Effect of vestibular rehabilitation games in patients with persistent postural perceptual dizziness and its relation to anxiety and depression: prospective study

PURPOSE

To evaluate the efficacy of vestibular rehabilitation therapy (VRT) for management of patients with persistent postural perceptual dizziness (PPPD) utilizing subjective and objectives outcome measures and to study the effect of degree of both anxiety and depression in patients on the response of vestibular rehabilitation therapy.

METHODS

Thirty-three PPPD patients participated in this study. Selection of patients was based on the diagnostic criteria for PPPD stated by Barany society in the International Classification of Vestibular Disorders (2017). Every patient was subjected to history taking, anxiety and depression assessment, Arabic version of Dizziness Handicap Inventory (DHI), and sensory organization test (SOT). All patients received vestibular rehabilitations therapy. Assessment of VRT outcome was conducted after 6 weeks of VRT.

RESULTS

The mean patients' age was 40.9 ± 16.3 years, and nearly equal gender distribution. Vestibular migraine was the most precipitating condition (24.2%) in patients with PPPD. (39.4%) of patients had abnormal scores of anxiety and depression tests, all patients had from moderate to severe degrees of handicap caused by dizziness as measured by DHI, most of patients had abnormal findings in all conditions of SOT. After vestibular rehabilitation therapy, DHI and SOT scores showed significant improvement after VRT. More improvement was found among the group with no anxiety and depression.

CONCLUSION

VRT were effective in improving balance abnormalities in patients with PPPD evidenced by subjectively by DHI scores and objectively by SOT results. PPPD patients with concomitant psychiatric disorders; anxiety and depression experienced the least degree of improvement.

Vestibular dysfunction leads to cognitive impairments: State of knowledge in the field and clinical perspectives (Review)

The vestibular system may have a critical role in the integration of sensory information and the maintenance of cognitive function. A dysfunction in the vestibular system has a significant impact on quality of life. Recent research has provided evidence of a connection between vestibular information and cognitive functions, such as spatial memory, navigation and attention. Although the exact mechanisms linking the vestibular system to cognition remain elusive, researchers have identified various pathways. Vestibular dysfunction may lead to the degeneration of cortical vestibular network regions and adversely affect synaptic plasticity and neurogenesis in the hippocampus, ultimately contributing to neuronal atrophy and cell death, resulting in memory and visuospatial deficits. Furthermore, the extent of cognitive impairment varies depending on the specific type of vestibular disease. In the present study, the current literature was reviewed, potential causal relationships between vestibular dysfunction and cognitive performance were discussed and directions for future research were proposed.

Anxiety and physical impairment in patients with central vestibular disorders

BACKGROUND

There is increasing evidence for close interrelations between vestibular and emotional brain networks. A study in patients with bilateral peripheral vestibulopathy (BVP) showed relatively low vertigo-related anxiety (VRA), despite high physical impairment. The current working hypothesis proposes the integrity of the peripheral vestibular system as a prerequisite for development of VRA. Here we contribute by evaluating VRA and vestibular-related handicap in central vestibular disorders.

METHODS

Of 6396 patients presenting in a tertiary vertigo centre, 306 were identified with four clear central vestibular disorders: pure cerebellar ocular motor disorder (COD; 61), cerebellar ataxia (CA; 63), atypical parkinsonian syndromes (APS; 28), vestibular migraine (VM; 154). Their results of the Vertigo Handicap Questionnaire (VHQ), with its subscales for anxiety and handicapped activity, were compared to those of 65 BVP patients. Postural instability was measured on a force-plate. Multivariate linear regression was used to adjust for patient demographics.

RESULTS

Patients with chronic central vestibular disorders (COD, CA, APS) had relatively low VRA levels comparable to those in BVP, independent of increased handicapped activity or postural instability. Only VM patients showed significantly higher VRA, although their activity impairment and postural instability were lowest. No significant differences within chronic central vestibular disorders were found for VRA and subjective activity impairment.

CONCLUSIONS

Subjective and objective vestibular-related impairment are not necessarily correlated with vestibular-related anxiety in central vestibular disorders. Our findings rather support the hypothesis that, in addition to an intact peripheral, an intact central vestibular system could also serve as a prerequisite to develop specific VRA.

The Effectiveness of Medical Prophylactic Treatment on Vestibular Migraine and Its Effect on the Quality Of Life

OBJECTIVES

The aim of the present study was to determine the efficacy of propranolol treatment in patients with vestibular migraine by the Visual Analog Scale, Dizziness Handicap Inventory (DHI), Vertigo Symptom Scale, and Vestibular Disorders Activities of Daily Living Scale (VADL) and its effect on the quality of life.

MATERIALS AND METHODS

The study population consisted of 38 patients with vertigo/dizziness who underwent routine evaluation and vestibular examinations, were diagnosed with definitive vestibular migraine, and received the same medical treatment protocol (propranolol). The questionnaires and scales that were applied to the patients before and after treatment were evaluated. The results were evaluated with 95% confidence interval, and p<0.05 was accepted as statistically significant.

RESULTS

The mean age of the patients was 47.55 (18-75) years, and 27 (71%) patients were female, and 11 (29%) were male. The mean total scores of the DHI before and after treatment were 50.21±22.39 (range: 8-92) and 9.31±9.86 (range: 0-58), respectively (p<0.001). The degree of disability after treatment was low in all patients (p<0.001). The total scores of the VADL before and after treatment were 186.63±79.65 (range: 32-280) and 55.52±51.89 (range: 28-273), respectively (p<0.001). There was no correlation between these two scales (p=0.235).

CONCLUSION

To our knowledge, this is the first study to evaluate both the efficacy of propranolol treatment and its effects on the quality of life in vestibular migraine. The severity, frequency, and number of attacks and disability scores were reduced, and the quality of life was improved in patients with vestibular migraine with propranolol treatment.

Internet based vestibular rehabilitation with and without physiotherapy support for adults aged 50 and older with a chronic vestibular syndrome in general practice: three armed randomised controlled trial

OBJECTIVE

To investigate the clinical effectiveness and safety of stand alone and blended internet based vestibular rehabilitation (VR) in the management of chronic vestibular syndromes in general practice.

DESIGN

Pragmatic, three armed, parallel group, individually randomised controlled trial.

SETTING

59 general practices in the Netherlands.

PARTICIPANTS

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

INTERVENTIONS

Stand alone VR comprising a six week, internet based intervention with weekly online sessions and daily exercises (10-20 minutes a day). In the blended VR group, the same internet based intervention was supplemented by face-to-face physiotherapy support (home visits in weeks 1 and 3). Participants in the usual care group received standard care from a general practitioner, without any restrictions.

