The VertiGO! Trial protocol: A prospective, single-center, patient-blinded study to evaluate efficacy and safety of prolonged daily stimulation with a multichannel vestibulocochlear implant prototype in bilateral vestibulopathy patients

BACKGROUND

A combined vestibular (VI) and cochlear implant (CI) device, also known as the vestibulocochlear implant (VCI), was previously developed to restore both vestibular and auditory function. A new refined prototype is currently being investigated. This prototype allows for concurrent multichannel vestibular and cochlear stimulation. Although recent studies showed that VCI stimulation enables compensatory eye, body and neck movements, the constraints in these acute study designs prevent them from creating more general statements over time. Moreover, the clinical relevance of potential VI and CI interactions is not yet studied. The VertiGO! Trial aims to investigate the safety and efficacy of prolonged daily motion modulated stimulation with a multichannel VCI prototype.

METHODS

A single-center clinical trial will be carried out to evaluate prolonged VCI stimulation, assess general safety and explore interactions between the CI and VI. A single-blind randomized controlled crossover design will be implemented to evaluate the efficacy of three types of stimulation. Furthermore, this study will provide a proof-of-concept for a VI rehabilitation program. A total of minimum eight, with a maximum of 13, participants suffering from bilateral vestibulopathy and severe sensorineural hearing loss in the ear to implant will be included and followed over a five-year period. Efficacy will be evaluated by collecting functional (i.e. image stabilization) and more fundamental (i.e. vestibulo-ocular reflexes, self-motion perception) outcomes. Hearing performance with a VCI and patient-reported outcomes will be included as well.

DISCUSSION

The proposed schedule of fitting, stimulation and outcome testing allows for a comprehensive evaluation of the feasibility and long-term safety of a multichannel VCI prototype. This design will give insights into vestibular and hearing performance during VCI stimulation. Results will also provide insights into the expected daily benefit of prolonged VCI stimulation, paving the way for cost-effectiveness analyses and a more comprehensive clinical implementation of vestibulocochlear stimulation in the future.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04918745. Registered 28 April 2021.

Ten-year association between change in speech-in-noise recognition and falls due to balance problems: a longitudinal cohort study

BACKGROUND

This study examined the relationship between speech-in-noise recognition and incident/recurrent falls due to balance problems ten years later (RQ-1); 10-year change in speech-in-noise recognition and falls (RQ-2a), as well as the role of dizziness in this relationship (RQ-2b). The association between hearing aid use and falls was also examined (RQ-3).

METHODS

Data was collected from the Netherlands Longitudinal Study on Hearing between 2006 and December 2022. Participants completed an online survey and digits-in-noise test every five years. For this study, data was divided into two 10-year follow-up time intervals: T0 (baseline) to T2 (10-year follow-up), and T1 (5-years) to T3 (15-years). For all RQs, participants aged ≥ 40 years at baseline, without congenital hearing loss, and non-CI users were eligible (n = 592). Additionally, for RQ-3 participants with a speech reception threshold in noise (SRTn) ≥ -5.5 dB signal-to-noise ratio were included (n = 422). Analyses used survey variables on hearing, dizziness, falls due to balance problems, chronic health conditions, and psychosocial health. Logistic regressions using General Estimating Equations were conducted to assess all RQs.

RESULTS

Among individuals with obesity, those with poor baseline SRTn had a higher odds of incident falls ten years later (odds ratio (OR):14.7, 95% confidence interval (CI) [2.12, 103]). A 10-year worsening of SRTn was significantly associated with a higher odds of recurrent (OR: 2.20, 95% CI [1.03, 4.71]) but not incident falls. No interaction was found between dizziness and change in SRTn. Hearing aid use (no use/ < 2 years use vs. ≥ 2 years) was not significantly associated with incident nor recurrent falls. Although there was a significant interaction with sex for this association, the effect of hearing aid use on incident/recurrent falls was not statistically significant among males nor females.

CONCLUSIONS

A longitudinal association between the deterioration in SRTn and recurrent falls due to balance problems after 10 years was confirmed in this study. This result stresses the importance of identifying declines in hearing earlier and justifies including hearing ability assessments within fall risk prevention programs. Mixed results of hearing aid use on fall risk warrant further investigation into the temporality of this association and possible differences between men and women.

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.

The DizzyQuest Combined with Accelerometry: Daily Physical Activities and Limitations among Patients with Bilateral Vestibulopathy Due to DFNA9

BACKGROUND

DFNA9 is a genetic disease of the inner ear, causing progressive bilateral sensorineural deafness and bilateral vestibulopathy (BV). In this study, DizzyQuest, a mobile vestibular diary, and the MOX accelerometer were combined to assess the daily life functional limitations and physical activity of patients with DFNA9 suffering from BV. These parameters might be appropriate as potential candidacy criteria and outcome measures for new therapeutic interventions for BV.

METHODS

Fifteen DFNA9 patients with BV and twelve age-matched healthy controls were included. The DizzyQuest was applied for six consecutive days, which assessed the participants' extent of functional limitations, tiredness, types of activities performed during the day, and type of activity during which the participant felt most limited. The MOX accelerometer was worn during the same six days of DizzyQuest use, measuring the participants intensity and type of physical activity. Mixed-effects linear and logistic regression analyses were performed to compare the DFNA9 patients and control group.

RESULTS

DFNA9 patients with BV felt significantly more limited in activities during the day compared to the age-matched controls, especially in social participation (p < 0.005). However, these reported limitations did not cause adjustment in the types of activities and did not reduce the intensity or type of physical activity measured with accelerometry. In addition, no relationships were found between self-reported functional limitations and physical activity.

CONCLUSIONS

This study demonstrated that self-reported functional limitations are significantly higher among DFNA9 patients with BV. As a result, these limitations might be considered as part of the candidacy criteria or outcome measures for therapeutic interventions. In addition, the intensity or type of physical activity performed during the day need to be addressed more specifically in future research.

Optimizing vestibular implant electrode positioning using fluoroscopy and intraoperative CT imaging

PURPOSE

 Vestibular implant electrode positioning close to the afferent nerve fibers is considered to be key for effective and selective electrical stimulation. However, accurate positioning of vestibular implant electrodes inside the semicircular canal ampullae is challenging due to the inability to visualize the target during the surgical procedure. This study investigates the accuracy of a new surgical protocol with real-time fluoroscopy and intraoperative CT imaging, which facilitates electrode positioning during vestibular implant surgery.

METHODS

 Single-center case-controlled cohort study with a historic control group at a tertiary referral center. Patients were implanted with a vestibulocochlear implant, using a combination of intraoperative fluoroscopy and cone beam CT imaging. The control group consisted of five patients who were previously implanted with the former implant prototype, without the use of intraoperative imaging. Electrode positioning was analyzed postoperatively with a high-resolution CT scan using 3D slicer software. The result was defined as accurate if the electrode position was within 1.5 mm of the center of the ampulla.

RESULTS

With the new imaging protocol, all electrodes could be positioned within a 1.5 mm range of the center of the ampulla. The accuracy was significantly higher in the study group with intraoperative imaging (21/21 electrodes) compared to the control group without intraoperative imaging (10/15 electrodes), (p = 0.008).

CONCLUSION

 The combined use of intraoperative fluoroscopy and CT imaging during vestibular implantation can improve the accuracy of electrode positioning. This might lead to better vestibular implant performance.

Practical tips by peer support in chronic vestibular hypofunction: an exploratory survey

Introduction

Patients with chronic vestibular hypofunction typically suffer from dizziness, imbalance and oscillopsia (blurred vision); symptoms that pose challenges to everyday life. Currently, advice on how to deal with such challenges is mainly provided by health care professionals (i.e., ENT-surgeons, neurologists, physiotherapists and psychologists). However, fellow patients with a similar condition and a true appreciation of the lived experiences, are likely to provide valuable support and advice as well. The purpose of this study, therefore, was to collect tips and advice from patients with chronic vestibular hypofunction.

Methods

An exploratory survey was designed to collect tips from fellow chronic vestibular hypofunction patients on how to cope with disease-related challenges in everyday life. The survey was distributed both online and in person. The list of tips was coded and analyzed thematically and deductively, by using the international classification of functioning, disability, and health (ICF) model.

Results

In total, 425 tips were obtained from the 179 participants. Most tips were coded under "environmental factors" (46%) and "activities and participation" (39%). The remaining tips were categorized as "body functions" (15%). No tips were about "body structures." The participants coped with their daily struggles by investing in assistive products and technology, like adapted bikes, special footwear, walking frames. They described the importance of ensuring minimal light intensity for visibility (i.e., installing light sources in dark places). During activities, participants gave the advice to avoid bumpy roads and obstacles, and highlighted the necessity of adequate visual fixation to maintain balance. To ensure optimal activity, participants emphasized the importance of managing energy and taking sufficient rest.

Discussion

This study gives insight into how patients with chronic vestibular hypofunction cope with everyday struggles due to their symptoms. These tips can expand advice given by healthcare professionals. Knowing that fellow patients experience similar struggles and learned to deal with their struggles in adequate ways, might offer support and help patients focus on possibilities rather than on disabilities. Further research should investigate the effect of sharing tips to see whether improvement in (mental) health can be achieved in patients with chronic vestibular hypofunction.

