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Akin FW, Swan AA, Kalvesmaki A, Hall CD, Riska KM, Stressman KD, Nguyen H, Amuan M, Pugh MJ. Factors That Impact the Long-Term Outcome of Postconcussive Dizziness Among Post-9/11 Veterans. Am J Audiol 2023; 32:706-720. [PMID: 37040302 DOI: 10.1044/2023_aja-22-00150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023] Open
Abstract
PURPOSE The primary aim of this study was to examine the factors associated with long-term outcomes of postconcussive disruptive dizziness in Veterans of the post-9/11 wars. METHOD For this observational cohort study, the Neurobehavioral Symptom Inventory-Vestibular subscale (NSI-V) score was used as an outcome measure for dizziness in 987 post-9/11 Veterans who indicated disruptive dizziness at an initial Veterans Health Administration Comprehensive Traumatic Brain Injury Evaluation (CTBIE). An NSI-V change score was calculated as the difference in the scores obtained at the initial CTBIE and on a subsequent survey. Differences in the NSI-V change scores were examined for demographics, injury characteristics, comorbidities, and vestibular and balance function variables, and multiple linear regression analyses were used to explore associations among the variables and the NSI-V change score. RESULTS The majority of Veterans (61%) demonstrated a decrease in the NSI-V score, suggesting less dizziness on the survey compared with the CTBIE; 16% showed no change; and 22% had a higher score. Significant differences in the NSI-V change score were observed for traumatic brain injury (TBI) status, diagnoses of post-traumatic stress disorder (PTSD), headache and insomnia, and vestibular function. Multivariate regressions revealed significant associations between the NSI-V change score and the initial CTBIE NSI-V score, education level, race/ethnicity, TBI status, diagnoses of PTSD or hearing loss, and vestibular function. CONCLUSIONS Postconcussive dizziness can continue for years following an injury. Factors associated with poor prognosis include TBI, diagnoses of PTSD or hearing loss, abnormal vestibular function, increased age, identification as a Black Veteran, and high school education level.
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Affiliation(s)
- Faith W Akin
- Vestibular and Balance Laboratory, James H. Quillen VA Medical Center, Mountain Home, TN
- Department of Audiology & Speech-Language Pathology, East Tennessee State University, Johnson City
| | - Alicia A Swan
- Department of Psychology, The University of Texas at San Antonio
- Polytrauma Rehabilitation Center, South Texas Veterans Health Care System, San Antonio
| | - Andrea Kalvesmaki
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, UT
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Courtney D Hall
- Vestibular and Balance Laboratory, James H. Quillen VA Medical Center, Mountain Home, TN
- Physical Therapy Program, East Tennessee State University, Johnson City
| | - Kristal M Riska
- Department of Head and Neck Surgery & Communication Sciences, Duke University, Durham, NC
| | - Kara D Stressman
- Vestibular and Balance Laboratory, James H. Quillen VA Medical Center, Mountain Home, TN
| | - Huong Nguyen
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, UT
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Megan Amuan
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, UT
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Mary Jo Pugh
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, UT
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
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Akin FW, Murnane OD, Hall CD, Riska KM, Sears J. Vestibular and balance function in veterans with chronic dizziness associated with mild traumatic brain injury and blast exposure. Front Neurol 2022; 13:930389. [PMID: 36119708 PMCID: PMC9481418 DOI: 10.3389/fneur.2022.930389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 08/15/2022] [Indexed: 11/13/2022] Open
Abstract
The purpose of this study was to examine vestibular and balance function in individuals with chronic dizziness associated with mTBI/blast. A prospective case-control study design was used to examine ocular motor, vestibular function, and postural stability in veterans with symptoms of dizziness and/or imbalance following an mTBI or blast exposure (n = 77) and a healthy control group (n = 32). Significant group differences were observed for saccadic accuracy, VOR gain during slow harmonic acceleration at 0.01 Hz, cervical vestibular evoked myogenic potentials asymmetry ratio, composite equilibrium score on the sensory organization test, total Dynamic Gait Index score, and gait. The frequency of test abnormalities in participants with mTBI/blast ranged from 0 to 70% across vestibular, ocular motor, and balance/gait testing, with the most frequent abnormalities occurring on tests of balance and gait function. Seventy-two percent of the mTBI/blast participants had abnormal findings on one or more of the balance and gait tests. Vestibular test abnormalities occurred in ~34% of the individuals with chronic dizziness and mTBI/blast, and abnormalities occurred more frequently for measures of otolith organ function (25% for cVEMP and 18% for oVEMP) than for measures of hSCC function (8% for SHA and 6% for caloric test). Abnormal ocular motor function occurred in 18% of the mTBI/blast group. These findings support the need for comprehensive vestibular and balance assessment in individuals with dizziness following mTBI/blast-related injury.