MAIN OUTCOME MEASURES

The primary outcome was vestibular symptoms after six months as measured by the vertigo symptom scale-short form (VSS-SF range 0-60, clinically relevant difference ≥3 points). Secondary outcomes were dizziness related impairment, anxiety, depressive symptoms, subjective improvement of vestibular symptoms after three and six months, and adverse events.

RESULTS

In the intention-to-treat analysis, participants in the stand alone and blended VR groups had lower VSS-SF scores at six months than participants in the usual care group (adjusted mean difference -4.1 points, 95% confidence interval -5.8 to -2.5; and -3.5 points, -5.1 to -1.9, respectively). Similar differences in VSS-SF scores were seen at three months follow-up. Participants in the stand alone and blended VR groups also experienced less dizziness related impairment, less anxiety, and more subjective improvement of vestibular symptoms at three and six months. No serious adverse events related to online VR occurred during the trial.

CONCLUSION

Stand alone and blended internet based VR are clinically effective and safe interventions to treat adults aged 50 and older with a chronic vestibular syndrome. Online VR is an easily accessible form of treatment, with the potential to improve care for an undertreated group of patients in general practice.

TRIAL REGISTRATION

Netherlands Trial Register NTR5712.

Increased Prevalence of Vestibular Loss in Mild Cognitive Impairment and Alzheimer's Disease

BACKGROUND/AIMS

Recent evidence has shown that Alzheimer's Disease (AD) patients have reduced vestibular function relative to healthy controls. In this study, we evaluated whether patients with Mild Cognitive Impairment (MCI) also have reduced vestibular function relative to controls, and compared the level of vestibular impairment between MCI and AD patients.

METHODS

Vestibular physiologic function was assessed in 77 patients (26 MCI, 51 AD) and 295 matched controls using 3 clinical vestibular tests. The association between vestibular loss and cognitive impairment was evaluated using conditional logistic regression models.

RESULTS

Individuals with vestibular impairment had a 3 to 4-fold increased odds of being in the MCI vs. control group (p-values < 0.05). MCI patients had a level of vestibular impairment that was intermediate between controls and AD.

CONCLUSION

These findings suggest a dose-response relationship between vestibular loss and cognitive status, and support the hypothesis that vestibular loss contributes to cognitive decline.

N-nitro-L-arginine, a nitric oxide synthase inhibitor, aggravates iminodipropionitrile-induced neurobehavioral and vestibular toxicities in rats

Exposure of iminodipropionitrile (IDPN) to rodents produces permanent behavioral syndrome characterized by repetitive head movements, circling and back walking. Other synthetic nitriles of industrial importance such as crotonitrile and allylnitrile are also able to produce similar motor deficits in experimental animals. However, due to the well-defined behavioral deficits and their easy quantification, IDPN-induced behavioral syndrome is a preferential animal model to test the interaction of various agents with synthetic nitriles. This study reports the effect of non-specific nitric oxide synthase inhibitor, N-nitro-L-arginine (NARG) on IDPN-induced neurobehavioral toxicity in adult male Wistar rats. Four groups of animals were given i.p. injections of IDPN (100 mg/kg) for 6 days. These rats were treated with oral administration of NARG in the doses of 0 (IDPN alone group), 50, 150 and 300 mg/kg, 60 min before IDPN, respectively. Control rats received vehicle only, whereas another group was treated with 300 mg/kg of NARG alone (without IDPN). The results showed that NARG significantly exacerbated the incidence and intensity of IDPN-induced dyskinetic head movements, circling and back walking. The histology of inner ear showed massive degeneration of the sensory hair cells in the crista ampullaris of rats receiving the combined treatment with IDPN and NARG, suggesting a possible role of nitric oxide in IDPN-induced neurobehavioral syndrome in rats.

[The importance of estimation of the quality of life in the patients with vestibular disorders]

The objective of the present study was to develop and introduce into clinical practice the method for the estimation of the quality of life in the patients with vestibular disorders as a measure of the efficacy of their treatment and as a diagnostic criterion to be used in regular medical examinations. Sixty eight patients presenting with total cochleovestibular syndrome were interviewed for the elucidation their quality of life using the questionnaire specially developed by the researchers of the Department of Otorhinolaryngology, I.I. Mechnikov Sankt-Peterburg State Medical Academy, in accordance with the internationally accepted guidelines. Special attention was given to the determination of significant changes indicative of the severity of the pathological process at different periods of time. It is concluded that the questionnaire designed to estimate the quality of life of the patients provides an efficacious diagnostic tool for the estimation of the health status of the subjects with vestibular dysfunction that reflects the patient's self-assessment. Such information is impossible to obtain by objective diagnostic methods, such as computed videooculography.

Experiences with complex vestibular rehabilitation

INTRODUCTION

Vestibular rehabilitation of patients suffering from balance disorders is a long and difficult process, the exact cause of therapeutic success or failure remains often unknown. In our practice, the complex vestibular rehabilitation consists of medical treatment and rehabilitation training program. Balance training comprises mostly statokinetic exercises, however, the training of the vestibulo-ocular pathways are as important as of the vestibulospinal pathways.

PATIENTS

The author used training exercises for the vestibulo-ocular and vestibulospinal pathways in patients who were treated with parenteral and oral vasoactive drugs.

METHODS

For measuring the improvement of the patients, a modified Dizziness Handicap Inventory questionnaire was used.

RESULTS

The results show that the vasoactive medical treatment combined with optokinetic training improved the patients' condition. Our findings suggest that psychiatric status of the patients influences the outcome of the treatment.

CONCLUSIONS

Medical treatment combined with optokinetic and statokinetic training program is effective in the rehabilitation of dizzy patients and improves the quality of life.

A clinical study of the subjective visual vertical during unilateral centrifugation and static tilt

CONCLUSION

The present study demonstrates that various response patterns of subjective visual vertical (SVV) can be identified during unilateral centrifugation (UC). It is proposed that these response types correspond to different degrees of compensation after disease. This is advantageous for monitoring the effect of rehabilitative measures and is useful in medico-legal issues. It also emerges that diagnosis of unilateral utricle function requires the determination not only of asymmetry ratio but also offset of SVV estimates.

OBJECTIVES

A retrospective clinical study of SVV test results was performed to establish a classification and model of response types in patients with suspected otolith disorder.

METHODS

SVV measurements were made in 473 patients recruited from the dizziness clinic. A control group of healthy subjects (n = 43) was tested with the same protocol. Testing with bilateral stimulation (stationary upright, 15°, 30° tilt) and UC was performed. A mathematical model for the UC results was developed.