Interaural and sex differences in the natural evolution of hearing levels in pre-symptomatic and symptomatic carriers of the p.Pro51Ser variant in the COCH gene

Hearing impairment constitutes a significant health problem in developed countries. If hearing loss is slowly progressive, the first signs may not be noticed in time, or remain untreated until the moment the auditory dysfunction becomes more apparent. The present study will focus on DFNA9, an autosomal dominant disorder caused by pathogenic variants in the COCH gene. Although several cross-sectional studies on this topic have been conducted, a crucial need for longitudinal research has been reported by many authors. Longitudinal trajectories of individual hearing thresholds were established as function of age and superimposed lowess curves were generated for 101 female and male carriers of the p.Pro51Ser variant. The average number of times patients have been tested was 2.49 years with a minimum of 1 year and a maximum of 4 years. In addition, interaural and sex differences were studied, as they could modify the natural evolution of the hearing function. The current study demonstrates that, both in female carriers and male carriers, the first signs of hearing decline, i.e. hearing thresholds of 20 dB HL, become apparent as early as the 3rd decade in the highest frequencies. In addition, a rapid progression of SNHL occurs between 40 and 50 years of age. Differences between male and female carriers in the progression of hearing loss are most obvious between the age of 50 and 65 years. Furthermore, interaural discrepancies also manifest from the age of 50 years onwards. High-quality prospective data on the long-term natural evolution of hearing levels offer the opportunity to identify different disease stages in each cochlea and different types of evolution. This will provide more insights in the window of opportunity for future therapeutic intervention trials.

Bilateral vestibulopathy: a clinical update and proposed diagnostic algorithm

Bilateral vestibulopathy (BVP) is characterized by its heterogeneous and chronic nature with various clinical presentations and multiple etiologies. This current narrative review reflects on the main insights and developments regarding clinical presentation. In addition, it proposes a new diagnostic algorithm, and describes available and potential future therapeutic modalities.

Capturing nystagmus during vertigo attacks using a smartphone: adherence, characteristics, pearls and pitfalls

OBJECTIVE

To investigate adherence, characteristics, and first clinical experiences of capturing ictal nystagmus at home, which can be performed to complement the diagnostic process in patients with episodic vestibular symptoms.

METHODS

Patients were recruited at a tertiary referral center in case capturing ictal nystagmus could contribute to the diagnostic process (e.g., to detect or rule out BPPV). They were asked to capture ictal nystagmus with their own smartphone at home, using a smartphone-based adapter (Nystagmocatcher, Balansdiagnos, Stockholm, Sweden). All recordings were analyzed by the last author (RvdB), and the adherence, characteristics, and first clinical experiences were evaluated.

RESULTS

Seventy patients with vestibular symptoms were asked to participate in this study. Sixty-two (89%) agreed to participate. The median period of participation was 86 days. Fifty-one patients experienced attacks during the study period. Eventually, 51% of them provided eye movement recordings sufficient for analysis. Different types of nystagmus were observed: positional nystagmus related to BPPV, positional nystagmus not related to BPPV, functional eye movements, and the absence of nystagmus or functional eye movements. Capturing ictal nystagmus could contribute to the diagnostic process in several ways, including to detect or rule out BPPV, to detect or rule out vestibular origin of symptoms, to determine the affected side, telemedicine, to monitor attack frequency, and to detect malingering. Furthermore, strict guidance of patients was necessary, which could be time-consuming.

CONCLUSION

Capturing ictal nystagmus can contribute to the diagnostic process in several ways, which motivates to rethink current clinical workflow in vestibular medicine. However, strict guidance is necessary and not all patients provide ictal recordings. In an outpatient setting, it would be advised to use ictal nystagmus recordings on indication, to complement the diagnostic process.

Study protocol for a nationwide implementation of internet-based vestibular rehabilitation for patients with chronic vestibular symptoms (I-RECOVER)

BACKGROUND

Vestibular rehabilitation is a safe and effective exercise-based treatment for patients with chronic vestibular symptoms. However, it is underused in general practice. Internet-based vestibular rehabilitation (Vertigo Training), which has proven to be effective as well, was developed to increase uptake. We now aim to improve the quality of care for patients with vestibular symptoms by carrying out a nationwide implementation of Vertigo Training. We will evaluate the effect of this implementation on primary care.

METHODS

Our implementation study consists of three successive phases: 1) We will perform a retrospective observational cohort study and a qualitative interview study to evaluate the current management of patients with vestibular symptoms in primary care, in particular anti-vertigo drug prescriptions, and identify areas for improvement. We will use the results of this phase to tailor our implementation strategy to the needs of general practitioners (GPs) and patients. 2) This phase entails the implementation of Vertigo Training using a multicomponent implementation strategy, containing: guideline adaptations; marketing strategy; pharmacotherapeutic audit and feedback meetings; education; clinical decision support; and local champions. 3) In this phase, we will evaluate the effect of the implementation in three ways. a. Interrupted time series. We will use routine primary care data from adult patients with vestibular symptoms to compare the number of GP consultations for vestibular symptoms, referrals for vestibular rehabilitation, prescriptions for anti-vertigo drugs, and referrals to physiotherapy and secondary care before and after implementation. b. Prospective observational cohort study. We will extract data from Vertigo Training to investigate the usage and the characteristics of participants. We will also determine whether these characteristics are associated with successful treatment. c. Qualitative interview study. We will conduct interviews with GPs to explore their experiences with the implementation.

DISCUSSION

This is one of the first studies to evaluate the effect of a nationwide implementation of an innovative treatment on Dutch primary care. Implementation strategies have been researched before, but it remains unclear which ones are the most effective and under what conditions. We therefore expect to gain relevant insights for future projects that aim to implement innovations in primary care.

Construct validity and reliability of the Bilateral Vestibulopathy Questionnaire (BVQ)

Background

The Bilateral Vestibulopathy Questionnaire (BVQ) is a recently developed 54-item Patient Reported Outcome Measure (PROM) that evaluates the clinically important symptoms of bilateral vestibulopathy (BVP) and its impact on daily life. This study aimed to assess the construct validity and reliability of the BVQ in a large BVP cohort.

Methods

Patients diagnosed with BVP were asked to complete a set of questionnaires, including the BVQ, the EuroQol-5D-5L, the Health Utilities Index, the Dizziness Handicap Inventory, the Hospital Anxiety and Depression Scale, and the Oscillopsia Severity Questionnaire. The construct validity of the BVQ was evaluated by confirmatory and exploratory factor analyses (CFA and EFA), followed by hypotheses testing and known groups validity. Structural properties were explored for each individual item. Reliability was assessed by testing the internal consistency of the BVQ constructs (Cronbach's alpha) and test-retest reliability [intraclass correlation coefficients (ICCs)].

Results

A total of 148 patients with BVP (50% women, mean age 66 years) completed the set of questionnaires. The CFA did not show a satisfactory model in the original BVQ. However, the EFA showed a four-factor solution with 20 Likert-scale items related to oscillopsia, imbalance, emotion, and cognition. The succeeding CFA provided evidence for construct validity and an acceptable model of fit. Hypothesis testing confirmed that this shortened version validly measures the constructs to be measured. Statistically significant differences in scores between known groups were found, providing further support for good construct validity. The structural properties were acceptable. Cronbach's alpha confirmed good internal consistency for the four constructs, ranging from 0.80 to 0.89. The ICCs of the 20 Likert-scale items and four visual analog scale (VAS) items were interpreted as good (range 0.76-0.93).

Conclusion

This study showed evidence of good construct validity of the new shortened version of the BVQ, consisting of four constructs with a total of 20 Likert-scale items and four VAS items. The final 24-item BVQ proved to be a reliable and valid multi-item PROM that captures the clinically important symptoms of BVP and evaluates its impact on daily life. Consequently, the BVQ enables the gathering of high-level evidence of treatment effectiveness in a systematic and quantitative manner.

Assessing balance in people with bilateral vestibulopathy using the Mini-Balance Evaluation Systems Test (Mini-BESTest): feasibility and comparison with healthy control data

OBJECTIVES

Bilateral vestibulopathy (BVP) leads to unsteadiness when walking, which worsens in darkness or on uneven ground, as well as falls. Since simple balance tests struggle to distinguish between BVP and healthy participants, we aimed (1) to test if the Mini-BESTest is feasible in BVP, (2) how people with BVP perform on the Mini-BESTest and (3) to compare these scores with healthy reference data.

METHODS

Fifty participants with BVP completed the Mini-BESTest. 12-month falls incidence was obtained by questionnaire. To compare the overall and sub-scores between our participants with BVP and those of healthy participants from the literature (n = 327; obtained via PubMed searches), Mann-Whitney U tests were used. Sub scores within the BVP group were also compared. Spearman correlations were used to investigate the relationships between Mini-BESTest score and age.

RESULTS

No floor or ceiling effects were observed. Participants with BVP had significantly lower Mini-BESTest total scores than the healthy group. Anticipatory, reactive postural control and sensory orientation sub scores of the Mini-BESTest were significantly lower in BVP, while dynamic gait sub scores were not significantly different. A stronger negative correlation between age and Mini-BESTest total score was found in BVP than in the healthy group. Scores did not differ between patients with different falls history.

CONCLUSION

The Mini-BESTest is feasible in BVP. Our results confirm the commonly reported balance deficits in BVP. The stronger negative association between age and balance in BVP might reflect the age-related decline in the remaining sensory systems with which people with BVP compensate.

