alterations in the brain of persistent postural-perceptual dizziness patients and non-pharmacological interventions for its management

Persistent postural perceptual dizziness (PPPD) is a relatively newer term, and this term is included in the International Classification of Diseases in its 11th revision. The typical features of PPPD include the presence of persistent dizziness, non-spinning vertigo, and unsteadiness, and these symptoms are exacerbated during upright posture, movement, or visual stimuli. Moreover, the structural changes have also been identified in the brains of PPPD patients, particularly in visual, vestibular, and limbic areas. These include a decrease in the volume and gyration of gray matter, a decrease in the blood flow to the cortex region, and alterations in the structural and functional connectivity, particularly in the visual-vestibular networks. Moreover, the impairment in sensory processing is restricted not only to the vestibular and visual regions; instead, there is a generalized impairment in the sensory processing, and thus, there is a multisensory dimension of sensory impairment. Selective serotonin uptake inhibitors and serotonin-norepinephrine reuptake inhibitors are the mainstay drugs for the management of PPPD patients. However, a significant proportion of PPPD patients do not show improvement in response to standard drug therapy. The employment of alternative and complementary treatment strategies, including vestibular rehabilitation therapy, cognitive behavioral therapy, and non-invasive vagal nerve stimulation, is effective in the management of PPPD patients. The present review discusses the alterations in the brains of PPPD patients along with the possible non-pharmacological treatment options in these types of patients.

Persistent postural-perceptual dizziness: current approaches to diagnosis and treatment

The cause of persistent postural-perceptual dizziness (PPPD) is considered to be chronic dysfunction of the regulatory system for maintaining equilibrium in general and that of the vestibular system in particular, which causes a persistent sensation of dizziness and/or unsteadiness. The pathogenetic mechanisms of PPPD are associated with impaired adaptation to an acute vertigo or unsteadiness episode due to various causes (vestibular, lipothymic, or emotional). Patients severely experience PPPD, which often leads to avoidant behavior and even disability. The timely diagnosis of this disorder and the use of right treatment, including vestibular rehabilitation, antidepressants, and cognitive behavioral therapy, are of great importance. Currently developed new treatments for PPPD are highly therapeutically effective. Among the medicines, Ginkgo biloba extract has been shown to be effective in improving vestibular compensation.

Effects of Vestibular Rehabilitation in the Management of a Vestibular Migraine: A Review

Vestibular rehabilitation (VR) has been shown to be effective for many vestibular disorders. This review focuses on the current evidence on the effects of physical therapy in the management of vestibular symptoms in individuals with a vestibular migraine (VM). The individuals with a history of a migraine tend to have a high incidence of vestibular symptoms with some or all of their headaches. A total of six included studies investigated the effects of VR in the management of VM. The critical review form for quantitative studies was used to appraise quality assessment and risk of bias in the selected studies. Previous studies validated the use of VR in the treatment of vestibular symptoms for individuals with a VM to include improved headache and migraine-related disability in patients with a VM. From the current evidence, it is difficult to provide conclusive evidence regarding the efficacy of VR to minimize vestibular symptoms in patients with VM. Therefore, more randomized controlled studies are required to make firm evidence on the effect of VR in reducing vestibular symptoms in patients with VM. The future prospective, blinded, randomized controlled studies may help to isolate possible therapeutic effects of VR and other general effects.