Recent advances in the diagnosis of some common vestibular disorders

The interest in the diagnosis of common vestibular disorders in children and adults is permanently increasing. In this survey, the applications of the main diagnostic methods in this interdisciplinary field are briefly discussed. The diagnostic capacities of the caloric test, video head impulse test, cervical and ocular vestibular evoked myogenic potentials, videonystagmography, electrococheography, magnetic resonance imaging, computed tomography, etc. are summarized. Special attention is paid to some common vestibular disorders such as Menière’s disease, benign paroxysmal positional vertigo, vestibular migraine, vestibular neuritis, and acute vestibular syndrome. United international efforts will contribute to further improvement of the diagnosis of the vestibular disorders, which warrants their adequate treatment

The role of non-invasive camera technology for gait analysis in patients with vestibular disorders

Purpose of the study Current balance assessments performed in clinical settings do not provide objective measurements of gait. Further, objective gait analysis typically requires expensive, large and dedicated laboratory facilities. The aim of this pilot study was to develop and assess a low-cost, non-invasive camera technology for gait analysis, to assist the clinical assessment of patients with vestibular disorders. Materials and methods used This is a prospective, case-controlled study that was developed jointly by the local Neurotology Department and the Centre for Sports Engineering Research. Eligible participants were approached and recruited at the local Neurotology Clinic. The gait assessment included two repetitions of a straight 7-metre walk. The gait analysis system, comprised of a camera (P3215-V, Axis Communications, Sweden) and analysis software was installed in an appropriately sized clinic room. Parameters extruded were walking velocity, step velocity, step length, cadence and step count per meter. The effect sizes (ESB) were calculated using the MatLab and were considered large, medium or small if >0.8, 0.5 and 0.2 respectively. This study was granted ethical approval by the Coventry and Warwickshire Research Ethics Committee (15/WM/0448). Results Six patients with vestibular dysfunction (P group) and six age-matched healthy volunteers (V group) were recruited in this study. The average velocity of gait for P group was 1189.1 ± 69.0 mm·s-1 whereas for V group it was 1351.4 ± 179.2 mm·s-1, (ESB: -0.91). The mean step velocities were 1353.1 ± 591.8 mm·s-1 and 1434.0 ± 396.5 mm·s-1 for P and V groups respectively (ESB: -0.20). The average cadence was 2.3 ± 0.9 Hz and 2.0 ± 0.5 Hz for P and V groups respectively (ESB: 0.60). The mean step length was 620.5 ± 150.7 mm for the P group and 728.5 ± 86.0 mm for the V group (ESB = -1.26). The average step count per meter was 1.7 ± 0.3 and 1.4 ± 0.1 for P and V groups respectively (ESB = 3.38). Conclusion This pilot study used a low-cost, non-invasive camera technology to identify changes in gait characteristics. Further, gait measurements were obtained without the application of markers or sensors to patients (i.e. non-invasive), thus allowing current, clinical practice to be supplemented by objective measurement, with minimal procedural impact. Further work needs to be undertaken to refine the device and produce normative data. In the future, similar technologies could be used in the community setting, providing an excellent diagnostic and monitoring tool for balance patients

Susceptibility to Fear of Heights in Bilateral Vestibulopathy and Other Disorders of Vertigo and Balance

Aims: To determine the susceptibility to visual height intolerance (vHI) in patients with acquired bilateral vestibulopathy (BVP). The question was whether postural instability in BVP, which is partially compensated for by visual substitution of the impaired vestibular control of balance, leads to an increased susceptibility. This is of particular importance since fear of heights is dependent on body posture, and visual control of balance at heights can no longer substitute vestibular input. For comparison susceptibility to vHI was determined in patients with other vestibular or functional disorders. Methods: A total of 150 patients aged 18 or above who had been referred to the German Center for Vertigo and Balance Disorders and diagnosed to have BVP were surveyed with a standardized questionnaire by specifically trained neurological professionals. Further, 481 patients with other vestibular or functional disorders were included. Results: Susceptibility to vHI was reported by 29% (32 % in females, 25% in males) of the patients with BVP. Patients with vHI were slightly younger (67 vs. 71 years). Seventy percent of those with vHI reported avoidance of climbing, hiking, stairs, darkness, cycling or swimming (84% of those without vHI). Mean age for onset of vHI was 40 years. Susceptibility to vHI was higher in patients with other vertigo disorders than in those with BVP: 64% in those with phobic postural vertigo, 61% in vestibular migraine, 56% in vestibular paroxysmia, 54% in benign paroxysmal positional vertigo, 49% in unilateral vestibulopathy and 48% in Menière's disease. Conclusions: The susceptibility to vHI in BVP was not higher than that of the general population (28%).This allows two explanations that need not be alternatives but contribute to each other: (1) Patients with a bilateral peripheral vestibular deficit largely avoid exposure to heights because of their postural instability. (2) The irrational anxiety to fall from heights triggers increased susceptibility to vHI, not the objective postural instability. However, patients with BVP do not exhibit increased comorbid anxiety disorders. This view is supported by the significantly increased susceptibility to vHI in other vestibular syndromes, which are characterized by an increased comorbidity of anxiety disorders