Self-Reported Cycling Performance and Impact on Falls in Persons With Bilateral Vestibulopathy

OBJECTIVES

The aim of this study was to investigate cycling skills, cycling difficulties, fall concern, and fall history while cycling in persons with bilateral vestibulopathy.

DESIGN

Fifty-one persons with bilateral vestibulopathy and 51 healthy control subjects filled out a questionnaire about cycling abilities. This questionnaire consisted of four parts: (1) general information about audiovestibular function, vision, and physical activity; (2) general cycling abilities, history, and difficulties; (3) fall concern while cycling in various situations; and (4) fall history.

RESULTS

Out of the 51 patients, 61% found riding a bicycle difficult, 29% were not able to cycle anymore, and 10% reported not having any problems riding a bicycle. Their mean cycling time decreased from 3.15 hrs weekly before to 1.27 hrs weekly after disease onset ( p = 0.002). The latter also differed significantly from the mean cycling time of 3.51 hrs weekly in control subjects ( p < 0.001). The main complaints while cycling were not being able to look behind (88%), having difficulties with visually stabilizing the environment (65%), and not being able to ride in a straight line (61%). The fall concern was significantly higher in the patient group, with cycling in the dark and at dusk, and turning the head as their main concerns ( p < 0.001). Falls and near-falls were respectively reported in 50% and 65% of the patient group. Only the latter differed significantly from the control group. However, the number of reported falls differed significantly between both groups.

CONCLUSIONS

This study demonstrates cycling difficulties in persons with bilateral vestibulopathy, related to problems with postural control and gaze stabilization. Knowledge about specific complaints and triggers is important to prevent future falls. A combination of coping strategies and aids, with vestibular rehabilitation focused on gaze stabilization might be considered, as well as avoidance of cycling in specific cases.

The impact of vestibular function on cognitive-motor interference: a case-control study on dual-tasking in persons with bilateral vestibulopathy and normal hearing

Bilateral vestibulopathy (BV) is a chronic vestibular disorder, characterized by bilaterally absent or significantly impaired vestibular function. Symptoms typically include, but are not limited to, unsteadiness and movement-induced blurred vision (oscillopsia). This prospective case-control study aimed to elucidate the impact of BV on cognitive and motor performance and on cognitive-motor interference. Cognitive and motor performance, as well as cognitive-motor interference were measured in persons with BV and normal hearing using the 2BALANCE dual-task protocol. The experimental group was matched to a healthy control group based on age, sex, and educational level. The 2BALANCE protocol comprises cognitive tests assessing visuospatial memory, mental rotation, visual and auditory response inhibition, visual and auditory working memory, and processing speed. The cognitive tests were performed in single-task condition (while seated), and in dual-task condition (during a static and a dynamic motor task). The static motor task consisted of balancing on a force platform with foam pad. The dynamic motor task consisted of walking at a self-selected speed. These motor tasks were also performed in single-task condition. A generalized estimating equations model was used to investigate group differences for all cognitive and motor outcome measures. The estimated marginal means, as well as the odds ratios (OR), and their 95% confidence intervals (CI) were calculated. For the backward digit recall test, a baseline measurement was performed and analyzed using a student-t test. A total of 22 patients with BV and normal hearing and 22 healthy control subjects were assessed [mean age (SD), BV = 53.66 (13.35) and HC = 53.21 (13.35), 68% male]. The BV group had poorer mental rotation skills in single-task condition, compared to the control group [odds ratio (OR) = 2.30, confidence interval (CI) = 1.12-4.73, P  =  0.024]. Similarly, auditory and visual working memory were also poorer in the BV group in single-task condition (P = 0.028 and P = 0.003, respectively). The BV group also performed poorer on the mental rotation task and the visual response inhibition task in dual-task condition (OR = 2.96, CI = 1.57-5.59, P  <  0.001 and OR = 1.08, CI = 1.01-1.16, P  =  0.032, respectively). Additionally, an interaction effect, indicating increased cognitive-motor interference in the BV group, was observed for mental rotation, response inhibition, and auditory working memory (P  =  0.003 to 0.028). All static motor outcome parameters indicated more postural sway in the BV group compared to the control group for all test conditions (P  <  0.001 to 0.026). No group differences were noted for the dynamic motor task. These findings suggest a link between vestibular function and cognitive performance, as well as a greater interference between cognitive and motor performance in BV, compared to healthy controls.

The Next Challenges of Vestibular Implantation in Humans

Patients with bilateral vestibulopathy suffer from a variety of complaints, leading to a high individual and social burden. Available treatments aim to alleviate the impact of this loss and improve compensatory strategies. Early experiments with electrical stimulation of the vestibular nerve in combination with knowledge gained by cochlear implant research, have inspired the development of a vestibular neuroprosthesis that can provide the missing vestibular input. The feasibility of this concept was first demonstrated in animals and later in humans. Currently, several research groups around the world are investigating prototype vestibular implants, in the form of vestibular implants as well as combined cochlear and vestibular implants. The aim of this review is to convey the presentations and discussions from the identically named symposium that was held during the 2021 MidWinter Meeting of the Association for Research in Otolaryngology, with researchers involved in the development of vestibular implants targeting the ampullary nerves. Substantial advancements in the development have been made. Yet, research and development processes face several challenges to improve this neuroprosthesis. These include, but are not limited to, optimization of the electrical stimulation profile, refining the surgical implantation procedure, preserving residual labyrinthine functions including hearing, as well as gaining regulatory approval and establishing a clinical care infrastructure similar to what exists for cochlear implants. It is believed by the authors that overcoming these challenges will accelerate the development and increase the impact of a clinically applicable vestibular implant.

Association of Bilateral Vestibulopathy With and Without Hearing Loss With Cognitive-Motor Interference

Importance

The past years, evidence suggested that the primary symptoms traditionally associated with bilateral vestibulopathy (BV) do not represent the full picture of this patient population. Recent literature also demonstrated cognitive impairment. However, although multitasking and dual-tasking are widely present in everyday activities, most of these studies assessed cognitive function only in single-task conditions.

Objective

To uncover the association of BV with and without hearing loss with cognitive and motor performance and cognitive-motor interference.

Design, Setting, and Participants

This prospective case-control study assessed persons with an isolated BV and persons with BV and a concomitant hearing loss compared with a healthy control group. Data were analyzed in December 2022. The study was conducted at Ghent University (Ghent, Belgium). Data collection took place between March 26, 2021, and November 29, 2022.

Main Outcomes and Measures

All participants completed the 2BALANCE dual-task protocol, comprising a static and a dynamic motor task that was combined with 5 visual cognitive tasks. These cognitive tasks assessed mental rotation, visuospatial memory, working memory, response inhibition (executive function), and processing speed. All cognitive tasks were performed in a single-task condition (while seated) and in a dual-task condition (combined with a static and a dynamic motor task). The static task comprised balancing on a force platform with foam pad, and the dynamic task comprised walking at a self-selected speed on the GAITRite Walkway. Both motor tasks were performed in the single-task and dual-task condition.

Results

Nineteen persons with BV and hearing loss (mean [SD] age, 56.70 [10.12] years; 10 women [52.6%]), 22 persons with an isolated BV (mean [SD] age, 53.66 [13.35] years; 7 women [31.8%]), and 28 healthy control participants were included (mean [SD] age, 53.73 [12.77] years; 12 women [42.9%]). Both patient groups had mental rotation and working memory impairment in a single-task condition and slower processing speed when walking (ie, during the dynamic dual-task condition). Additionally, the patient group with hearing loss had impaired visuospatial memory and executive function deficits in single-task and dual-task conditions, while this could only be elicited when performing a motor task in persons with isolated BV (ie, when dual-tasking).

Conclusion and Relevance

The findings of this case-control study suggest an association between vestibular function and cognitive and motor performance, even greater in persons with a concomitant hearing loss than in persons with an isolated BV.

Chronic symptoms in patients with unilateral vestibular hypofunction: systematic review and meta-analysis

Objective

To systematically evaluate the full spectrum of self-reported chronic symptoms in patients with unilateral vestibular hypofunction (UVH) and to investigate the effect of interventions on these symptoms.

Methods

A systematic review was conducted following the guidelines of the Preferred Reporting Items for Systematic Review and Meta-Analysis Statement (PRISMA). A literature search was performed in Pubmed, Web of Science, Embase, and Scopus to investigate self-reported symptoms and self-report questionnaires in patients with UVH. All original studies ranging from full-text clinical trials to case reports, written in English, German, and French, were included. The frequency of self-reported symptoms was presented. For self-report questionnaires, a meta-analysis was carried out to synthesize scale means by the pre- and post-intervention means and mean changes for studies that investigated interventions.