RESULTS

During UC testing 61% of the patients showed an asymmetric response indicating a unilateral utricular hypofunction/dysfunction. These results could be classified into three subgroups, indicating different degrees of compensation. The model parameters can be adapted to reflect this classification.

Oral factitious injury in a child diagnosed with Kabuki syndrome

Factitious injury or self-injurious behavior is a common manifestation in children affected by neurologic, developmental, or psychiatric disease. The nature and presentation of this behavior in the oral cavity varies among diagnoses, and such behavior can be easily missed. This report describes the presence of self-injurious behavior in a child diagnosed with Kabuki syndrome who presented to a pediatric dentistry referral practice for evaluation of gingival bleeding, and provides a brief overview of the known etiology and management of this challenging condition. Clinicians should be aware of the possibility of self-injurious behavior when treating children diagnosed with Kabuki syndrome.

[Somatosensorial disorders. Alterations in the quality of life in patients presenting with peripheral vestibular dysfunction]

The authors undertook the assessment of the available methods for the analysis of the sensations of patients suffering pathology of the vestibular analyzer. The fact that such conditions as dizziness and disequilibrium have great influence on the social status of a patient and his (her) position in society accounts for the use of functional stabilometry in the clinical practice along with the evaluation of quality of life. It is emphasized that the timely diagnosis of these disorders and elucidation of their primary causes are as important for the successful treatment of this pathology as the choice of an adequate course of medicamental and rehabilitative therapy.

[Vertigo--comorbidity with psychiatric disorders]

Vertigo is one of the most common symptom and complaint in the clinical practice. The differential diagnosis can only be attained by a careful interdisciplinary way of thinking and activity, given the fact that the vestibular, neurological and psychiatric disorders--considered as pathogenic factors--are being present simultaneously in triggering the symptoms, and there can be overlaps between the certain pathological processes. The author deals with the co-morbidity of the vertigo and the psychiatric symptoms--anxiety, panic-disorder--, pointing out the common neurobiological and neurophysiological factors in the background of the symptoms, emphasizing the importance of the SSRI-s in the restoration of the serotonerg dysfunction.

Who is at risk for ongoing dizziness and psychological strain after a vestibular disorder?

Patients with vestibular vertigo syndromes often suffer from anxiety and depression, whereas patients with psychiatric disorders often experience subjective unsteadiness, dizziness, or vertigo. Thus, it has been hypothesized that the vestibular system may be interlinked with the emotion processing systems. The aim of the current study was to evaluate this hypothesis by correlating vestibular and psychiatric symptoms with the course of the disease over 1 year. This interdisciplinary, prospective, longitudinal study included a total of 68 patients with acute vestibular vertigo syndromes. Four subgroups of patients with benign paroxysmal positioning vertigo (BPPV, n=19), acute vestibular neuritis (VN, n=14), vestibular migraine (VM, n=27), or Menière's disease (MD, n=8) were compared. All patients underwent neurological and neuro-otological examinations and filled out standardized self-report inventories including the Vertigo Symptom Scale (VSS), the Vertigo Handicap Questionnaire (VHQ) and the Symptom Checklist 90R (GSI, SCL-90R) at five different times (T0-T4) in the course of 1 year. VM patients experienced significantly more "vertigo and related symptoms" (VSS-VER), "somatic anxiety and autonomic arousal" (VSS-AA), and "vertigo induced handicap" (VHQ) than all other patients (P<0.001-P=0.006). Patients with a positive history of psychiatric disorders had significantly more emotional distress (GSI, SCL-90R), regardless of the specific phenomenology of the four diagnostic subgroups. Finally, fluctuations of vestibular excitability correlated positively with the extent of subjectively perceived vertigo. VM patients are significantly more handicapped by vertigo and related symptoms. They show significantly elevated fluctuations of vestibular excitability, which correlate with the (subjective) severity of vertigo symptoms.

Vestibular syndrome: a change in internal spatial representation

The vestibular system contributes to a wide range of functions from reflexes to spatial representation. This paper reviews behavioral, perceptive, and cognitive data that highlight the role of changes in internal spatial representation on the vestibular syndrome. Firstly, we review how visual vertical perception and postural orientation depend on multiple reference frames and multisensory integration and how reference frames are selected according to the status of the peripheral vestibular system (i.e., unilateral or bilateral hyporeflexia), the environmental constraints (i.e., sensory cues), and the postural constraints (i.e., balance control). We show how changes in reference frames are able to modify vestibular lesion-induced postural and locomotor deficits and propose that fast changes in reference frame may be considered as fast-adaptive processes after vestibular loss. Secondly, we review data dealing with the influence of vestibular loss on higher levels of internal representation sustaining spatial orientation and navigation. Particular emphasis is placed on spatial performance according to task complexity (i.e., the required level of spatial knowledge) and to the sensory cues available to define the position and orientation within the environment (i.e., real navigation in darkness or visual virtual navigation without any actual self-motion). We suggest that vestibular signals are necessary for other sensory cues to be properly integrated and that vestibular cues are involved in extrapersonal space representation. In this respect, vestibular-induced changes would be based on a dynamic mental representation of space that is continuously updated and that supports fast-adaptive processes.

Symptoms of detachment from the self or from the environment in patients with an acquired deficiency of the special senses

To compare the frequency of symptoms of detachment from the self or from the environment (DD) in patients with an acquired deficiency of the special senses, a questionnaire for DD symptoms [12] and the GHQ12 questionnaire for common mental disorders [16] were auto-administered to patients with hearing-loss (N = 40), peripheral vestibular disease (N = 40) or bilateral retinal disease (N = 40), and to 80 healthy subjects. Patients with retinal disease and patients with vestibular disease reported DD symptoms more frequently & severe than patients with hearing loss and healthy subjects. DD scores were related to the GHQ12 scores and to the type of sensory dysfunction. DD symptoms are more frequent & severe in patients with an acquired deficiency of the special senses, associated to symptoms of common mental disorders.

Improving the quality of life in patients with vestibular disorders: the role of medical treatments and physical rehabilitation

Vertigo, dizziness and imbalance are the main symptoms of vestibular disorders. They can lead to physical consequences, such as reduced postural control and falls, to psychologic/psychiatric consequences, such as anxiety-depression symptoms, panic and agoraphobia, and to cognitive defects, especially in the elderly. Consequently, the general health status and the quality of life (QoL) of vestibular patients can be significantly impaired. Several questionnaires have been developed in an attempt to quantify the degree of handicap and disability, the self-perceived health status and the quality of life in vestibular patients with dizziness and imbalance. Additionally, the main goal of the treatments of vestibular disorders should be to control symptoms, reduce functional disability and to improve patients' QoL. This article reviews the physical and psychological consequences of the vestibular disorders, their impact on the patients' QoL, and the treatment options, including drug prescriptions and vestibular rehabilitation protocols. A profile of the compound betahistine and its efficacy on QoL indices in the treatment of Menière's disease and other forms of peripheral vertigo is also presented.

