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Ibrahim NMK, Hazza NMA, Yaseen DM, Galal EM. Effect of vestibular rehabilitation games in patients with persistent postural perceptual dizziness and its relation to anxiety and depression: prospective study. Eur Arch Otorhinolaryngol 2024; 281:2861-2869. [PMID: 38127098 PMCID: PMC11065905 DOI: 10.1007/s00405-023-08369-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/20/2023] [Indexed: 12/23/2023]
Abstract
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.
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Affiliation(s)
| | | | | | - Eman Mohamed Galal
- Audiology Unit, Otorhinolaryngology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
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Perez DL, Finkelstein S, Adams C, Saxena A. Toward a Precision Medicine Approach to the Outpatient Assessment and Treatment of Functional Neurological Disorder. Neurol Clin 2023; 41:681-693. [PMID: 37775198 DOI: 10.1016/j.ncl.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
Functional neurological disorder (FND) is a neuropsychiatric condition. In this field, prospective psychotherapy trials and consensus recommendations for physiotherapy, occupational therapy, and speech language therapy have been published. However, significant clinical complexities remain. "Rule in" signs - while critical for making a positive diagnosis - do not equate to a personalized treatment plan in many instances. Here, we propose that the neuropsychiatric assessment and real-time development of a work-in-progress biopsychosocial clinical formulation aids the development of a patient-centered outpatient treatment plan. This precision medicine approach is based on the literature, expert opinions and our clinical experience working in an interdisciplinary FND service.
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Affiliation(s)
- David L Perez
- Division of Behavioral Neurology, Functional Neurological Disorder Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, USA.
| | - Sara Finkelstein
- Division of Behavioral Neurology, Functional Neurological Disorder Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Caitlin Adams
- Division of Behavioral Neurology, Functional Neurological Disorder Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, USA
| | - Aneeta Saxena
- Division of Behavioral Neurology, Functional Neurological Disorder Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Finkelstein SA, Carson A, Edwards MJ, Kozlowska K, Lidstone SC, Perez DL, Polich G, Stone J, Aybek S. Setting up Functional Neurological Disorder Treatment Services: Questions and Answers. Neurol Clin 2023; 41:729-743. [PMID: 37775201 DOI: 10.1016/j.ncl.2023.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
Functional neurologic disorder (FND) is commonly encountered across outpatient and inpatient medical settings. Given the potential for a high burden of disability in some patients and mounting evidence for the efficacy of FND-specific multidisciplinary treatment services, expanding clinical services for this population is a necessity. In this perspective article, we discuss considerations for creating FND services, including the types of services that exist, how to start, how to identify appropriate referrals, and how to develop and monitor individualized treatment plans. In addition, we discuss how this effort can be done sustainably - balancing patient needs with limited healthcare resources.
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Affiliation(s)
- Sara A Finkelstein
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, USA.
| | - Alan Carson
- Department of Clinical Neurosciences, Centre for Clinical Brain Sciences, University of Edinburgh, Royal Infirmary of Edinburgh, 50 Little France Cres, Edinburgh EH16 4SA, UK
| | - Mark J Edwards
- Institute of Psychiatry, Psychology and Neuroscience, King's College 16 De Crespigny Park, London, SE5 8AF, UK
| | - Kasia Kozlowska
- Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Westmead Institute for Medical Research, Psychological Medicine, The Children's Hospital at Westmead, Cn Hawkesbury Road, Hainsworth Street, Westmead, NSW 2145, Australia
| | - Sarah C Lidstone
- Integrated Movement Disorders Program, Toronto Rehabilitation Institute, University Centre, Room 3-131, 550 University Avenue, Toronto ON M5G 2A2, Canada
| | - David L Perez
- Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Ginger Polich
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Brigham and Women's Hospital, Harvard Medical School, 300 1st Avenue, Charlestown, MA 02129, USA
| | - Jon Stone
- Department of Clinical Neurosciences, Centre for Clinical Brain Sciences, University of Edinburgh, Royal Infirmary of Edinburgh, 50 Little France Cres, Edinburgh EH16 4SA, UK
| | - Selma Aybek
- Faculté des Sciences et de Médecine, Université de Fribourg, Bureau 2.106d, Chemin du Musée 5, 1700 Fribourg, Suisse
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Scarff JR, Lippmann S. Treating Psychiatric Symptoms in Persistent Postural Perceptual Dizziness. Innov Clin Neurosci 2023; 20:49-54. [PMID: 38193106 PMCID: PMC10773599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
Persistent postural perceptual dizziness (PPPD) is a functional neurological disorder characterized by troublesome feelings of dizziness and might be precipitated by vestibular events, postural changes, psychopathologies, and/or a person's perceptual experiences. The diagnosis is confirmed by assessing a patient's history. A variety of psychiatric symptoms are associated with PPPD; anxiety and depression are the most common. Psychotherapy and pharmacotherapy can be clinically helpful in reducing psychiatric symptoms and dizziness. Early intervention improves prognosis.