Results

A total of 2,110 studies were retrieved. Forty-seven studies were included after title-abstract selection and full-text selection by two independent reviewers. The symptoms of UVH patients included chronic dizziness (98%), imbalance (81%), symptoms worsened by head movements (75%), visually induced dizziness (61%), symptoms worsened in darkness (51%), and oscillopsia (22%). Additionally, UVH could be accompanied by recurrent vertigo (77%), tiredness (68%), cognitive symptoms (58%), and autonomic symptoms (46%). Regarding self-report questionnaires, UVH resulted on average in a moderate handicap, with an estimated mean total score on the Dizziness Handicap Inventory (DHI) and the Vertigo Symptom Scale (VSS) of 46.31 (95% CI: 41.17-51.44) and 15.50 (95% CI: 12.59-18.41), respectively. In studies that investigated the effect of vestibular intervention, a significant decrease in the estimated mean total DHI scores from 51.79 (95% CI: 46.61-56.97) (pre-intervention) to 27.39 (95% CI: 23.16-31.62) (post intervention) was found (p < 0.0001). In three studies, the estimated mean total Visual Analog Scale (VAS) scores were 7.05 (95% CI, 5.64-8.46) (pre-intervention) and 2.56 (95% CI, 1.15-3.97) (post-intervention). Finally, a subgroup of patients (≥32%) persists with at least a moderate handicap, despite vestibular rehabilitation.

Conclusion

A spectrum of symptoms is associated with UVH, of which chronic dizziness and imbalance are most frequently reported. However, semi-structured interviews should be conducted to define the whole spectrum of UVH symptoms more precisely, in order to establish a validated patient-reported outcome measure (PROM) for UVH patients. Furthermore, vestibular interventions can significantly decrease self-reported handicap, although this is insufficient for a subgroup of patients. It could therefore be considered for this subgroup of patients to explore new intervention strategies like vibrotactile feedback or the vestibular implant.

Systematic review registration

[https://www.crd.york.ac.uk/prospero/], identifier [CRD42023389185].

Gait and Falls in Benign Paroxysmal Positional Vertigo: A Systematic Review and Meta-analysis

BACKGROUND AND PURPOSE

Benign paroxysmal positional vertigo (BPPV) is one of the most common vestibular disorders, and is treated effectively with particle repositioning maneuvers (PRM). The aim of this study was to assess the influence of BPPV and treatment effects of PRM on gait, falls, and fear of falling.

METHODS

Three databases and the reference lists of included articles were systematically searched for studies comparing gait and/or falls between (1) people with BPPV (pwBPPV) and controls and (2) pre- and posttreatment with PRM. The Joanna Briggs Institute critical appraisal tools were used to assess risk of bias.

RESULTS

Twenty of the 25 included studies were suitable for meta-analysis. Quality assessment resulted in 2 studies with high risk of bias, 13 with moderate risk, and 10 with low risk. PwBPPV walked slower and demonstrated more sway during tandem walking compared with controls. PwBPPV also walked slower during head rotations. After PRM, gait velocity during level walking increased significantly, and gait became safer according to gait assessment scales. Impairments during tandem walking and walking with head rotations did not improve. The number of fallers was significantly higher for pwBPPV than for controls. After treatment, the number of falls, number of pwBPPV who fell, and fear of falling decreased.

DISCUSSION AND CONCLUSIONS

BPPV increases the odds of falls and negatively impacts spatiotemporal parameters of gait. PRM improves falls, fear of falling, and gait during level walking. Additional rehabilitation might be necessary to improve gait while walking with head movements or tandem walking.Video Abstract available for more insights from the authors (see the Supplemental Digital Content Video, available at: http://links.lww.com/JNPT/A421 ).

Large Variability of Head Angulation During the Epley Maneuver: Use of a Head-Mounted Guidance System with Visual Feedback to Improve Outcomes

BACKGROUND

The aim of this study was to show the variability in head angulation during the canalolith repositioning maneuvers to treat benign paroxysmal positional vertigo and to describe a head-mounted benign paroxysmal positional vertigo guidance system to measure the head orientation.

METHODS

A guidance system for benign paroxysmal positional vertigo was developed by NeuroEquilibrium Diagnostic Systems to measure head orientation and provide visual feedback and instructions to examiners during various maneuvers for benign paroxysmal positional vertigo. Twenty-five experienced examiners and 25 healthy volunteers (aged 21-35 years) were recruited. Each examiner applied the Epley maneuver twice in 1 volunteer: without and with the use visual feedback from a guidance system. Head orientation in both procedures was measured and compared.

RESULTS

The trained examiners demonstrated a large variability in head orientation during the Epley maneuver, which was reduced by using the benign paroxysmal positional vertigo guidance system. There was a variability of 39-65° in head orientation measured without the guidance system. The use of the guidance system reduced the variation range to a sixfold decrease in variability.

CONCLUSION

There is a large variability in head orientation when performing repositioning maneuvers, which could compromise the efficacy of benign paroxysmal positional vertigo treatment. Treatment for benign paroxysmal positional vertigo can be optimized by reducing this variability with a benign paroxysmal positional vertigo guidance system. It might also be a useful tool for teaching.

Sound localization in patients with bilateral vestibulopathy

PURPOSE

The goal of this study was to evaluate if bilaterally (partially) absent vestibular function during static sound localization testing, would have a negative impact on sound localization skills. Therefore, this study compared horizontal static sound localization skills of normal-hearing patients with bilateral vestibulopathy (BV) and healthy controls.

METHODS

Thirteen normal-hearing patients with BV and thirteen age-matched healthy controls were included. Sound localization skills were tested using seven loudspeakers in a frontal semicircle, ranging from - 90° to + 90°. Sound location accuracy was analyzed using the root-mean-square error (RMSE) and the mean absolute error (MAE). To evaluate the severity of the BV symptoms, the following questionnaires were used: Dizziness Handicap Inventory (DHI), Oscillopsia severity questionnaire (OSQ), 12-item Spatial, Speech, and Qualities Questionnaire (SSQ12), and Health Utilities Index Mark 3 (HUI3).

RESULTS

The RMSE and MAE were significantly larger (worse) in the BV group than in the healthy control group, with respective median RMSE of 4.6° and 0°, and a median MAE of 0.7° and 0°. The subjective reporting of speech perception, spatial hearing, and quality of life only demonstrated a moderate correlation between DHI (positive correlation) and HUI total score (negative correlation), and localization scores.

CONCLUSION

Static sound localization skills of patients with BV were only mildly worse compared to healthy controls. However, this difference was very small and therefore most likely due to impaired cognitive function. The vestibular system does not seem to have a modulating role in sound localization during static conditions, and its impact is negligible in contrast to the impact of hearing impairment. Furthermore, the subjective reporting of speech perception, spatial hearing, and quality of life was not strongly correlated with localization scores.

Optimized Signal Analysis to Quantify the Non-Linear Behaviour of the Electrically Evoked Vestibulo-Ocular Reflex in Patients with a Vestibular Implant

INTRODUCTION

Different eye movement analysis algorithms are used in vestibular implant research to quantify the electrically evoked vestibulo-ocular reflex (eVOR). Often, standard techniques are used as applied for quantification of the natural VOR in healthy subjects and patients with vestibular loss. However, in previous research, it was observed that the morphology of the VOR and eVOR may differ substantially. In this study, it was investigated if the analysis techniques for eVOR need to be adapted to optimize a truthful quantification of the eVOR (VOR gain, orientation of the VOR axis, asymmetry, and phase shift).

METHODS

"Natural" VOR responses were obtained in six age-matched healthy subjects, and eVOR responses were obtained in eight bilateral-vestibulopathy patients fitted with a vestibular implant. Three conditions were tested: "nVOR" 1-Hz sinusoidal whole-body rotations of healthy subjects in a rotatory chair, "eVOR" 1-Hz sinusoidal electrical vestibular implant stimulation without whole-body rotations in bilateral-vestibulopathy patients, and "dVOR" 1-Hz sinusoidal whole-body rotations in bilateral-vestibulopathy patients using the chair-mounted gyroscope output to drive the electrical vestibular implant stimulation (therefore also in sync 1 Hz sinusoidal). VOR outcomes were determined from the obtained VOR responses, using three different eye movement analysis paradigms: (1) peak eye velocity detection using the raw eye traces; (2) peak eye velocity detection using full-cycle sine fitting of eye traces; (3) peak eye velocity detection using half-cycle sine fitting of eye traces.

RESULTS

The type of eye movement analysis algorithm significantly influenced VOR outcomes, especially regarding the VOR gain and asymmetry of the eVOR in bilateral-vestibulopathy patients fitted with a vestibular implant. Full-cycle fitting lowered VOR gain in the eVOR condition (mean difference: 0.14 ± 0.06 95% CI, p = 0.018). Half-cycle fitting lowered VOR gain in the dVOR condition (mean difference: 0.08 ± 0.04 95% CI, p = 0.009). In the eVOR condition, half-cycle fitting was able to demonstrate the asymmetry between the excitatory and inhibitory phases of stimulation in comparison with the full-cycle fitting (mean difference: 0.19 ± 0.12 95% CI, p = 0.024). The VOR axis and phase shift did not differ significantly between eye movement analysis algorithms. In healthy subjects, no clinically significant effect of eye movement analysis algorithms on VOR outcomes was observed.

CONCLUSION

For the analysis of the eVOR, the excitatory and inhibitory phases of stimulation should be analysed separately due to the inherent asymmetry of the eVOR. A half-cycle fitting method can be used as a more accurate alternative for the analysis of the full-cycle traces.

Comparison of EOG and VOG obtained eye movements during horizontal head impulse testing

Introduction

Video head impulse testing is frequently used to evaluate the vestibular function. During this test, eye movement responses are recorded with video-oculography (VOG). However, the use of VOG can sometimes be challenging, especially due to pupil detection problems (e.g., blinking, droopy eyelids, etc.). Therefore, this study investigated whether electro-oculography (EOG), a technique that does not depend on pupil tracking but on the orientation of the corneoretinal potential, might be an alternative to VOG for quantifying eye movement responses during head impulse testing.