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Affiliation(s)
- Faith W. Akin
- Mountain Home Hearing and Balance Research Program, James H. Quillen VA Medical Center, Mountain Home, TN, United States
- Department of Audiology and Speech-Language Pathology, East Tennessee State University, Johnson City, TN, United States
- *Correspondence: Faith W. Akin
| | - Owen D. Murnane
- Mountain Home Hearing and Balance Research Program, James H. Quillen VA Medical Center, Mountain Home, TN, United States
- Department of Audiology and Speech-Language Pathology, East Tennessee State University, Johnson City, TN, United States
| | - Courtney D. Hall
- Mountain Home Hearing and Balance Research Program, James H. Quillen VA Medical Center, Mountain Home, TN, United States
- Physical Therapy Program, Department of Rehabilitative Sciences, East Tennessee State University, Johnson City, TN, United States
| | - Kristal M. Riska
- Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, Durham, NC, United States
| | - Jennifer Sears
- Mountain Home Hearing and Balance Research Program, James H. Quillen VA Medical Center, Mountain Home, TN, United States
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Swan AA, Akin FW, Amuan ME, Riska KM, Hall CD, Kalvesmaki A, Padilla S, Crowsey E, Pugh MJ. Disruptive Dizziness Among Post-9/11 Veterans With Deployment-Related Traumatic Brain Injury. J Head Trauma Rehabil 2022; 37:199-212. [PMID: 34320551 DOI: 10.1097/htr.0000000000000714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To identify disruption due to dizziness symptoms following deployment-related traumatic brain injury (TBI) and factors associated with receiving diagnoses for these symptoms. SETTING Administrative medical record data from the Department of Veterans Affairs (VA). PARTICIPANTS Post-9/11 veterans with at least 3 years of VA care who reported at least occasional disruption due to dizziness symptoms on the comprehensive TBI evaluation. DESIGN A cross-sectional, retrospective, observational study. MAIN MEASURES International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes of dizziness, vestibular dysfunction, and other postconcussive conditions; neurobehavioral Symptom Inventory. RESULTS Increased access to or utilization of specialty care at the VA was significant predictors of dizziness and/or vestibular dysfunction diagnoses in the fully adjusted model. Veterans who identified as Black non-Hispanic and those with substance use disorder diagnoses or care were substantially less likely to receive dizziness and vestibular dysfunction diagnoses. CONCLUSIONS Access to specialty care was the single best predictor of dizziness and vestibular dysfunction diagnoses, underscoring the importance of facilitating referrals to and utilization of specialized, comprehensive clinical facilities or experts for veterans who report disruptive dizziness following deployment-related TBI. There is a clear need for an evidence-based pathway to address disruptive symptoms of dizziness, given the substantial variation in audiovestibular tests utilized by US providers by region and clinical specialty. Further, the dearth of diagnoses among Black veterans and those in more rural areas underscores the potential for enhanced cultural competency among providers, telemedicine, and patient education to bridge existing gaps in the care of dizziness.
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Affiliation(s)
- Alicia A Swan
- Department of Psychology, The University of Texas at San Antonio, San Antonio (Dr Swan and Ms Crowsey); South Texas Veterans Health Care System, San Antonio (Dr Swan); James H Quillen VA Medical Center, Mountain Home, Tennessee (Drs Akin and Hall); Departments of Audiology and Speech Language Pathology (Dr Akin) and Rehabilitative Sciences (Dr Hall), East Tennessee State University, Johnson City; Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS 2.0), VA Salt Lake City Health Care System, Salt Lake City, Utah (Mss Amuan and Padilla and Drs Kalvesmaki and Pugh); Department of Internal Medicine, University of Utah, Salt Lake City (Mss Amuan and Padilla and Drs Kalvesmaki and Pugh); Department of Head and Neck Surgery & Communication Sciences, Duke University, Durham, North Carolina (Dr Riska); and Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, North Carolina (Dr Riska)
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Swan AA, Nelson JT, Pogoda TK, Akin FW, Riska KM, Hall CD, Amuan ME, Yaffe K, Pugh MJ. Association of Traumatic Brain Injury With Vestibular Dysfunction and Dizziness in Post-9/11 Veterans. J Head Trauma Rehabil 2021; 35:E253-E265. [PMID: 31569144 DOI: 10.1097/htr.0000000000000513] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe the prevalence and impact of vestibular dysfunction and nonspecific dizziness diagnoses and explore their associations with traumatic brain injury (TBI) severity, mechanism, and postconcussive comorbidities among post-9/11 veterans. SETTING Administrative medical record data from the US Departments of Defense and Veterans Affairs (VA). PARTICIPANTS Post-9/11 veterans with at least 3 years of VA care. DESIGN Cross-sectional, retrospective, observational study. MAIN MEASURES International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for TBI, vestibular dysfunction, dizziness, and other commonly associated postconcussive conditions; Neurobehavioral Symptom Inventory. RESULTS Of the 570 248 post-9/11 veterans in this sample, 0.45% had a diagnosis of vestibular dysfunction and 2.57% had nonspecific dizziness. Those with either condition were more likely to have evidence of TBI (57.11% vs 28.51%) and reported more disruption from neurobehavioral symptoms. Blast and nonblast injuries were associated with greater symptom disruption, particularly in combination. CONCLUSIONS There was a consistent, significant association between TBI and vestibular dysfunction or nonspecific dizziness, after controlling for sociodemographic factors, injury mechanism, and comorbid conditions. Given that most deployed post-9/11 veterans report blast and/or nonblast injuries, the need for prompt identification and management of these conditions and symptoms is clear.