Relationship between dynamic balance and self-reported handicap in patients who have unilateral peripheral vestibular loss

OBJECTIVE

The purpose of this study was to investigate whether Dizziness Handicap Inventory (DHI) score is related to postural performance as assessed by dynamic posturography.

STUDY DESIGN

Retrospective study.

SETTING

Outpatient in a tertiary referral center.

PATIENTS

Ninety-two complete unilateral vestibular loss patients, categorized into 3 groups according to the postlesion stage: 1 to 2 months (n = 32; age, 47.6 +/- 10.7 yr), 4 to 7 months (n= 23; 47.1 +/- 8.37 yr), and 1 year and older (n = 37; 49.2 +/- 9.5 yr).

MAIN OUTCOME MEASURES

Dizziness Handicap Inventory and dynamic balance measured with a seesaw platform moving either in the anterior-posterior or in the mediolateral direction.

RESULTS

The mean DHI score was 25.8 +/- 18.7 and the range was 0 to 68. Dizziness Handicap Inventory scores did not differ significantly between the different unilateral vestibular loss groups studied. No difference was detected between the groups for the 3 subscores (emotional, functional, and physical), except that the older-than-1-year group had a significantly higher physical score than the 2 others. No correlation was found between DHI scores and postural indicators for either direction of the platform. However, patients unable to maintain balance when the seesaw platform moved in the mediolateral direction had significantly higher DHI scores than those who did not fall.

CONCLUSION

Even if they are not directly related, we suggest that DHI and dynamic posturography are complementary approaches for appreciating the vestibular compensation process and are thus useful for postoperative counseling for vestibular loss patients.

Effects of vestibular rehabilitation therapy on emotional aspects in chronic vestibular patients

OBJECTIVE

A strong relationship exists between vestibular dysfunction and anxiety disorders. The aim of this study was to assess the anxiety and depression levels in patients with chronic dizziness and to assess the effects of vestibular rehabilitation (VR) therapy, on the anxiety and depression levels, without a behavioural or pharmacological therapy.

METHOD

Two groups of 40 patients, each affected by chronic vestibular deficit, were studied. The first one underwent VR, and the latter did not. The psychometric tests used were the State-Trait Anxiety Inventory (STAI) and the Centre for Epidemiological Studies Depression Scale (CES-D).

RESULTS

Psychological factors influence the level of handicap experienced by chronic dizziness patients, and disequilibrium influences the anxiety and depression levels. STAI and CES-D scales significantly decrease after VR therapy (P<.001) and remain stable at follow-up.

CONCLUSIONS

The VR therapy positively influences the emotional condition of chronic vestibular deficit patients without pharmacological or psychotherapy treatments.

Behavioral Disturbances and Hair Cell Loss in the Inner Ear Following Nitrile Exposure in Mice, Guinea Pigs, and Frogs

Several nitriles have been demonstrated to cause hair cell loss in the inner ear of the rat, but the susceptibility of other species to this toxic effect has not been investigated. Adult male Swiss mice were administered (po) control vehicle, cis-crotononitrile (2.75 mmol/kg), or 3,3'-iminodipropionitrile (IDPN, at 8, 16, and 24 mmol/kg), and the changes in vestibular function were assessed by behavioral endpoints. In addition, surface preparations of the vestibular sensory epithelia were examined for hair cell loss using scanning electron microscopy (SEM). IDPN, in a dose-dependent manner, and cis-crotononitrile induced both vestibular dysfunction and loss of hair bundles. Male Dunkin Hartley guinea pigs were administered IDPN (0, 1.6, 2.4, or 3.2 mmol/kg, ip), and their vestibular and auditory sensory epithelia were examined by SEM. The guinea pigs developed behavioral abnormalities indicative of vestibular dysfunction, with more overt effects observed in the animals treated with larger doses, and displayed a dose-dependent loss of hair bundles in both the vestibular and the auditory epithelia. Frogs (Rana perezi) were administered IDPN (0, 16, 24, or 32 mmol/kg, ip), and their sensory epithelia in the inner ear were examined by SEM. IDPN caused behavioral abnormalities indicative of vestibular dysfunction and loss of hair bundles. We conclude that some nitriles are thorough ototoxic compounds affecting hair cells in a wide range of species. This conclusion highlights the potential interest of this toxic effect and offers new animal models in which to decipher its basis.

Impairment and recovery on a food foraging task following unilateral vestibular deafferentation in rats

It has been suggested that the vestibular system may contribute to the development of higher cognitive function, especially spatial learning and memory that uses idiothetic cues (e.g., dead reckoning). However, few studies have been done using behavioral tasks that could potentially separate the animals' ability for dead reckoning from piloting. The food foraging task requires the animal to continuously monitor and integrate self-movement cues and generate an accurate return path. It has been shown that bilateral vestibular-lesioned rats were impaired on this task. The present study used the same task to further examine the contribution of vestibular information to spatial navigation by comparing unilateral and bilateral lesions and by testing the animals at different time points following the lesion. The results demonstrated that animals with unilateral vestibular deafferentation were impaired in performing the task in the dark at 3 months after the lesion, and this impairment disappeared at 6 months after the lesion. This supports the notion that vestibular information contributes to dead reckoning and suggests possible recovery of function over time after the lesion. Animals with bilateral vestibular deafferentation were not able to be tested on the foraging task because they exhibited behavior distinct from the unilateral-lesioned animals, with significant hesitation in leaving their home cage for as long as 6 months after the lesion.

Depersonalisation/derealisation symptoms in vestibular disease

BACKGROUND

Depersonalisation is a subjective experience of unreality and detachment from the self often accompanied by derealisation; the experience of the external world appearing to be strange or unreal. Feelings of unreality can be evoked by disorienting vestibular stimulation.

OBJECTIVE

To identify the prevalence of depersonalisation/derealisation symptoms in patients with peripheral vestibular disease and experimentally to induce these symptoms by vestibular stimulation.

METHODS

121 healthy subjects and 50 patients with peripheral vestibular disease participated in the study. For comparison with the patients a subgroup of 50 age matched healthy subjects was delineated. All completed (1) an in-house health screening questionnaire; (2) the General Health Questionnaire (GHQ-12); (3) the 28-item depersonalisation/derealisation inventory of Cox and Swinson (2002). Experimental verification of "vestibular induced" depersonalisation/derealisation was assessed in 20 patients and 20 controls during caloric irrigation of the labyrinths.