Subjects and methods

Head impulse testing was performed in 19 healthy subjects without a prior history of vestibular symptoms. Horizontal eye movements were recorded simultaneously with EOG (using an EOG system) and VOG (using a VHIT system: ICS Impulse). The eye movement responses to each side of both techniques were compared using a concordance correlation coefficient (r_c), t-testing, and Bayes Factor (BF) paired t-testing.

Results

EOG and VOG obtained eye movement traces that correlated well with each other during head impulse testing (average r_c = 0.89). Average VOR gains obtained with EOG and VOG were not significantly different from each other for all subjects during left head impulses. However, VOG gains differed between both techniques regarding right head impulses. VOG showed significant VOR gain asymmetry (5% to the right), whereas EOG showed no significant asymmetry (1% to the right).

Conclusion

This study demonstrated the use of EOG to record eye movements during head impulse testing for the first time. EOG and VOG obtained eye movement traces that correlated well with each other during horizontal head impulse testing. In addition, EOG showed smaller VOR gain asymmetry in healthy individuals, in contrast to VOG. These findings indicate that EOG might potentially be applicable as an alternative to VOG for collecting eye movement responses during head impulse testing.

Trial registration number

10192021-38 dated 19.10.21.

Suppression Head Impulse Test (SHIMP) versus Head Impulse Test (HIMP) When Diagnosing Bilateral Vestibulopathy

The Suppression Head Impulse (SHIMP) test was introduced as an alternative to the Head Impulse Paradigm (HIMP) to overcome challenges in VOR gain calculation due to the interference of covert saccades. The objectives of this study were (1) to determine if SHIMP, compared to HIMP, reduces covert saccades in BV patients and (2) to define the agreement on diagnosing BV between SHIMP and HIMP. First, the number of covert saccades was compared between SHIMP and HIMP. Secondly, VOR gain was compared between SHIMP and HIMP. Lastly, the agreement between SHIMP and HIMP on identifying BV (horizontal VOR gain <0.6) was evaluated. A total of 98 BV patients were included. To our knowledge, this is the largest study population on SHIMP testing in BV patients. Covert saccades were significantly reduced, and a lower VOR gain was found during SHIMP compared to HIMP (p < 0.001). However, the clinical relevance of these statistically significant differences is small. In 93% of the patients, an agreement was found between the two paradigms regarding the diagnosis of BV, and both paradigms detect BV in the vast majority of patients.

Patterns of Vestibular Impairment in Bilateral Vestibulopathy and Its Relation to Etiology

Objective

This study aimed to investigate (1) the patterns of vestibular impairment in bilateral vestibulopathy (BVP) and subsequently, the implications regarding patient eligibility for vestibular implantation, and (2) whether this pattern and severity of vestibular impairment is etiology dependent.

Methods

A total of one hundred and seventy-three subjects from three tertiary referral centers in Europe were diagnosed with BVP according to the Bárány Society diagnostic criteria. The subjects underwent vestibular testing such as the caloric test, torsion swing test, video Head Impulse Test (vHIT) in horizontal and vertical planes, and cervical and/or ocular vestibular evoked myogenic potentials (c- and oVEMPs). The etiologies were split into idiopathic, genetic, ototoxicity, infectious, Menière's Disease, (head)trauma, auto-immune, neurodegenerative, congenital, and mixed etiology.

Results

The caloric test and horizontal vHIT more often indicated horizontal semicircular canal impairment than the torsion swing test. The vHIT results showed significantly higher gains for both anterior canals compared with the horizontal and posterior canals (p < 0.001). The rates of bilaterally absent oVEMP responses were higher compared to the bilaterally absent cVEMP responses (p = 0.010). A total of fifty-four percent of the patients diagnosed with BVP without missing data met all three Bárány Society diagnostic test criteria, whereas 76% of the patients were eligible for implantation according to the vestibular implantation criteria. Regarding etiology, only horizontal vHIT results were significantly lower for trauma, neurodegenerative, and genetic disorders, whereas the horizontal vHIT results were significantly higher for Menière's Disease, infectious and idiopathic BVP. The exploration with hierarchical cluster analysis showed no significant association between etiology and patterns of vestibular impairment.

Conclusion

This study showed that caloric testing and vHIT seem to be more sensitive for measuring vestibular impairment, whereas the torsion swing test is more suited for measuring residual vestibular function. In addition, no striking patterns of vestibular impairment in relation to etiology were found. Nevertheless, it was demonstrated that although the implantation criteria are stricter compared with the Bárány Society diagnostic criteria, still, 76% of patients with BVP were eligible for implantation based on the vestibular test criteria. It is advised to carefully examine every patient for their overall pattern of vestibular impairment in order to make well-informed and personalized therapeutic decisions.

Development and Content Validity of the Bilateral Vestibulopathy Questionnaire

Background

To date, the burden and severity of the full spectrum of bilateral vestibulopathy (BVP) symptoms has not yet been measured in a standardized manner. Since therapeutic interventions aiming to improve BVP symptoms are emerging, the need for a new standardized assessment tool that encompasses the specific aspects of BVP arises. Therefore, the aim of this study was to develop a multi-item Patient Reported Outcome Measure (PROM) that captures the clinically important symptoms of BVP and assesses its impact on daily life.

Methods

The development of the Bilateral Vestibulopathy Questionnaire (BVQ) consisted of two phases: (I) initial item generation and (II) face and content validity testing. Items were derived from a literature review and individual semi-structured interviews focusing on the full spectrum of reported BVP symptoms (I). Subsequently (IIa), individual patient interviews were conducted using “thinking aloud” and concurrent verbal probing techniques to assess the comprehensibility of the instructions, questions and response options, and the relevance, missing domains, or missing items. Interviews continued until saturation of input was reached. Finally, international experts with experience in the field of the physical, emotional, and cognitive symptoms of BVP participated in an online focus group to assess the relevance and comprehensiveness of the BVQ (IIb).

Results

The BVQ consisted of two sections. The first section included 50 items scored on a six-point Likert scale arranged into seven constructs (i.e., imbalance, oscillopsia, other physical symptoms, cognitive symptoms, emotional symptoms, limitations and behavioral changes and social life). The second section consisted of four items, scored on a visual analog scale from 0 to 100, to inquire about limitations in daily life, perceived health and expectations regarding future recovery. Interviews with BVP patients [n = 8, 50% female, mean age 56 years (range 24–88 years)] and the expert meeting confirmed face and content validity of the developed BVQ.

Conclusion

The BVQ, which was developed to assess the spectrum of BVP symptoms and its impact on daily life, proved to have good face and content validity. It can be used to characterize current self-reported symptoms and disability and to evaluate symptom burden before and after therapeutic interventions in future research and clinical practice.

Fitting the determined impedance in the guinea pig inner ear to randles circuit using square error minimization in the range of 100 Hz to 50 kHz

OBJECTIVE

A number of lumped and distributed parameter models of the inner ear have been proposed in order to improve the vestibular implant stimulation. The models should account for all significant physical phenomena influencing the current propagation: electrical double layer (EDL) and medium polarization. The electrical properties of the medium are reflected in the electrical impedance, therefore the aim of this study was to measure the impedance in the guinea pig inner ear and construct its equivalent circuit.

APPROACH

The electrical impedance was measured from 100 Hz to 50 kHz between a pair of platinum electrodes immersed in saline solution using sinusoidal voltage signals. The Randles circuit was fitted to the measured impedance in the saline solution in order to estimate the EDL parameters (C, W, and R_ct) of the electrode interface in saline. Then, the electrical impedance was measured between all combinations of the electrodes located in semicircular canal ampullae and the vestibular nerve in the guinea pig in vitro. The extended Randles circuit considering the medium polarization (R_i, R_e, C_m) together with EDL parameters (C, R_ct) obtained from the saline solution was fitted to the measured impedance of the guinea pig inner ear. The Warburg element was assumed negligible and was not considered in the guinea pig model.

MAIN RESULTS

For the set-up used, the obtained EDL parameters were: C=27.09*10^-8F, R_ct=18.75 kΩ. The average values of intra-, extracellular resistances, and membrane capacitance were R_i=4.74 kΩ, R_e=45.05 kΩ, C_m=9.69*10^-8F, respectively.

SIGNIFICANCE

The obtained values of the model parameters can serve as a good estimation of the EDL for modelling work. The EDL, together with medium polarization, plays a significant role in the electrical impedance of the guinea pig inner ear, therefore, they should be considered in electrical conductivity models to increase the credibility of the simulations.

Falls Among People With Bilateral Vestibulopathy: A Review of Causes, Incidence, Injuries, and Methods

Importance

People with bilateral vestibulopathy experience severe balance and mobility issues. Fear and anxiety are associated with reduced activity, which can further affect balance and fall risk. Understanding and intervening on falls in this population is essential. The aims of this narrative review are to provide an overview of the current knowledge and applied methods on fall incidence, causes, and injuries in bilateral vestibulopathy.