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Affiliation(s)
- Alicia A Swan
- University of Texas at San Antonio (Dr Swan); Department of Defense Hearing Center of Excellence, Defense Health Agency, San Antonio, Texas (Dr Nelson); Ho-Chunk, Inc, Alexandria, Virginia (Dr Nelson); Department of Radiology and Imaging Sciences, School of Medicine, Indiana University, Indianapolis (Dr Nelson); Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts (Dr Pogoda); Boston University School of Public Health, Boston, Massachusetts (Dr Pogoda); James H. Quillen VA Medical Center, Mountain Home, Tennessee (Drs Akin and Hall); Departments of Audiology and Speech Language Pathology (Dr Akin) and Physical Therapy (Dr Hall), East Tennessee State University, Johnson City; Division of Head and Neck Surgery & Communication Sciences, Department of Surgery, Duke University, Durham, North Carolina (Dr Riska); Center for Health Care Organization and Implementation Research, Edith Nourse Rogers VA Medical Center, Bedford, Massachusetts (Ms Amuan); Departments of Psychiatry, Neurology and Epidemiology, School of Medicine, University of California San Francisco (Dr Yaffe); Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS 2.0), VA Salt Lake City Health Care System, Salt Lake City, Utah (Dr Pugh); and Department of Internal Medicine, The University of Utah, Salt Lake City (Dr Pugh)
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Stewart CE, Holt AG, Altschuler RA, Cacace AT, Hall CD, Murnane OD, King WM, Akin FW. Effects of Noise Exposure on the Vestibular System: A Systematic Review. Front Neurol 2020; 11:593919. [PMID: 33324332 PMCID: PMC7723874 DOI: 10.3389/fneur.2020.593919] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 09/28/2020] [Indexed: 11/13/2022] Open
Abstract
Despite our understanding of the impact of noise-induced damage to the auditory system, much less is known about the impact of noise exposure on the vestibular system. In this article, we review the anatomical, physiological, and functional evidence for noise-induced damage to peripheral and central vestibular structures. Morphological studies in several animal models have demonstrated cellular damage throughout the peripheral vestibular system and particularly in the otolith organs; however, there is a paucity of data on the effect of noise exposure on human vestibular end organs. Physiological studies have corroborated morphological studies by demonstrating disruption across vestibular pathways with otolith-mediated pathways impacted more than semicircular canal-mediated pathways. Similar to the temporary threshold shifts observed in the auditory system, physiological studies in animals have suggested a capacity for recovery following noise-induced vestibular damage. Human studies have demonstrated that diminished sacculo-collic responses are related to the severity of noise-induced hearing loss, and dose-dependent vestibular deficits following noise exposure have been corroborated in animal models. Further work is needed to better understand the physiological and functional consequences of noise-induced vestibular impairment in animals and humans.