RESULTS

The frequency and severity of symptoms in vestibular patients was significantly higher than in controls. In controls the most common experiences were of "déjà vu" and "difficulty in concentrating/attending". In contrast, apart from dizziness, patients most frequently reported derealisation symptoms of "feel as if walking on shifting ground", "body feels strange/not being in control of self", and "feel 'spacey' or 'spaced out'". Items permitted discrimination between healthy subjects and vestibular patients in 92% of the cases. Apart from dizziness, caloric stimulation induced depersonalisation/derealisation symptoms which healthy subjects denied ever experiencing before, while patients reported that the symptoms were similar to those encountered during their disease.

CONCLUSIONS

Depersonalisation/derealisation symptoms are both different in quality and more frequent under conditions of non-physiological vestibular stimulation. In vestibular disease, frequent experiences of derealisation may occur because distorted vestibular signals mismatch with the other sensory input to create an incoherent frame of spatial reference which makes the patient feel he or she is detached or separated from the world.

Interaction of somatoform and vestibular disorders

BACKGROUND

The high coincidence of organic vestibular and somatoform vertigo syndromes has appeared to support pathogenic models showing a strong linkage between them. It was hypothesised that a persisting vestibular dysfunction causes the development of anxiety disorders.

OBJECTIVE

To determine the relation between vestibular deficits and somatoform vertigo disorders in an interdisciplinary prospective study.

METHODS

Participants were divided into eight diagnostic groups: healthy volunteers (n=26) and patients with benign paroxysmal positioning vertigo (BPPV, n=11), vestibular neuritis (n=11), Menière's disease (n=7), vestibular migraine (n=15), anxiety (n=23), depression (n=12), or somatoform disorders (n=22). Neuro-otological diagnostic procedures included electro-oculography with rotatory and caloric testing, orthoptic examination with measurements of subjective visual vertical (SVV) and ocular torsion, and a neurological examination. Psychosomatic diagnostic procedures comprised interviews and psychometric instruments.

RESULTS

Patients with BPPV (35.3%) and with vestibular neuritis (52.2%) had pathological test values on caloric irrigation (p<0.001). Otolith dysfunction with pathological tilts of SVV and ocular torsion was found only in patients with vestibular neuritis (p<0.001). Patients with Menière's disease, vestibular migraine, and psychiatric disorders showed normal parameters for vestibular testing but pathological values for psychometric measures. There was no correlation between pathological neurological and pathological psychometric parameters.

CONCLUSIONS

High anxiety scores are not a result of vestibular deficits or dysfunction. Patients with Menière's disease and vestibular migraine but not vestibular deficits showed the highest psychiatric comorbidity. Thus the course of vertigo syndromes and the possibility of a pre-existing psychopathological personality should be considered pathogenic factors in any linkage between organic and psychometric vertigo syndromes.

Epidemiology of vestibular vertigo: a neurotologic survey of the general population

OBJECTIVE

The purpose of this study was to determine the prevalence and incidence of vestibular vertigo in the general population and to describe its clinical characteristics and associated factors.

METHODS

The neurotologic survey had a two-stage general population sampling design: nationwide modified random digit dialing sampling for participation in the German National Telephone Health Interview Survey 2003 (response rate 52%) with screening of a random sample of 4,869 participants for moderate or severe dizziness or vertigo, followed by detailed neurotologic interviews developed through piloting and validation (n = 1,003, response rate 87%). Diagnostic criteria for vestibular vertigo were rotational vertigo, positional vertigo, or recurrent dizziness with nausea and oscillopsia or imbalance. Vestibular vertigo was detected by our interview with a specificity of 94% and a sensitivity of 84[corrected]% in a concurrent validation study using neurotology clinic diagnoses as an accepted standard (n = 61).

RESULTS

The lifetime prevalence of vestibular vertigo was 7.4[corrected]%, the 1-year prevalence was 4.9[corrected]%, and the incidence was 1.4[corrected]%. In 80% of affected individuals, vertigo resulted in a medical consultation, interruption of daily activities, or sick leave. Female sex, age, lower educational level, and various comorbid conditions, including tinnitus, depression, and several cardiovascular diseases and risk factors, were associated with vestibular vertigo in the past year in univariate analysis. In multivariable analysis, only female sex, self-reported depression, tinnitus, hypertension, and dyslipidemia had an independent effect on vestibular vertigo.

CONCLUSIONS

Vestibular vertigo is common in the general population, affecting [corrected] 5% of adults in 1 year. The frequency and health care impact of vestibular symptoms at the population level have been underestimated.

Chronic dizziness: the interface between psychiatry and neuro-otology

PURPOSE OF REVIEW

This paper reviews the often-enigmatic relationships between dizziness and psychiatric symptoms. Psychiatric causes of dizziness, neuro-otologic causes of anxiety, underrecognized co-morbid conditions, and medical illnesses that masquerade as 'psychogenic' dizziness are examined. Key clinical features and data from recent treatment trials are presented with potential pathophysiologic mechanisms.

RECENT FINDINGS

Investigations at the interface between psychiatry and neuro-otology have identified the distinguishing features of several clinical conditions that present with non-vertiginous dizziness, subjective imbalance, and psychiatric symptoms. The most common condition is chronic subjective dizziness; a refinement of earlier concepts of psychogenic dizziness, phobic postural vertigo, and space-motion phobia. Chronic subjective dizziness is consistent with advancing research on anxiety and somatoform disorders and offers greater insights into the relationships between neuro-otologic illnesses and anxiety. Migraine, post-concussional syndrome, and dysautonomias also cause persistent dizziness and may be misdiagnosed or malingering or psychogenic dizziness because they often present with comorbid psychiatric symptoms in the absence of identifiable vestibular deficits.

SUMMARY

Recent research has defined the key features of several medical-psychiatric conditions that cause chronic dizziness, permitting greater diagnostic precision and insight into underlying pathophysiologic processes. Treatment studies have identified potentially effective interventions, which must be evaluated in controlled clinical trials.

Disability and rehabilitation in the dizzy patient

PURPOSE OF REVIEW

This review focuses on prospective studies of vertigo and balance therapy in the past 3 years, including advances in vertigo-habituation exercises for adults, pediatric intervention, and virtual reality techniques, and, in more depth, the literature pertinent to driving motor vehicles.