Observations

Eleven articles reporting falls incidence in people with bilateral vestibulopathy were deemed eligible, including 3 prospective and 8 retrospective studies, with a total of 359 participants, of whom 149 (42%) fell during the assessed period. When reported, the most common perceived causes of falls were loss of balance, darkness, and uneven ground. Information on sustained injuries was limited, with bruises and scrapes being the most common, and only 4 fractures were reported. As most studies included falls as a secondary, descriptive outcome measure, fall data obtained using best practice guidelines were lacking. Only 6 studies reported their definition of a fall, of which 2 studies explicitly reported the way participants were asked about their fall status. Only 3 studies performed a prospective daily fall assessment using monthly fall diaries (a recommended practice), whereas the remaining studies retrospectively collected fall-related data through questionnaires or interviews. While most studies reported the number of people who did and did not fall, the number of total falls in individual studies was lacking.

Conclusions and Relevance

The findings from this review suggest that falls in people with bilateral vestibulopathy are common but remain an understudied consequence of the disease. Larger prospective studies that follow best practice guidelines for fall data collection with the aim of obtaining and reporting fall data are required to improve current fall risk assessments and interventions in bilateral vestibulopathy.

2BALANCE: Test-retest reliability of a cognitive-motor dual-task protocol

PURPOSE

Aside from typical symptoms such as dizziness and vertigo, persons with vestibular disorders often have cognitive and motor problems. These symptoms have been assessed in single-task condition. However, dual-tasks assessing cognitive-motor interference might be an added value as they reflect daily life situations better. Therefore, the 2BALANCE protocol was developed. In the current study, the test-retest reliability of this protocol was assessed.

METHODS

The 2BALANCE protocol was performed twice in 20 healthy young adults with an in-between test interval of two weeks. Two motor tasks and five different cognitive tasks were performed in single and dual-task condition. Intraclass correlation coefficients (ICC), the standard error of measurement, and the minimal detectable difference were calculated.

RESULTS

All cognitive tasks, with the exception of the mental rotation task, had favorable reliability results (0.26≤ICC≤0.91). The dynamic motor task indicated overall substantial reliability values in all conditions (0.67≤ICC≤0.98). Similar results were found for the static motor task during dual-tasking (0.50≤ICC≤0.92), but were slightly lower in single-task condition (-0.26≤ICC≤0.75).

CONCLUSIONS

The 2BALANCE protocol was overall consistent across trials. However, the mental rotation task showed lowest reliability values.

Bilateral vestibulopathy patients' perspectives on vestibular implant treatment: a qualitative study

Objectives

The aim of this study was to explore expectations of patients with bilateral vestibulopathy regarding vestibular implant treatment. This could advance the definition of recommendations for future core outcome sets of vestibular implantation and help to determine on which characteristics of bilateral vestibulopathy future vestibular implant research should focus.

Methods

Semi-structured interviews were conducted with 50 patients diagnosed with bilateral vestibulopathy at Maastricht UMC + . Interviews followed a semi-structured interview guide and were recorded and transcribed. Transcripts were analyzed thematically by two independent researchers. A consensus meeting took place to produce a joint interpretation for greater dimensionality and to confirm key themes.

Results

Overall, patient expectations centralized around three key themes: (physical) symptom reduction, functions and activities, and quality of life. These themes appeared to be interrelated. Patient expectations focused on the activity walking (in a straight line), reducing the symptom oscillopsia and being able to live the life they had before bilateral vestibulopathy developed. In general, patients indicated to be satisfied with small improvements.

Conclusion

This study demonstrated that patient expectations regarding a vestibular implant focus on three key themes: symptom reduction, functions and activities, and quality of life. These themes closely match the functional improvements shown in recent vestibular implantation research. The results of this study provide a clear guideline from the patient perspective on which characteristics of bilateral vestibulopathy, future vestibular implant research should focus.

Trial registration

NL52768.068.15/METC

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-021-10920-z.

A non-invasive, automated diagnosis of Menière's disease using radiomics and machine learning on conventional magnetic resonance imaging: A multicentric, case-controlled feasibility study

Purpose

This study investigated the feasibility of a new image analysis technique (radiomics) on conventional MRI for the computer-aided diagnosis of Menière’s disease.

Materials and methods

A retrospective, multicentric diagnostic case–control study was performed. This study included 120 patients with unilateral or bilateral Menière’s disease and 140 controls from four centers in the Netherlands and Belgium. Multiple radiomic features were extracted from conventional MRI scans and used to train a machine learning-based, multi-layer perceptron classification model to distinguish patients with Menière’s disease from controls. The primary outcomes were accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of the classification model.

Results

The classification accuracy of the machine learning model on the test set was 82%, with a sensitivity of 83%, and a specificity of 82%. The positive and negative predictive values were 71%, and 90%, respectively.

Conclusion

The multi-layer perceptron classification model yielded a precise, high-diagnostic performance in identifying patients with Menière’s disease based on radiomic features extracted from conventional T2-weighted MRI scans. In the future, radiomics might serve as a fast and noninvasive decision support system, next to clinical evaluation in the diagnosis of Menière’s disease.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11547-021-01425-w.

DISCOHAT: An Acronym to Describe the Spectrum of Symptoms Related to Bilateral Vestibulopathy

Objective: To assess the prevalence of each symptom listed in the acronym DISCOHAT (worsening of symptoms in Darkness and/or uneven ground, Imbalance, Supermarket effect, Cognitive complaints, Oscillopsia, Head movements worsen symptoms, Autonomic complaints, and Tiredness) in patients with bilateral vestibulopathy (BVP), compared to patients with unilateral vestibulopathy (UVP). Methods: A descriptive case-control study was performed on BVP and UVP patients who were evaluated for their vestibular symptoms by two of the authors (RvdB, MCG) at a tertiary referral center, between 2017 and 2020. During history taking, the presence of each DISCOHAT symptom was checked and included in the electronic health record. Presence of a symptom was categorized into: "present," "not present," and "missing." Results: Sixty-six BVP patients and 144 UVP patients were included in this study. Prevalence of single DISCOHAT symptoms varied from 52 to 92% in BVP patients and 18-75% in UVP patients. Patients with BVP reported "worsening of symptoms in darkness," "imbalance," "oscillopsia," and "worsening of symptoms with fast head movements" significantly more than UVP patients (p ≤ 0.004). Conclusion: The DISCOHAT acronym is able to capture a wide spectrum of symptoms related to vestibulopathy, while it is easy and quickly to use in clinic. Application of this acronym might facilitate a more thorough and uniform assessment of bilateral vestibulopathy, within and between vestibular clinics worldwide.

The vestibular implant: Opinion statement on implantation criteria for research

This opinion statement proposes a set of candidacy criteria for vestibular implantation of adult patients with bilateral vestibulopathy (BVP) in a research setting. The criteria include disabling chronic symptoms like postural imbalance, unsteadiness of gait and/or head movement-induced oscillopsia, combined with objective signs of reduced or absent vestibular function in both ears. These signs include abnormal test results recorded during head impulses (video head impulse test or scleral coil technique), bithermal caloric testing and rotatory chair testing (sinusoidal stimulation of 0.1 Hz). Vestibular implant (VI) implantation criteria are not the same as diagnostic criteria for bilateral vestibulopathy. The major difference between VI-implantation criteria and the approved diagnostic criteria for BVP are that all included vestibular tests of semicircular canal function (head impulse test, caloric test, and rotatory chair test) need to show significant impairments of vestibular function in the implantation criteria. For this, a two-step paradigm was developed. First, at least one of the vestibular tests needs to fulfill stringent criteria, close to those for BVP. If this is applicable, then the other vestibular tests have to fulfill a second set of criteria which are less stringent than the original criteria for BVP. If the VI-implantation is intended to excite the utricle and/or saccule (otolith stimulation), responses to cervical and ocular vestibular evoked myogenic potentials must be absent in addition to the above mentioned abnormalities of semicircular canal function. Finally, requirements for safe and potentially effective stimulation should be met, including implanting patients with BVP of peripheral origin only, and assessing possible medical and psychiatric contraindications.

The resilience of the inner ear-vestibular and audiometric impact of transmastoid semicircular canal plugging

Background

Certain cases of superior semicircular canal dehiscence or benign paroxysmal positional vertigo can be treated by plugging of the affected semicircular canal. However, the extent of the impact on vestibular function and hearing during postoperative follow-up is not known.

Objective

To evaluate the evolution of vestibular function and hearing after plugging of a semicircular canal.

Methods

Six patients underwent testing before and 1 week, 2 months, and 6 months after plugging of the superior or posterior semicircular canal. Testing included caloric irrigation test, video Head Impulse Test (vHIT), cervical and ocular Vestibular Evoked Myogenic Potentials (VEMPs) and audiometry.

Results

Initially, ipsilateral caloric response decreased in all patients and vHIT vestibulo-ocular reflex (VOR) gain of each ipsilateral semicircular canal decreased in 4/6 patients. In 4/6 patients, postoperative caloric response recovered to > 60% of the preoperative value. In 5/6 patients, vHIT VOR gain was restored to > 85% of the preoperative value for both ipsilateral non-plugged semicircular canals. In the plugged semicircular canal, this gain decreased in 4/5 patients and recovered to > 50% of the preoperative value. Four patients preserved cervical and ocular VEMP responses. Bone conduction hearing deteriorated in 3/6 patients, but recovered within 6 months postoperatively, although one patient had a persistent loss of 15 dB at 8 kHz.