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Affiliation(s)
- Courtney Elaine Stewart
- University of Michigan Department of Otolaryngology/Head-Neck Surgery, Kresge Hearing Research Institute, Ann Arbor, MI, United States.,VA Ann Arbor Healthcare System, Research Service, Ann Arbor, MI, United States
| | - Avril Genene Holt
- Department of Ophthalmology Visual and Anatomical Sciences, Wayne State University School of Medicine, Detroit, MI, United States.,John D. Dingell VA Medical Center, Molecular Anatomy of Central Sensory Systems Laboratory, Research Service, Detroit, MI, United States
| | - Richard A Altschuler
- University of Michigan Department of Otolaryngology/Head-Neck Surgery, Kresge Hearing Research Institute, Ann Arbor, MI, United States.,VA Ann Arbor Healthcare System, Research Service, Ann Arbor, MI, United States
| | - Anthony Thomas Cacace
- Department of Communication Sciences and Disorders, Wayne State University, Detroit, MI, United States
| | - Courtney D Hall
- Department of Rehabilitative Sciences, Doctor of Physical Therapy Program, East Tennessee State University, Johnson City, TN, United States.,Gait and Balance Research Laboratory, James H. Quillen VA Medical Center, Mountain Home, TN, United States
| | - Owen D Murnane
- Department of Audiology and Speech-Language Pathology, East Tennessee State University, Johnson City, TN, United States.,Vestibular Research Laboratory, James H. Quillen VA Medical Center, Mountain Home, TN, United States
| | - W Michael King
- University of Michigan Department of Otolaryngology/Head-Neck Surgery, Kresge Hearing Research Institute, Ann Arbor, MI, United States
| | - Faith W Akin
- Department of Audiology and Speech-Language Pathology, East Tennessee State University, Johnson City, TN, United States.,Vestibular Research Laboratory, James H. Quillen VA Medical Center, Mountain Home, TN, United States
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Murnane OD, Akin FW, Kelly JK, Byrd S. Effects of Stimulus and Recording Parameters on the Air Conduction Ocular Vestibular Evoked Myogenic Potential. J Am Acad Audiol 2020; 22:469-80. [DOI: 10.3766/jaaa.22.7.7] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Vestibular evoked myogenic potentials (VEMPs) have been recorded from the sternocleidomastoid muscle (cervical VEMP or cVEMP) and more recently from the eye muscles (ocular VEMP or oVEMP) in response to air conduction and bone conduction stimuli. Both cVEMPs and oVEMPs are mediated by the otoliths and thereby provide diagnostic information that is complementary to videonystagmography and rotational chair tests. In contrast to the air conduction cVEMP, which originates from the saccule/inferior vestibular nerve, recent evidence suggests the possibility that the air conduction oVEMP may be mediated by the utricle/superior vestibular nerve. The oVEMP, therefore, may provide complementary diagnostic information relative to the cVEMP. There are relatively few studies, however, that have quantified the effects of stimulus and recording parameters on the air conduction oVEMP, and there is a paucity of normative data.
Purpose: To evaluate the effects of several stimulus and recording parameters on the air conduction oVEMP and to establish normative data for clinical use.
Research Design: A prospective repeated measures design was utilized.
Study Sample: Forty-seven young adults with no history of neurologic disease, hearing loss, middle ear pathology, open or closed head injury, cervical injury, or audiovestibular disorder participated in the study.
Data Collection and Analysis: The effects of stimulus frequency, stimulus level, gaze elevation, and recording electrode location on the amplitude and latency of the oVEMP for monaural air conduction stimuli were assessed using repeated measures analyses of variance in an initial group of 17 participants. The optimal stimulus and recording parameters obtained in the initial group were used subsequently to obtain oVEMPs from 30 additional participants.
Results: The effects of stimulus frequency, stimulus level, gaze elevation, and electrode location on the response prevalence, amplitude, and latency of the oVEMP for monaural air conduction stimuli were significant. The maximum N1-P1 amplitude and response prevalence were obtained for contralateral oVEMPs using a 500 Hz tone burst presented at 125 dB peak SPL during upward gaze at an elevation of 30°.
Conclusions: The optimal stimulus and recording parameters quantified in this study were used to establish normative data that may be useful for the clinical application of the air conduction oVEMP.
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Akin FW, Murnane OD, Pearson A, Byrd S, Kelly JK. Normative Data for the Subjective Visual Vertical Test during Centrifugation. J Am Acad Audiol 2020; 22:460-8. [DOI: 10.3766/jaaa.22.7.6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: The otoliths act as gravito-inertial force sensors and contribute to the perception of spatial orientation. The perception of gravitational vertical can be assessed by asking a subject to adjust a light bar to the vertical. Prior to clinical use of the SVV (subjective visual vertical) test, normative data and test-retest reliability must be established.
Purpose: To obtain normative data and d etermine the test-retest reliability for the SVV test performed in static and dynamic test conditions.
Research Design: A descriptive design was used to obtain normative data.
Study Sample: Twenty-four young adults with no history of neurological disease, middle-ear pathology, open or closed head injury, cervical injury, or audiovestibular disorder participated in the study.
Data Collection and Analysis: The SVV angle was measured in the static position and in three dynamic conditions: (1) on-axis clockwise (CW) rotation, (2) off-axis CW rotation of right ear, and (3) off-axis CW rotation of left ear.
Results: In young healthy individuals, the SVV was <2° for static and on-axis rotation, and shifted up to 11° during unilateral centrifugation. Test-retest reliability of the SVV was good for all test conditions.
Conclusions: The normative data obtained in this study may be useful in identifying patients with chronic utricular dysfunction. We recommend the use of difference angles (on-axis SVV – off-axis SVV) to remove baseline bias and decrease the variability of the SVV angles for the off-axis conditions.