RECENT FINDINGS

Increased support has been generated for the efficacy of a minimal, home-based vertigo-habituation program for adults with peripheral vestibular disorders. Vestibular rehabilitation has been shown to be associated with improvements in independence and dynamic visual acuity. Community-based vestibular rehabilitation has been shown to be efficacious for selected patients, after careful screening, when trained personnel provide intervention. Vestibular rehabilitation has been incorporated into the rehabilitation program for head-injured military personnel who will be returned to duty, and multifactorial balance rehabilitation has been shown to be useful for children with hearing and balance impairments. Virtual reality techniques have made significant advances, so immersive environments have potential for rehabilitation for patients with vestibular disorders and for developing training regimens for astronauts to ameliorate some effects of exposure to microgravity. Driving skill, in general, is affected by use of benzodiazepines. For many patients with vestibular impairments driving is a particularly problematic activity of daily living.

SUMMARY

Progress has been made in studies of acute care, community-based, and pediatric vestibular rehabilitation. Work on simulator-based paradigms has moved toward readiness for implementation. Studies of driving have provided some insight into the problems of these patients. More work remains to be done on all of these problems.

The assessment of increased sensitivity to visual stimuli in patients with chronic dizziness

Patients with chronic vestibular dysfunction often experience visually-induced aggravation of dizzy symptoms (visual vertigo; VV). The Situational Characteristics Questionnaire (SCQ), Computerized Dynamic Posturography or Rod and Frame Test (RFT) are used to assess VV symptoms. This study evaluates whether correlations exist between these three tests, their ability to identify patients with VV and whether emotional state correlates with VV symptoms. Tests were completed by 20 normal controls (Group NC), 20 patients with vestibular dysfunction plus VV (Group VV) and 13 without VV (Group NVV). Additionally, the Vertigo Symptom Scale (VSS-V) was applied to quantify general, non-visually induced vertigo (dizziness, lightheadedness and/or spinning) and imbalance. Autonomic (VSS-A) and psychological symptoms (Hospital Anxiety and Depression questionnaire; HAD) were also assessed. With the SCQ 100% of Group VV scored outside normal ranges and scores differed significantly between Group VV and both Groups NC and NVV. RFT values were not significantly different between groups; only 15% of patients scored outside normal ranges. Posturography scores were abnormal for 50% of patients; significant differences were noted between Groups NC and VV for composite scores and ratios 3/1, 4/1, 5/1 and 6/1 (indicative of abnormal sensory re-weighting). There were no correlations between the three data sets in patients. Anxiety and depression scores significantly differed between Groups NC and VV but not between patient groups; this indicates that psychological symptoms may be present in either patient group. The SCQ can be used to corroborate an initial clinical diagnosis of VV and quantify its severity in patients with vestibular dysfunction. Posturography data suggested patients with VV have a sensory re-weighting abnormality. The rod and frame test results and posturography findings agree less with the clinical diagnosis of VV. Psychological symptoms may need to be addressed.

Spatial neglect--a vestibular disorder?

The phenomenon of spatial neglect after right brain damage greatly helps our understanding of the normal mechanisms of directing and maintaining spatial attention, of spatial orientation, and the characteristics of neural representation of space. The intriguing symptom is a spontaneous orientation bias towards the right leading to neglect of objects or persons on the left. Interestingly, we observe similar symptoms namely a spontaneous bias of eyes and head along the horizontal dimension of space in patients with unilateral vestibular dysfunction. Further similarities concern anatomical findings. Both spatial neglect and vestibular processing at cortical level show dominance in the right hemisphere and involve common brain areas. Lesion studies in human and monkey, electrical and transcranial magnetic stimulation, as well as functional imaging results have revealed the superior temporal cortex, insula and the temporo-parietal junction to be substantial parts of the multisensory (vestibular) system as well as to be affected in spatial neglect. We argue that these structures are not strictly 'vestibular' but rather have a multimodal character representing a significant site for the neural transformation of converging vestibular, auditory, neck proprioceptive and visual input into higher order spatial representations. Neurons of these regions provide us with redundant information about the position and motion of our body in space. They seem to play an essential role in adjusting body position relative to external space. This view may initiate further development of those strategies to treat spatial neglect that use routes to rehabilitation based on specific manipulations of sensory input feeding into this system.

Direction and distance deficits in path integration after unilateral vestibular loss depend on task complexity

The effects of peripheral vestibular disorders on the direction and distance components of the internal spatial representation were investigated. The ability of Menière's patients to perform path integration was assessed in different situations aimed at differentiating the level of spatial processing (simple versus complex tasks), the available sensory cues (proprioceptive, vestibular, or visual conditions), and the side of the path (towards the healthy versus the lesioned side). After exploring two legs of a triangle, participants were required either to reproduce the exploration path, to follow the reverse path, or to take a shortcut to the starting point of the path (triangle completion). Patients' performances were recorded before unilateral vestibular neurotomy (UVN) and during the time-course of recovery (1 week and 1 month) and were compared to those of matched control subjects tested at similar time intervals. Both the angular and linear path components of the trajectory were impaired for patients compared to controls. However, deficits were restricted to the complex tasks, which required a higher level of spatial processing. Most deficits were maximal 1 week after UVN, and some remained up to the first post-operative month. Spatial representation was differentially impaired according to the available sensory cues: deficits were absent in active locomotor blindfolded condition, appeared in conditions involving visual and vestibular information, and were maximal when visual cues alone were available. Finally, concerning the side of the path, unilateral vestibular loss led to global impairment of the internal spatial representation, yet some asymmetrical spatial performances were observed 1 week after UVN. On the whole, results suggest that the environment experienced by the patients is different after UVN and that a different internal spatial representation is constructed, especially for tasks requiring high levels of spatial processing.

Vestibular loss causes hippocampal atrophy and impaired spatial memory in humans

The human hippocampal formation plays a crucial role in various aspects of memory processing. Most literature on the human hippocampus stresses its non-spatial memory functions, but older work in rodents and some other species emphasized the role of the hippocampus in spatial learning and memory as well. A few human studies also point to a direct relation between hippocampal size, navigation and spatial memory. Conversely, the importance of the vestibular system for navigation and spatial memory was until now convincingly demonstrated only in animals. Using magnetic resonance imaging volumetry, we found that patients (n = 10) with acquired chronic bilateral vestibular loss (BVL) develop a significant selective atrophy of the hippocampus (16.9% decrease relative to controls). When tested with a virtual variant (on a PC) of the Morris water task these patients exhibited significant spatial memory and navigation deficits that closely matched the pattern of hippocampal atrophy. These spatial memory deficits were not associated with general memory deficits. The current data on BVL patients and bilateral hippocampal atrophy revive the idea that a major--and probably phylogenetically ancient--function of the archicortical hippocampal tissue is still evident in spatial aspects of memory processing for navigation. Furthermore, these data demonstrate for the first time in humans that spatial navigation critically depends on preserved vestibular function, even when the subjects are stationary, e.g. without any actual vestibular or somatosensory stimulation.