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Affiliation(s)
- Jonathan R Scarff
- Dr. Scarff is Staff Psychiatrist, Veterans Affairs Medical Center in Lexington, Kentucky
| | - Steven Lippmann
- Dr. Lippmann is Professor Emeritus, University of Louisville School of Medicine in Louisville, Kentucky
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Azzi JL, Khoury M, Séguin J, Rourke R, Hogan D, Tse D, Lelli DA. Characteristics of persistent postural perceptual dizziness patients in a multidisciplinary dizziness clinic. J Vestib Res 2021; 32:285-293. [PMID: 34151875 DOI: 10.3233/ves-190749] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Persistent Postural Perceptual Dizziness (PPPD) is a newly defined condition which was added to the International Classification of Vestibular Disorders in 2017. Little is known about its impact on patients. OBJECTIVE The goal of this study was to analyze the symptomology, epidemiology and impact of PPPD on patients. METHODS A retrospective chart review was done to identify patients who attended the Multidisciplinary Dizziness Clinic (MDC) and were diagnosed with PPPD. Responses to demographic questions, health-related quality of life surveys and several well-validated questionnaires commonly used to assess dizziness severity were analyzed. RESULTS One hundred patients were diagnosed with PPPD between March 2017 and January 2019, of which 80%(80/100) were females. The average Dizziness Handicap Index score was 60.3±19.0. Responses to the Patient Health Questionnaire classified 53 patients (53/99;53.5%) as moderately to severely depressed. Sixty-four patients (64/100;64.0%) were minimally or mildly anxious according to the Generalized Anxiety Disorder scale. The average Vertigo Symptom Scale score was 24.1/60. The average Situational Vertigo Questionnaire score was 2.00. Forty-nine (49/100;49.0%) patients had migraine symptoms according to the Migraine Screen Questionnaire. CONCLUSIONS In conclusion, patients with PPPD display important handicap and an elevated risk of depression, anxiety and migraines.