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Swan AA, Nelson JT, Pogoda TK, Amuan ME, Akin FW, Pugh MJ. Sensory dysfunction and traumatic brain injury severity among deployed post-9/11 veterans: a Chronic Effects of Neurotrauma Consortium study. Brain Inj 2018; 32:1197-1207. [DOI: 10.1080/02699052.2018.1495340] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Alicia A. Swan
- South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Jeremy T. Nelson
- Department of Defense Hearing Center of Excellence, San Antonio, TX, USA
| | - Terri K. Pogoda
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA
- Boston University School of Public Health, Boston, MA, USA
| | - Megan E. Amuan
- Center for Health Care Organization and Implementation Research, Edith Nourse Rogers VA Medical Center, Bedford, MA, USA
| | - Faith W. Akin
- James H Quillen VA Medical Center, Mountain Home, TN, USA
- Department of Audiology and Speech Language Pathology, East Tennessee State University, Johnson City, TN, USA
| | - Mary Jo Pugh
- South Texas Veterans Health Care System, San Antonio, TX, USA
- Department of Epidemiology and Biostatistics, University of Texas Health Science Center San Antonio, San Antonio, TX, USA
- Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS 2.0) VA Salt Lake City Health Care System and Department of Internal Medicine, University of Utah, USA
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Riska KM, Murnane O, Akin FW, Hall C. Video Head Impulse Testing (vHIT) and the Assessment of Horizontal Semicircular Canal Function. J Am Acad Audiol 2018; 26:518-523. [PMID: 26055841 DOI: 10.3766/jaaa.14083] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Vestibular function (specifically, horizontal semicircular canal function) can be assessed across a broad frequency range using several different techniques. The head impulse test is a qualitative test of horizontal semicircular canal function that can be completed at bedside. Recently, a new instrument (video head impulse test [vHIT]) has been developed to provide an objective assessment to the clinical test. Questions persist regarding how this test may be used in the overall vestibular test battery. PURPOSE The purpose of this case report is to describe vestibular test results (vHIT, rotational testing, vestibular evoked myogenic potentials, and balance and gait performance) in an individual with a 100% unilateral caloric weakness who was asymptomatic for dizziness, vertigo or imbalance. DATA COLLECTION AND/OR ANALYSIS Comprehensive assessment was completed to evaluate vestibular function. Caloric irrigations, rotary chair testing, vHIT, and vestibular evoked myogenic potentials were completed. RESULTS A 100% left-sided unilateral caloric weakness was observed in an asymptomatic individual. vHIT produced normal gain with covert saccades. CONCLUSIONS This case demonstrates the clinical usefulness of vHIT as a diagnostic tool and indicator of vestibular compensation and functional status.
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Akin FW, Riska KM, Williams L, Rouse SB, Murnane OD. Characteristics and Treatment Outcomes of Benign Paroxysmal Positional Vertigo in a Cohort of Veterans. Am J Audiol 2017; 26:473-480. [PMID: 28973090 DOI: 10.1044/2017_aja-16-0118] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 04/24/2017] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The Mountain Home Veterans Affairs (VA) Medical Center has been diagnosing and treating veterans with benign paroxysmal positional vertigo (BPPV) for almost 2 decades. The clinic protocol includes a 2-week follow-up visit to determine the treatment outcome of the canalith repositioning treatment (CRT). To date, the characteristics of BPPV and treatment efficacy have not been reported in a cohort of veterans with BPPV. PURPOSE To determine the prevalence and characteristics of veterans diagnosed with BPPV in a Veterans Affairs Medical Center Audiology Clinic and to examine treatment outcomes. RESEARCH DESIGN Retrospective chart review. STUDY SAMPLE A total of 102 veterans who tested positive for BPPV in the Vestibular Clinic at the Mountain Home VA Medical Center from March 2010 to August 2011. RESULTS In 102 veterans who were diagnosed with BPPV, the posterior semicircular canal was most often involved (75%), motion-provoked vertigo was the most common symptom (84%), and the majority (43%) were diagnosed with BPPV in their sixth decade. The prevalence of BPPV in the Audiology Vestibular Clinic was 15.6%. Forty-one percent of veterans reported a symptom onset within 12 months of treatment for BPPV; however, 36% reported their symptoms began > 36 months prior to treatment. CRT was effective (negative Dix-Hallpike/roll test) in most veterans (86%) following 1 treatment appointment (M = 1.6), but more than half reported incomplete symptom resolution (residual dizziness) at the follow-up appointment. Eighteen percent of veterans experienced a recurrence (M = 1.8 years; SD = 1.7 years). CONCLUSIONS The characteristics and treatment outcomes of BPPV in our veteran cohort was similar to what has been reported in the general population. Future work should focus on improving the timeliness of evaluation and treatment of BPPV and examining the time course and management of residual dizziness.