Long-term follow-up after acute unilateral vestibular loss and comparison between subjects with and without remaining symptoms

CONCLUSIONS

About half of the subjects in this study reported remaining symptoms 3-6 years after acute unilateral vestibular loss. Differences could be seen between subjects with and without remaining symptoms regarding health-related quality of life, anxiety and depression.

OBJECTIVE

To evaluate the presence of self-rated remaining symptoms 3-6 years after acute unilateral vestibular loss, and to compare subjects with and without such symptoms.

MATERIAL AND METHODS

Firstly, 51 subjects answered a questionnaire which included the EuroQol EQ-5D, the Hospital Anxiety and Depression Scale, the University of California Los Angeles Dizziness Questionnaire, visual analogue scales and the Dizziness Handicap Inventory. Secondly, nine subjects with and nine without remaining symptoms participated in an extended testing procedure, including electronystagmography (ENG), determination of vestibular-evoked myogenic potentials (VEMPs) and clinical balance tests.

RESULTS

In the first part of the study, 27 subjects reported remaining symptoms, 3 reported 1 additional period of symptoms and 21 had not experienced any symptoms at all in the 3-6 years since acute unilateral vestibular loss. In the second part, the group with remaining symptoms rated a lower health-related quality of life and a higher level of anxiety and depression. There were no differences between the two groups in terms of ENG tests, VEMPs or clinical balance tests.

Does vestibular damage cause cognitive dysfunction in humans?

For more than a decade, evidence from animal studies has suggested that damage to the vestibular system leads to deficits in spatial navigation which are indicative of impaired spatial learning and memory. More recently, direct evidence has emerged to demonstrate that humans with vestibular disorders exhibit a range of cognitive deficits that are not just spatial in nature, but also include non-spatial functions such as object recognition memory. Vestibular dysfunction has been shown to adversely affect attentional processes and increased attentional demands can worsen the postural sway associated with vestibular disorders. Recent MRI studies also show that humans with bilateral vestibular damage undergo atrophy of the hippocampus which correlates with their degree of impairment on spatial memory tasks. These results are consistent with those from animal studies and, together, suggest that humans with vestibular disorders are likely to experience cognitive dysfunction which is not necessarily related to any particular episode of vertigo or dizziness, and therefore may occur even in patients who are otherwise well compensated. These findings may be related to the observation that patients with vestibular deficits experience a high incidence of depression and anxiety disorders.

[Psychosomatic status of patients with cochleovestibular disorders. Correction methods]

Psychosomatic status was studied in 106 patients aged 18-65 years with acute and chronic cochleovestibular disorders. Hearing problems, noise in the ears and vestibular disorders have a negative psychogenic effect in patients with cochleovestibulopathy. The majority of the patients need psychological and psychopharmacological care to relieve anxiety and form adequate attitude to the disease. Correction of psychosomatic disorders raises efficacy of the treatment of cochleovestibular diseases.

Hyperventilation in the vestibular clinic: use of the Nijmegen Questionnaire

The objective of the present study was to determine the prevalence of hyperventilation syndrome in patients seen for vestibular assessment and to assess the clinical utility of the Nijmegen Questionnaire in this group. The Nijmegen Questionnaire and Dizziness Handicap Inventory (DHI) were administered prospectively to a consecutive series of 100 patients identified as candidates for vestibular assessment within the University Hospital Neuro-otology practice. Twenty-three per cent of patients seen for vestibular assessment were diagnosed with hyperventilation syndrome using the Nijmegen Questionnaire. Seventeen of these (74%) would have remained undetected had the Nijmegen questionnaire not been used. No relationship was found between vestibular assessment results and either Nijmegen or DHI scores. A significant correlation was found between DHI scores and Nijmegen Questionnaire scores (rho = 0.348, P = 0.0005). In conclusion, the Nijmegen Questionnaire is a quick, easy to administer and low-impact assessment tool for hyperventilation syndrome and is a useful adjunct to the otological consultation. Diagnosed patients can then be offered breathing control exercises as part of a vestibular rehabilitation programme.

[Current methods of rehabilitation of patients with vestibular disorders]

Efficacy of pharmacological, physical treatments in monotherapy and in combination was compared in rehabilitation of 173 patients with various forms of vestibular disorders. High efficacy of physical methods especially with the use of biological feedback is shown. Factors influencing final results of the above rehabilitation are analysed. Wide use of physical rehabilitation is recommended.

Vestibular adaptation and rehabilitation

PURPOSE OF REVIEW

This article reviews current literature pertaining to vestibular adaptation and rehabilitation.

RECENT FINDINGS

Properly conducted and supervised vestibular rehabilitation therapy ameliorates a wide variety of peripheral and central balance disorders in patients of all ages. The best outcomes result from individualized vestibular rehabilitation therapy programs that correct or compensate for the negative impact of specific vestibular functional deficits and comorbid conditions on patient function. Comorbid conditions such as anxiety, depression, and cognitive dysfunction may affect vestibular rehabilitation therapy outcome. As objective postural instability improves in response to vestibular rehabilitation therapy, self-reported handicap lessens.

SUMMARY

Successful vestibular rehabilitation therapy improves activities of daily living and reduces fall risk.

Neurovestibular symptoms following space flight

Neurovestibular symptoms experienced by astronauts in the post-flight period were examined using data from medical debriefs contained in the NASA Longitudinal Study of Astronaut Health database. Ten symptoms were identified (clumsiness, difficulty concentrating, persisting sensation aftereffects, nausea, vomiting, vertigo while walking, vertigo while standing, difficulty walking a straight line, blurred vision, and dry heaves), of which eight were crossed with twelve demographic parameters (mission duration, astronaut gender, age, one-g piloting experience, previous space flight experience, g-suit inflation, g-suit deflation, in-flight space motion sickness, in-flight exercise, post-flight exercise, mission role, fluid loading). Three symptoms were experienced by a majority of subjects, and another two by more than a quarter of the subjects. Intensity of the symptoms was mild, suggesting that they are unlikely to pose a risk to the crew during landing and the post-flight period. Seven of the symptoms and eight of the parameters under study were found to be significantly associated with each other.

Bilateral peripheral vestibular lesions produce long-term changes in spatial learning in the rat

In order to investigate whether bilateral peripheral vestibular lesions cause long-term impairment of spatial learning, rats were tested in a reference memory radial arm maze learning task at least 5 weeks following a bilateral labyrinthectomy (BL) or sham control lesion. All control rats reached criterion (i.e., 1 error or less, averaged across 7 trials for 3 consecutive days of training) but only 4 of the 8 BL rats had reached criterion by day 21 of the training sessions. The control rats reached criterion more quickly than the lesioned rats (Control, 7.0 +/- 0.63 days, Lesioned, 15.8 +/- 1.4 days, t10= 5.84, p < 0.0001). This difference resulted from the greater number of errors made by the BL animals. However, the latency to respond was comparable as a result of the increased locomotor activity of the BL group (i.e., 'hyperkinesis), and the overall rate of acquisition of the task, as indicated by analysis of the exponential decrease in errors over the entire training period, was not significantly different between the 2 groups. The results of this study demonstrate that BL in rats produces long-term changes in performance in a spatial reference memory task, which are not simply due to the inability to move but may relate to the way that the brain uses vestibular information to create spatial representations and determines behavioural strategies on the basis of these representations.