Conclusion

Plugging of a semicircular canal can affect both vestibular function and hearing. After initial deterioration, most patients show recovery during follow-up. However, a vestibular function loss or high-frequency hearing loss can persist. This stresses the importance of adequate counseling of patients considering plugging of a semicircular canal.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-021-10693-5.

Bilateral vestibulopathy decreases self-motion perception

Objective

Current diagnostic criteria for bilateral vestibulopathy (BV) primarily involve measurements of vestibular reflexes. Perceptual self-motion thresholds however, are not routinely measured and their clinical value in this specific population is not yet fully determined. Objectives of this study were (1) to compare perceptual self-motion thresholds between BV patients and control subjects, and (2) to explore patterns of self-motion perception performance and vestibular function in BV patients.

Methods

Thirty-seven BV patients and 34 control subjects were included in this study. Perceptual self-motion thresholds were measured in both groups using a CAREN platform (Motek Medical BV, Amsterdam, The Netherlands). Vestibular function was evaluated (only in BV patients) by the caloric test, torsion swing test, video head impulse test of all semicircular canals, and cervical- and ocular vestibular-evoked myogenic potentials. Differences in thresholds between both groups were analyzed. Hierarchical cluster analysis was performed to visualize patterns between self-motion perception and vestibular function within the group of BV patients.

Results

Perceptual self-motion thresholds were significantly higher in BV patients compared to control subjects, regarding nearly all rotations and translations (depending on the age group) (p ≤ 0.001). Cluster analysis showed that within the group of BV patients, higher perceptual self-motion thresholds were generally associated with lower vestibular test results (significant for yaw rotation, caloric test, torsion swing test, and video head impulse test (p ≤ 0.001)).

Conclusion

Self-motion perception is significantly decreased in BV patients compared to control subjects regarding nearly all rotations and translations. Furthermore, decreased self-motion perception is generally associated with lower residual vestibular function in BV patients.

Trial registration

Trial registration number NL52768.068.15/METC

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-021-10695-3.

Driving ability in patients with dizziness: a systematic review

PURPOSE

The aim of this systematic review was to identify and evaluate studies dealing with driving performance of dizzy patients or patients with a vestibular disorder.

METHODS

A systematic review was performed according to the preferred reporting items for systematic reviews and meta-analysis guidelines. (1) PubMed, Embase, and Cochrane library. (2) Study selection: articles about driving ability and reported driving difficulties in patients with dizziness, or a diagnosed vestibular disorder, were included. (3) Data extraction was performed by two independent authors using predefined data fields: patient's characteristics, diagnostic criteria, sample size, and type of evaluation of driving ability and outcome of the study.

RESULTS

Eight out of 705 articles matched the inclusion criteria but varied widely regarding the study population, study design, and outcome measures. The majority of studies reported a negative impact of dizziness and/or vestibular disorders on self-reported driving ability and car accidents. Yet several studies could not identify any impairment of driving ability.

CONCLUSIONS

Driving ability was negatively affected by dizziness or a vestibular disorder in the majority of included studies with low risk of bias. This systematic review revealed a significant heterogeneity in studies reporting driving performance and contradictory results. We were, therefore, unable to identify a causal relationship between dizziness and driving ability. There is a need for prospective studies in populations with different vestibular disorders using subjective and objective outcome measures that have been validated to evaluate driving performance.

Superior semicircular canal dehiscence syndrome: Diagnostic criteria consensus document of the committee for the classification of vestibular disorders of the Bárány Society

This paper describes the diagnostic criteria for superior semicircular canal dehiscence syndrome (SCDS) as put forth by the classification committee of the Bárány Society. In addition to the presence of a dehiscence of the superior semicircular canal on high resolution imaging, patients diagnosed with SCDS must also have symptoms and physiological tests that are both consistent with the pathophysiology of a ‘third mobile window’ syndrome and not better accounted for by another vestibular disease or disorder. The diagnosis of SCDS therefore requires a combination of A) at least one symptom consistent with SCDS and attributable to ‘third mobile window’ pathophysiology including 1) hyperacusis to bone conducted sound, 2) sound-induced vertigo and/or oscillopsia time-locked to the stimulus, 3) pressure-induced vertigo and/or oscillopsia time-locked to the stimulus, or 4) pulsatile tinnitus; B) at least 1 physiologic test or sign indicating that a ‘third mobile window’ is transmitting pressure including 1) eye movements in the plane of the affected superior semicircular canal when sound or pressure is applied to the affected ear, 2) low-frequency negative bone conduction thresholds on pure tone audiometry, or 3) enhanced vestibular-evoked myogenic potential (VEMP) responses (low cervical VEMP thresholds or elevated ocular VEMP amplitudes); and C) high resolution computed tomography (CT) scan with multiplanar reconstruction in the plane of the superior semicircular canal consistent with a dehiscence. Thus, patients who meet at least one criterion in each of the three major diagnostic categories (symptoms, physiologic tests, and imaging) are considered to have SCDS.

An exploratory investigation on spatiotemporal parameters, margins of stability, and their interaction in bilateral vestibulopathy

Integration of accurate vestibular, visual, and proprioceptive information is crucial in managing the centre of mass in relation to the base of support during gait. Therefore, bilateral loss of peripheral vestibular function can be highly debilitating when performing activities of daily life. To further investigate the influence of an impaired peripheral vestibular system on gait stability, spatiotemporal parameters, step-to-step variability, and mechanical stability parameters were examined in 20 patients with bilateral vestibulopathy and 20 matched healthy controls during preferred overground walking. Additionally, using a partial least squares analysis the relationship between spatiotemporal parameters of gait and the margins of stability was explored in both groups. Patients with bilateral vestibulopathy showed an increased cadence compared to healthy controls (121 ± 9 vs 115 ± 8 steps/min; p = 0.02; d = 0.77). In addition, although not significant (p = 0.07), a moderate effect size (d = 0.60) was found for step width variability (Coefficient of Variation (%); Bilateral vestibulopathy: 19 ± 11%; Healthy controls: 13 ± 5%). Results of the partial least squares analysis suggest that patients with peripheral vestibular failure implement a different balance control strategy. Instead of altering the step parameters, as is the case in healthy controls, they use the single and double support phases to control the state of the centre of mass to improve the mechanical stability.

Vestibular Migraine of Childhood and Recurrent Vertigo of Childhood: Diagnostic criteria Consensus document of the Committee for the Classification of Vestibular Disorders of the Bárány Society and the International Headache Society

This paper describes the diagnostic criteria for “Vestibular Migraine of Childhood”, “probable Vestibular Migraine of Childhood” and “Recurrent Vertigo of Childhood” as put forth by the Committee for the Classification of Vestibular Disorders of the Bárány Society (ICVD) and the Migraine Classification subgroup of the International Headache Society. Migraine plays an important role in some subgroups of children with recurrent vertigo. In this classification paper a spectrum of three disorders is described in which the migraine component varies from definite to possibly absent. These three disorders are: Vestibular Migraine of Childhood, probable Vestibular Migraine of Childhood and Recurrent Vertigo of Childhood. The criteria for Vestibular Migraine of Childhood (VMC) include (A) at least five episodes with vestibular symptoms of moderate or severe intensity, lasting between five minutes and 72 hours, (B) a current or past history of migraine with or without aura, and (C) at least half of episodes are associated with at least one migraine feature. Probable Vestibular Migraine of Childhood (probable VMC) is considered when at least three episodes with vestibular symptoms of moderate or severe intensity, lasting between five minutes and 72 hours, are accompanied by at least criterion B or C from the VMC criteria. Recurrent Vertigo of Childhood (RVC) is diagnosed in case of at least three episodes with vestibular symptoms of moderate or severe intensity, lasting between 1 minute and 72 hours, and none of the criteria B and C for VMC are applicable. For all disorders, the age of the individual needs to be below 18 years old. It is recommended that future research should particularly focus on RVC, in order to investigate and identify possible subtypes and its links or its absence thereof with migraine.

Diagnosing vestibular hypofunction: an update

Unilateral or bilateral vestibular hypofunction presents most commonly with symptoms of dizziness or postural imbalance and affects a large population. However, it is often missed because no quantitative testing of vestibular function is performed, or misdiagnosed due to a lack of standardization of vestibular testing. Therefore, this article reviews the current status of the most frequently used vestibular tests for canal and otolith function. This information can also be used to reach a consensus about the systematic diagnosis of vestibular hypofunction.

The "hype" of hydrops in classifying vestibular disorders: a narrative review

Background

Classifying and diagnosing peripheral vestibular disorders based on their symptoms is challenging due to possible symptom overlap or atypical clinical presentation. To improve the diagnostic trajectory, gadolinium-based contrast-enhanced magnetic resonance imaging of the inner ear is nowadays frequently used for the in vivo confirmation of endolymphatic hydrops in humans. However, hydrops is visualized in both healthy subjects and patients with vestibular disorders, which might make the clinical value of hydrops detection on MRI questionable.

Objective

To investigate the diagnostic value of clinical and radiological features, including the in vivo visualization of endolymphatic hydrops, for the classification and diagnosis of vestibular disorders.

Methods

A literature search was performed in February and March 2019 to estimate the prevalence of various features in healthy subjects and in common vestibular disorders to make a graphical comparison between healthy and abnormal.