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Affiliation(s)
- Faith W. Akin
- Vestibular Balance Laboratory and Auditory Vestibular Research Enhancement Award Program, James H. Quillen VA Veterans Affairs Medical Center, Mountain Home, TN
- Department of Audiology and Speech-Language Pathology, East Tennessee State University, Johnson City
| | - Kristal M. Riska
- Vestibular Balance Laboratory and Auditory Vestibular Research Enhancement Award Program, James H. Quillen VA Veterans Affairs Medical Center, Mountain Home, TN
- Department of Audiology and Speech-Language Pathology, East Tennessee State University, Johnson City
| | - Laura Williams
- Department of Audiology and Speech-Language Pathology, East Tennessee State University, Johnson City
- Audiology and Speech Pathology Service, San Diego VA Medical Center, La Jolla, CA
| | - Stephanie B. Rouse
- Vestibular Balance Laboratory and Auditory Vestibular Research Enhancement Award Program, James H. Quillen VA Veterans Affairs Medical Center, Mountain Home, TN
| | - Owen D. Murnane
- Vestibular Balance Laboratory and Auditory Vestibular Research Enhancement Award Program, James H. Quillen VA Veterans Affairs Medical Center, Mountain Home, TN
- Department of Audiology and Speech-Language Pathology, East Tennessee State University, Johnson City
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Riska KM, Akin FW, Williams L, Rouse SB, Murnane OD. A Benign Paroxysmal Positional Vertigo Triage Clinic. Am J Audiol 2017; 26:481-485. [PMID: 28975255 DOI: 10.1044/2017_aja-16-0119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 04/24/2017] [Indexed: 11/09/2022] Open
Abstract
PURPOSE The purpose of this study was to evaluate the effectiveness of triaging patients with motion-provoked dizziness into a benign paroxysmal positional vertigo (BPPV) clinic. METHOD A retrospective chart review was performed of veterans who were tested and treated for BPPV in a triaged BPPV clinic and veterans who were tested and treated for BPPV in a traditional vestibular clinic. RESULTS The BPPV triage clinic had a hit rate of 39%. On average, the triaged BPPV clinic reduced patient wait times by 23 days relative to the wait times for the traditional vestibular clinic while also reducing patient costs. CONCLUSION Triaging patients with BPPV is one method to improve access to evaluation and treatment and a mechanism for the effective use of clinic time and resources.
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Affiliation(s)
- Kristal M. Riska
- Vestibular Balance Laboratory and Auditory Vestibular Research Enhancement Award Program, Mountain Home Veterans Affairs Medical Center, TN
- Department of Audiology and Speech-Language Pathology, East Tennessee State University, Johnson City
| | - Faith W. Akin
- Vestibular Balance Laboratory and Auditory Vestibular Research Enhancement Award Program, Mountain Home Veterans Affairs Medical Center, TN
- Department of Audiology and Speech-Language Pathology, East Tennessee State University, Johnson City
| | - Laura Williams
- Department of Audiology and Speech-Language Pathology, East Tennessee State University, Johnson City
- Audiology and Speech Pathology Service, San Diego Veterans Affairs Medical Center, La Jolla, CA
| | - Stephanie B. Rouse
- Vestibular Balance Laboratory and Auditory Vestibular Research Enhancement Award Program, Mountain Home Veterans Affairs Medical Center, TN
| | - Owen D. Murnane
- Vestibular Balance Laboratory and Auditory Vestibular Research Enhancement Award Program, Mountain Home Veterans Affairs Medical Center, TN
- Department of Audiology and Speech-Language Pathology, East Tennessee State University, Johnson City
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Affiliation(s)
- Faith W. Akin
- Vestibular Laboratory, James H. Quillen VA Medical Center, Mountain Home, Tennessee, USA
- Department of Audiology and Speech Language Pathology, East Tennessee State University, Johnson City, Tennessee, USA
| | - Owen D. Murnane
- Vestibular Laboratory, James H. Quillen VA Medical Center, Mountain Home, Tennessee, USA
- Department of Audiology and Speech Language Pathology, East Tennessee State University, Johnson City, Tennessee, USA
| | - Courtney D. Hall
- Gait and Balance Laboratory, James H. Quillen VA Medical Center, Mountain Home, Tennessee, USA
- Department of Physical Therapy, East Tennessee State University, Johnson City, Tennessee, USA
| | - Kristal M. Riska
- Vestibular Laboratory, James H. Quillen VA Medical Center, Mountain Home, Tennessee, USA
- Department of Audiology and Speech Language Pathology, East Tennessee State University, Johnson City, Tennessee, USA
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Gattu R, Akin FW, Cacace AT, Hall CD, Murnane OD, Haacke EM. Vestibular, balance, microvascular and white matter neuroimaging characteristics of blast injuries and mild traumatic brain injury: Four case reports. Brain Inj 2016; 30:1501-1514. [DOI: 10.1080/02699052.2016.1219056] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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15