Outcomes in vestibular ablative procedures

OBJECTIVE

To assess dizziness handicap and postural recovery in 17 patients undergoing a vestibular ablative procedure.

STUDY DESIGN

Outcomes were compared between nine patients who underwent selective vestibular neurectomy and eight patients who underwent a transmastoid labyrinthectomy.

SETTING

Patients underwent ablative procedures at a tertiary care facility.

METHODS

Patients were tested with posturography (sensory organization test [SOT]) and the Dizziness Handicap Inventory (DHI) before and 4 to 5 weeks after their procedure.

RESULTS

The mean change scores for each of the DHI subscales and the total DHI score showed significant improvement for the labyrinthectomy group. For the neurectomy group, only the emotional DHI subscale change score showed significant improvement. No difference was noted between preprocedure and postprocedure SOT scores for either group. The results indicated that the largest proportion of significant correlations existed between DHI and the somatosensory and vestibular subtests of platform posturography. In regression analyses, a model with age (p = 0.04) and vestibular score (p = 0.001) fitted the data well and explained 52.9% of the variance. Persons who were less than 69 years old were three times more likely to report persistent episodes of dizziness after the ablative procedure, and those who had neurectomies were 2.3 times more likely to report episodes of dizziness than those who underwent transmastoid labyrinthectomy.

CONCLUSION

Dizziness handicap after an ablative procedure is influenced by the type of procedure (labyrinthectomy versus neurectomy), age, and preoperative vestibular score on the SOT. Preoperative vestibular SOT score is highly associated with the emotional, physical, and functional domains of perceived handicap and quality of life after the surgery.

Attentional demands of continuously monitoring orientation using vestibular information

The aim of this series of experiments was to determine whether attention is normally required for continuously processing vestibular information concerning orientation, or is required only when orientation is disrupted (eg by vestibular dysfunction or by conflicting visual and vestibular orientation cues). In the first two studies, healthy subjects were passively oscillated, and indicated when they perceived they were passing through their starting position. There was only weak evidence for interference between performance on this 'continuous orientation monitoring task' and on concurrent mental tasks. However, a third study showed that when patients with vestibular imbalance carried out the continuous orientation monitoring task their performance on a concurrent mental arithmetic task was substantially impaired. This dual task interference was correlated with inaccuracy in judging orientation on the continuous orientation monitoring task, which in turn correlated with severity of recent vestibular symptomatology (assessed by questionnaire). In a fourth experiment, disorientation was induced in healthy subjects by rotating the visual field about the line of sight. Bidirectional interference was observed between monitoring orientation (assessed by accuracy in setting a rod to the perceived vertical) and performance of an arithmetic task. Dual task interference was correlated with baseline levels of disorientation induced by the visual field, as indicated by inaccuracy in judging the visual vertical. These findings suggest that monitoring orientation makes significant demands upon cortical processing resources when disorientation is induced, whether the disorientation results from deficient sensory functioning or from ambiguous perceptual information.

A review of physical and psychological factors in vulvar vestibulitis syndrome

This review is based on a MEDLINE search of all papers on vulvar vestibulitis syndrome (VVS) published 1995-2000. The causation, natural history and prevalence of VVS are unknown. There is no convincing evidence that VVS is the result of an infection or of an allergy. It has been proposed that it is an atypical pain syndrome but there is currently no clear evidence that this is so. The usual diagnostic criteria used in VVS are of doubtful discriminative value. Findings from biopsies of women with VVS are inconsistent. While there is some evidence to suggest that women with VVS attending clinics differ psychologically from normal controls, it is not clear whether these differences reflect the effects of VVS, are the result of patient selection or influence the development of the disease. Several treatments, including biofeedback, psychosexual treatment and surgery have been reported to be successful in some patients but there is a lack of proper placebo-controlled trials on which to base estimates of efficacy. There is a vital need for further, high-quality, research in this area.

Sensory modulation dysfunction in children with attention-deficit-hyperactivity disorder

This study investigates the presence of sensory modulation dysfunction (SMD) among children with attention-deficit-hyperactivity disorder (ADHD). Twenty-six children with ADHD (mean age 8.3 years, 18 males, 8 females), and 30 typically developing children (mean age 8.2 years, 21 males, 9 females) were tested using a laboratory procedure that gauges responses to repeated sensory stimulation by measuring electrodermal reactivity (EDR). Parental report measures of limitations in sensory, emotional, and attentional dimensions were administered using the Short Sensory Profile, the Leiter International Performance Scale-Revised, Parent Rating subscales, and the Child Behavior Checklist (CBCL). Compared to the typical sample, the children with ADHD displayed greater abnormalities in sensory modulation on both physiological and parent-report measures. The children with ADHD also displayed more variability in responses. Within the group with ADHD, levels of SMD were highly correlated with measures of psychopathology on the CBCL. Implications of findings relate to the importance of considering sensory processing abilities in a subgroup of children with ADHD.

Psychiatric consequences of vestibular dysfunction

Anxiety and dizziness are co-morbid symptoms in a larger percentage of patients than would be expected from chance alone. Such patients have an increased handicap and poorer prognosis. In this review, we discuss the interface between vestibular disorders and anxiety disorders. The two conditions are functionally related via both somatopsychic and psychosomatic mechanisms, and are linked via overlapping neural circuits that include monoaminergic pathways and the parabrachial nucleus network. An alternative conceptualization to the common notion of 'psychogenic' dizziness is presented. Implications for patient management are discussed.

Psychological factors influencing recovery from balance disorders

This article reviews evidence for three mechanisms whereby psychological factors may aggravate dizziness and retard recovery from balance disorders. Firstly, a common behavioral response to dizziness is to avoid activities and environments that provoke symptoms, yet such avoidance deprives the individual of the exposure necessary to promote psychological and neurophysiological adaptation. Secondly, anxiety arousal and hyperventilation may add to, amplify, and disinhibit the somatic symptoms induced by balance disorder. Thirdly, attention and cognitive load may influence the central processing of information required for the perception and control of orientation. The need to combine physiotherapy for dizziness with psychotherapy is discussed.