Results

Of the features studied, hydrops was found to be a highly prevalent feature in Menière’s disease (99.4%). Though, hydrops has also a relatively high prevalence in patients with vestibular schwannoma (48.2%) and in healthy temporal bones (12.5%) as well. In patients diagnosed with (definite or probable) Menière’s disease, hydrops is less frequently diagnosed by magnetic resonance imaging compared to the histological confirmation (82.3% versus 99.4%). The mean prevalence of radiologically diagnosed hydrops was 31% in healthy subjects, 28.1% in patients with vestibular migraine, and 25.9% in patients with vestibular schwannoma. An interesting finding was an absolute difference in hydrops prevalence between the two diagnostic techniques (histology and radiology) of 25.2% in patients with Menière’s disease and 29% in patients with vestibular schwannoma.

Conclusions

Although the visualization of hydrops has a high diagnostic value in patients with definite Menière’s disease, it is important to appreciate the relatively high prevalence of hydrops in healthy populations and other vestibular disorders. Endolymphatic hydrops is not a pathognomic phenomenon, and detecting hydrops should not directly indicate a diagnosis of Menière’s disease. Both symptom-driven and hydrops-based classification systems have disadvantages. Therefore, it might be worth to explore features “beyond” hydrops. New analysis techniques, such as Radiomics, might play an essential role in (re)classifying vestibular disorders in the future.

Electronic supplementary material

The online version of this article (10.1007/s00415-020-10278-8) contains supplementary material, which is available to authorized users.

Impact of Superior Canal Dehiscence Syndrome on Health Utility Values: A Prospective Case-Control Study

Introduction: Superior canal dehiscence syndrome (SCDS) is a condition characterized by a defect in the bone overlying the superior semicircular canal, creating a third mobile window into the inner ear. Patients can experience disabling symptoms and opt for surgical management. Limited data are available on the impact of SCDS on health-related quality of life (HRQoL) and disease-specific HRQoL more specifically.

Objective: To perform a prospective analysis on generic HRQoL in SCDS patients compared to healthy age-matched controls.

Methods: A prospective study was performed on patients diagnosed with SCDS and who did not undergo reconstructive surgery yet. Patients were recruited between November 2017 and January 2020 and asked to complete the Health Utility Index (HUI) Mark 2 (HUI2)/Mark 3 (HUI3) questionnaire. For the control group, age-matched participants without otovestibular pathology or other chronic pathology were recruited. The multi-attribute utility function (MAUF) score was calculated for the HUI2 and HUI3. Results of both groups were compared using the Mann-Whitney U test.

Results: A total of 20 patients completed the questionnaire. Age ranged from 37 to 79 years with a mean age of 56 years (45% males and 55% females). The control group consisted of 20 participants with a mean age of 56.4 years and ranged from 37 to 82 years (35% males and 65% females). For the case group, median HUI2 MAUF score was 0.75 and median HUI3 MAUF score was 0.65. For the control group, the median scores were 0.88 and 0.86 respectively. There was a statistically significant difference for both HUI2 (p = 0.024) and HUI3 (p = 0.011). SCDS patients had a worse generic HRQoL than age-matched healthy controls. One patient with unilateral SCDS had a negative HUI3 MAUF score (−0.07), indicating a health-state worse than death.

Conclusion: SCDS patients have significantly lower health utility values than an age-matched control group. This confirms the negative impact of SCDS on generic HRQoL, even when using an instrument that is not designed to be disease-specific but to assess health state in general. These data can be useful to compare impact on HRQoL among diseases.

A Systematic Review on Balance Performance in Patients With Bilateral Vestibulopathy

OBJECTIVE

Patients with bilateral vestibulopathy (BVP) have severe balance deficits, but it is unclear which balance measures are best suited to quantify their deficits and approximate the diversity of their self-reports. The purpose of this study was to explore measures of balance control for quantifying the performance of patients with BVP related to different balance domains, allowing targeted assessment of response to intervention.

METHODS

MEDLINE, Web of Science, and Embase were systematically searched on October 9, 2019. The Scottish Intercollegiate Guidelines Network checklist for case-control studies was applied to assess each individual study's risk of bias. Standardized mean differences (SMD) were calculated based on the extracted numeric data and reported according to the type of sensory perturbation in the balance tasks.

RESULTS

Twelve studies (1.3%) met the eligibility criteria and were analyzed, including data of 176 patients with BVP, 196 patients with unilateral vestibulopathy, and 205 healthy controls between 18 and 92 years old. In general, patients with BVP were either unable to maintain (or had reduced) balance during tasks with multisensory perturbations compared with healthy controls (range of mean SMD = 1.52-6.92) and patients with unilateral vestibulopathy (range of absolute mean SMD = 0.86-1.66).

CONCLUSIONS

During clinical assessment to quantify balance control in patients with BVP, tasks involving multisensory perturbations should be implemented in the test protocol.

IMPACT

As patients with BVP show difficulties with movement strategies, control of dynamics, orientation in space, and cognitive processing, clinicians should implement these aspects of balance control in their assessment protocol to fully comprehend the balance deficits in these patients.

The Virtual Morris Water Task in 64 Patients With Bilateral Vestibulopathy and the Impact of Hearing Status

Background: Previous studies have demonstrated spatial cognitive deficits in patients with bilateral vestibulopathy (BVP). However, BVP patients frequently present with a concomitant sensorineural hearing loss, which is a well-established risk factor of cognitive impairment and incident dementia. Nonetheless, previous research on spatial cognitive deficits in BVP patients have not taken hearing status into account.

Objective: This study aims to compare spatial cognition of BVP patients with healthy controls, with analyses adjusting for hearing status.

Methods: Spatial cognition was assessed in 64 BVP patients and 46 healthy controls (HC) by use of the Virtual Morris Water Task (VMWT). All statistical analyses were adjusted for hearing (dys)function, sex, age, education, and computer use.

Results: Overall, patients with BVP performed worse on all outcome measures of the VMWT. However, these differences between BVP patients and healthy controls were not statistically significant. Nonetheless, a statistically significant link between sensorineural hearing loss and spatial cognition was observed. The worse the hearing, the longer subjects took to reach the hidden platform in the VMWT. Furthermore, the worse the hearing, the less time was spent by the subjects in the correct platform quadrant during the probe trial of the VMWT.

Conclusion: In this study, no difference was found regarding spatial cognition between BVP patients and healthy controls. However, a statistically significant link was observed between sensorineural hearing loss and spatial cognition.

2BALANCE: a cognitive-motor dual-task protocol for individuals with vestibular dysfunction

INTRODUCTION

Aside from primary vestibular symptoms such as vertigo and dizziness, persons with vestibular dysfunction frequently express cognitive and motor problems. These symptoms have mainly been assessed in single-task setting, which might not represent activities of daily living accurately. Therefore, a dual-task protocol, consisting of the simultaneous performance of cognitive and motor tasks, was developed. This protocol assesses cognitive and motor performance in general, as well as cognitive-motor interference in specific.

METHODS AND ANALYSIS

The motor component of the 2BALANCE protocol consists of a static and dynamic postural task. These motor tasks are combined with different cognitive tasks assessing visuospatial cognition, processing speed, working memory and response inhibition. First, test-retest reliability will be assessed with an interval of 2 weeks in a group of young adults. Second, the 2BALANCE protocol will be validated in persons with bilateral vestibulopathy. Finally, the protocol will be implemented in persons with unilateral vestibular loss.

DISCUSSION AND CONCLUSIONS

The 2BALANCE project aims to elucidate the impact of vestibular dysfunction on cognitive and motor performance in dual-task setting. This protocol represents everyday situations better than single-task protocols, as dual-tasks such as reading street signs while walking are often encountered during daily activities. Ultimately, this project could enable individualised and holistic clinical care in these patients, taking into account single as well as dual-task performance.

ETHICS AND DISSEMINATION

The current study was approved by the ethics committee of Ghent University Hospital on 5 July 2019 with registration number B670201940465. All research findings will be disseminated in peer-reviewed journals and presented at vestibular as well as multidisciplinary international conferences and meetings.

TRIALS REGISTRATION NUMBER

NCT04126798, pre-results phase.

The walking speed-dependency of gait variability in bilateral vestibulopathy and its association with clinical tests of vestibular function

Understanding balance and gait deficits in vestibulopathy may help improve clinical care and our knowledge of the vestibular contributions to balance. Here, we examined walking speed effects on gait variability in healthy adults and in adults with bilateral vestibulopathy (BVP). Forty-four people with BVP, 12 healthy young adults and 12 healthy older adults walked at 0.4 m/s to 1.6 m/s in 0.2 m/s increments on a dual belt, instrumented treadmill. Using motion capture and kinematic data, the means and coefficients of variation for step length, time, width and double support time were calculated. The BVP group also completed a video head impulse test and examinations of ocular and cervical vestibular evoked myogenic potentials and dynamic visual acuity. Walking speed significantly affected all gait parameters. Step length variability at slower speeds and step width variability at faster speeds were the most distinguishing parameters between the healthy participants and people with BVP, and among people with BVP with different locomotor capacities. Step width variability, specifically, indicated an apparent persistent importance of vestibular function at increasing speeds. Gait variability was not associated with the clinical vestibular tests. Our results indicate that gait variability at multiple walking speeds has potential as an assessment tool for vestibular interventions.