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Nelson MD, Akin FW, Riska KM, Andresen K, Mondelli SS. Vestibular Assessment and Rehabilitation: Ten-Year Survey Trends of Audiologists' Opinions and Practice. J Am Acad Audiol 2016; 27:126-40. [PMID: 26905532 DOI: 10.3766/jaaa.15035] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The past decade has yielded changes in the education and training of audiologists and technological advancements that have become widely available for clinical balance function testing. It is unclear if recent advancements in vestibular instrumentation or the transition to an AuD degree have affected audiologists' vestibular clinical practice or opinions. PURPOSE The purpose of this study was to examine predominant opinions and practices for vestibular assessment (VA) and vestibular rehabilitation (VR) over the past decade and between master's- and AuD-level audiologists. METHOD A 31-question survey was administered to audiologists via U.S. mail in 2003 (N = 7,500) and electronically in 2014 (N = 9,984) with a response rate of 12% and 10%, respectively. RESULTS There was an increase in the number of audiologists providing vestibular services in the past decade. Most respondents agreed that audiologists were the most qualified professionals to conduct VA. Less than half of the surveyed audiologists felt that graduate training was adequate for VA. AuD-level audiologists were more satisfied with graduate training and felt more comfortable performing VA compared to master's-level audiologists. Few respondents agreed that audiologists were the most qualified professionals to conduct VR or that graduate training prepared them to conduct VR. The basic vestibular test battery was unchanged across surveys and included: calorics, smooth pursuit, saccades, search for spontaneous, positional, gaze and optokinetic nystagmus, Dix-Hallpike, case history, and hearing evaluation. There was a trend toward greater use of air (versus water) calorics, videonystagmography (versus electronystagmography), and additional tests of vestibular and balance function. CONCLUSIONS VA is a growing specialty area in the field of audiology. Better training opportunities are needed to increase audiologists' knowledge and skills for providing vestibular services. The basic tests performed during VA have remained relatively unchanged over the past 10 yr.
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Affiliation(s)
- M Dawn Nelson
- Department of Communication Disorders, Central Michigan University, Mount Pleasant, MI
| | - Faith W Akin
- Auditory Vestibular Research Enhancement Award Program (REAP), Department of Audiology (126), Mountain Home Veterans Affairs Medical Center, Mountain Home, TN.,Department of Audiology and Speech-Language Pathology, East Tennessee State University, Johnson City, TN
| | - Kristal M Riska
- Auditory Vestibular Research Enhancement Award Program (REAP), Department of Audiology (126), Mountain Home Veterans Affairs Medical Center, Mountain Home, TN.,Department of Audiology and Speech-Language Pathology, East Tennessee State University, Johnson City, TN
| | - Kimberly Andresen
- Department of Communication Disorders, Central Michigan University, Mount Pleasant, MI
| | - Stephanie Stamps Mondelli
- Department of Audiology and Speech-Language Pathology, East Tennessee State University, Johnson City, TN
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Papathanasiou ES, Murofushi T, Akin FW, Colebatch JG. International guidelines for the clinical application of cervical vestibular evoked myogenic potentials: an expert consensus report. Clin Neurophysiol 2014; 125:658-666. [PMID: 24513390 DOI: 10.1016/j.clinph.2013.11.042] [Citation(s) in RCA: 144] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Revised: 10/15/2013] [Accepted: 11/20/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Cervical vestibular evoked myogenic potentials (cVEMPs) are electromyogram responses evoked by high-level acoustic stimuli recorded from the tonically contracting sternocleidomastoid (SCM) muscle, and have been accepted as a measure of saccular and inferior vestibular nerve function. As more laboratories are publishing cVEMP data, there is a wider range of recording methods and interpretation, which may be confusing and limit comparisons across laboratories. OBJECTIVE To recommend minimum requirements and guidelines for the recording and interpretation of cVEMPs in the clinic and for diagnostic purposes. MATERIAL AND METHODS We have avoided proposing a single methodology, as clinical use of cVEMPs is evolving and questions still exist about its underlying physiology and its measurement. The development of guidelines by a panel of international experts may provide direction for accurate recording and interpretation. RESULTS cVEMPs can be evoked using air-conducted (AC) sound or bone conducted (BC) vibration. The technical demands of galvanic stimulation have limited its application. For AC stimulation, the most effective frequencies are between 400 and 800 Hz below safe peak intensity levels (e.g. 140 dB peak SPL). The highpass filter should be between 5 and 30 Hz, the lowpass filter between 1000 and 3000 Hz, and the amplifier gain between 2500 and 5000. The number of sweeps averaged should be between 100 and 250 per run. Raw amplitude correction by the level of background SCM activity narrows the range of normal values. There are few publications in children with consistent results. CONCLUSION The present recommendations outline basic terminology and standard methods. Because research is ongoing, new methodologies may be included in future guidelines.