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Affiliation(s)
- Jayson Lee Azzi
- Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Michel Khoury
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jeanne Séguin
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Ryan Rourke
- Department of Otolaryngology -Head and Neck Surgery, University of Ottawa, Ontario, Canada
| | - Debora Hogan
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Darren Tse
- Department of Otolaryngology -Head and Neck Surgery, University of Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Daniel A Lelli
- Division of Neurology, Department of Internal Medicine, University of Ottawa, Ontario, Canada
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Nigro S, Indovina I, Riccelli R, Chiarella G, Petrolo C, Lacquaniti F, Staab JP, Passamonti L. Reduced cortical folding in multi-modal vestibular regions in persistent postural perceptual dizziness. Brain Imaging Behav 2019; 13:798-809. [PMID: 29860587 DOI: 10.1007/s11682-018-9900-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Persistent postural perceptual dizziness (PPPD) is a common functional vestibular disorder that is triggered and sustained by a complex interaction between physiological and psychological factors affecting spatial orientation and postural control. Past functional neuroimaging research and one recent structural (i.e., voxel-based morphometry-VBM) study have identified alterations in vestibular, visuo-spatial, and limbic brain regions in patients with PPPD and anxiety-prone normal individuals. However, no-one thus far has employed surface based morphometry (SBM) to explore whether cortical morphology in patients with PPPD differs from that of healthy people. We calculated SBM measures from structural MR images in 15 patients with PPPD and compared them to those from 15 healthy controls matched for demographics, personality traits known to confer risk for PPPD as well as anxiety and depressive symptoms that are commonly comorbid with PPPD. We tested for associations between SBM measures and dizziness severity in patients with PPPD. Relative to controls, PPPD patients showed significantly decreased local gyrification index (LGI) in multi-modal vestibular regions bilaterally, specifically the posterior insular cortices, supra-marginal gyri, and posterior superior temporal gyri (p < 0.001). Within the PPPD group, dizziness severity positively correlated with LGI in visual areas and negatively with LGI in the right superior parietal cortex. These findings demonstrate abnormal cortical folding in vestibular cortices and correlations between dizziness severity and cortical folding in visual and somatosensory spatial association areas in PPPD patients, which provides new insights into the pathophysiological mechanisms underlying this disorder.
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Wurthmann S, Naegel S, Schulte Steinberg B, Theysohn N, Diener HC, Kleinschnitz C, Obermann M, Holle D. Cerebral gray matter changes in persistent postural perceptual dizziness. J Psychosom Res 2017; 103:95-101. [PMID: 29167054 DOI: 10.1016/j.jpsychores.2017.10.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 10/12/2017] [Accepted: 10/13/2017] [Indexed: 01/29/2023]
Abstract
BACKGROUND Persistent postural perceptual dizziness (PPPD) is the most common vestibular syndrome in middle-aged patients. Multisensory maladjustment involving alterations of sensory response pattern including vestibular, visual and motion stimuli is thought to be a key pathophysiological correlate of this disorder. OBJECTIVE We aimed to identify regional gray matter changes in PPPD patients that might be involved in the underlying pathophysiology of this disorder. METHODS 42 PPPD patients and healthy age and gender matched controls were investigated using magnetic resonance imaging-based voxel-based morphometry. All patients fulfilled the current diagnostic criteria for PPPD, established by the Bárány-Society based on previous criteria for chronic subjective dizziness and phobic postural vertigo. RESULTS PPPD patients showed gray matter volume decrease in the temporal cortex, cingulate cortex, precentral gyrus, hippocampus, dorsolateral prefrontal cortex, caudate nucleus and the cerebellum. A negative correlation of disease duration and gray matter volume was observed in the visual cortex, supplementary motor area and somatosensory processing structures. CONCLUSIONS In patients with PPPD areas involved in multisensory vestibular processing show gray matter volume decrease. These brain regions resemble those previously described for other vestibular disorders. Longer duration of disease leads to a more pronounced gray matter alteration, which might represent maladaptive mechanisms within the course of disease.
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Affiliation(s)
- Sebastian Wurthmann
- Department of Neurology and Dizziness, Vertigo Center Essen, University of Duisburg-Essen, Germany.
| | - Steffen Naegel
- Department of Neurology and Dizziness, Vertigo Center Essen, University of Duisburg-Essen, Germany.
| | | | - Nina Theysohn
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University of Duisburg-Essen, Germany.
| | - Hans-Christoph Diener
- Department of Neurology and Dizziness, Vertigo Center Essen, University of Duisburg-Essen, Germany.
| | - Christoph Kleinschnitz
- Department of Neurology and Dizziness, Vertigo Center Essen, University of Duisburg-Essen, Germany.
| | - Mark Obermann
- Department of Neurology and Dizziness, Vertigo Center Essen, University of Duisburg-Essen, Germany; Center for Neurology, Asklepios Hospitals Schildautal, Karl-Herold-Straße 1, 38723 Seesen, Germany.
| | - Dagny Holle
- Department of Neurology and Dizziness, Vertigo Center Essen, University of Duisburg-Essen, Germany.
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