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Affiliation(s)
| | - Toshihisa Murofushi
- Department of Otolaryngology, Teikyo University School of Medicine, Mizonokuchi Hospital, 3-8-3 Mizonokuchi, Takatsu-ku, Kawasaki, Japan
| | - Faith W Akin
- Audiology 126, VA Medical Center, Mountain Home, TN 37684, USA
| | - James G Colebatch
- Prince of Wales Clinical School and Neuroscience Research Australia, University of New South Wales, Sydney NSW 2052, Australia
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Akin FW, Hall CD, Murnane OD. The role of rotational stimulation in vestibular compensation. Otolaryngol Head Neck Surg 2012; 148:176-7. [PMID: 22983679 DOI: 10.1177/0194599812460989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Faith W Akin
- Audiology, VA Medical Center, Mountain Home, Tennessee 37684, USA.
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Abstract
The Motion Sensitivity Test (MST) is a clinical protocol designed to measure motion-provoked dizziness during a series of 16 quick changes to head or body positions. The MST has been used as a guide for developing an exercise program for patients with motion-provoked dizziness and as a treatment outcome measure to monitor the effectiveness of vestibular rehabilitation therapy. This study determined validity, test-retest reliability, and interrater reliability of the MST. Fifteen individuals with motion-provoked dizziness and ten control individuals were tested during sessions occurring 90 min and/or 24 hr after baseline testing. The MST was found to be reliable across raters (intraclass correlation coefficient [ICC] = 0.99) and test sessions (ICC = 0.98 and 0.96). Test validity was good. The results indicated that the MST can be used reliably in clinical practice to develop exercise programs for patients with motion-provoked dizziness and to provide evidence of intervention efficacy.
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Affiliation(s)
- Faith W Akin
- Auditory and Vestibular Dysfunction Research Enhancement Award Program, Audiology and Speech Pathology Service, James H. Quillen VA Medical Center, Mountain Home, TN 37684, USA.
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Akin FW, Murnane OD, Panus PC, Caruthers SK, Wilkinson AE, Proffitt TM. The influence of voluntary tonic EMG level on the vestibular-evoked myogenic potential. ACTA ACUST UNITED AC 2004; 41:473-80. [PMID: 15543465 DOI: 10.1682/jrrd.2003.04.0060] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Vestibular-evoked myogenic potentials (VEMPs) are proposed as a reliable test to supplement the current vestibular test battery by providing diagnostic information about saccular and/or inferior vestibular nerve function. VEMPs are short-latency electromyograms (EMGs) evoked by high-level acoustic stimuli and recorded from surface electrodes over the tonically contracted sternocleidomastoid muscle. VEMP amplitude is influenced by the EMG level, which must be controlled. This study examined the ability of subjects to achieve the EMG target levels over a range of target levels typically used during VEMP recordings. In addition, the influence of target EMG level on the latency and amplitude of the click- and tone-evoked VEMP was examined. The VEMP amplitude increased as a function of EMG target level, and the latency remained constant. EMG target levels ranging from 30 microV to 50 microV are suggested for clinical application of the VEMP.
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Affiliation(s)
- Faith W Akin
- James H. Quillen Department of Veterans Affairs (VA) Medical Center, Mountain Home, TN 37684, USA.
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Akin FW, Murnane OD. Vestibular evoked myogenic potentials: preliminary report. J Am Acad Audiol 2001; 12:445-52; quiz 491. [PMID: 11699815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
Vestibular evoked myogenic potentials (VEMPs) are short-latency electromyograms evoked by high-level acoustic stimuli recorded from surface electrodes over the tonically contracted sternocleidomastoid (SCM) muscle. These responses are presumed to originate in the saccule. The purpose of this preliminary report is to provide an overview of our initial experience with the VEMP by describing the responses obtained in five subjects. Click-evoked VEMPs were present at short latencies in two normal-hearing subjects, one patient with profound congenital sensorineural hearing loss, and one patient with a severe sensorineural hearing loss due to Meniere's disease. Additionally, VEMPs were absent in a patient with profound sensorineural hearing loss following removal of a cerebellopontine angle tumor. The amplitude of the VEMP was influenced by the amount of background activity of the SCM muscle, stimulus level, and stimulus frequency. Tone-burst evoked responses showed an inverse relationship between stimulus frequency and response latency. VEMPs may prove to be a reliable technique in the clinical assessment of vestibular function.
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Affiliation(s)
- F W Akin
- Audiology and Speech Pathology Service, James H. Quillen VA Medical Center, Mountain Home, Tennessee 37684, USA
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