The Audiologist’s Role in Assessment and Management of Mild Traumatic Brain Injuries

Mild Traumatic Brain Injuries (mTBI) are caused by a blow to the head and have many severe consequences from amnesia and loss of consciousness to cognitive symptoms such as fatigue, pain, dizziness, light and sound sensitivity, blurry vision, and may even have vestibular symptoms like vertigo secondary to the injury. The purpose of this doctoral scholarly project is to investigate the overlap of mTBIs and vestibular disorders to understand and emphasize how audiologists can be a valuable member of a multidisciplinary team to help assess and manage patients who experience traumatic brain injuries. Audiologists can play a key role in diagnosing vestibular disorders that may otherwise be overlooked due to overlap in mTBI symptoms. Audiologists may also be the best professional to help provide treatment options such as vestibular therapy to help patients heal from a mTBI. Recommendations for future directions are included for integrating audiologists into a multidisciplinary team for managing patients with mTBIs

Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Evidence-Based Clinical Practice Guideline: From the American Physical Therapy Association Neurology Section

Background: Uncompensated vestibular hypofunction results in postural instability, visual blurring with head movement, and subjective complaints of dizziness and/or imbalance. We sought to answer the question, \ Is vestibular exercise effective at enhancing recovery of function in people with peripheral (unilateral or bilateral) vestibular hypofunction?\ Methods: A systematic review of the literature was performed in 5 databases published after 1985 and 5 additional sources for relevant publications were searched. Article types included meta-analyses, systematic reviews, randomized controlled trials, cohort studies, case control series, and case series for human subjects, published in English. One hundred thirty-five articles were identified as relevant to this clinical practice guideline. Results/Discussion: Based on strong evidence and a preponderance of benefit over harm, clinicians should offer vestibular rehabilitation to persons with unilateral and bilateral vestibular hypofunction with impairments and functional limitations related to the vestibular deficit. Based on strong evidence and a preponderance of harm over benefit, clinicians should not include voluntary saccadic or smooth-pursuit eye movements in isolation (ie, without head movement) as specific exercises for gaze stability. Based on moderate evidence, clinicians may offer specific exercise techniques to target identified impairments or functional limitations. Based on moderate evidence and in consideration of patient preference, clinicians may provide supervised vestibular rehabilitation. Based on expert opinion extrapolated from the evidence, clinicians may prescribe a minimum of 3 times per day for the performance of gaze stability exercises as 1 component of a home exercise program. Based on expert opinion extrapolated from the evidence (range of supervised visits: 2-38 weeks, mean = 10 weeks), clinicians may consider providing adequate supervised vestibular rehabilitation sessions for the patient to understand the goals of the program and how to manage and progress themselves independently. As a general guide, persons without significant comorbidities that affect mobility and with acute or subacute unilateral vestibular hypofunction may need once a week supervised sessions for 2 to 3 weeks; persons with chronic unilateral vestibular hypofunction may need once a week sessions for 4 to 6 weeks; and persons with bilateral vestibular hypofunction may need once a week sessions for 8 to 12 weeks. In addition to supervised sessions, patients are provided a daily home exercise program. Disclaimer: These recommendations are intended as a guide for physical therapists and clinicians to optimize rehabilitation outcomes for persons with peripheral vestibular hypofunction undergoing vestibular rehabilitation

Diagnostic accuracy and usability of the EMBalance decision support system for vestibular disorders in primary care: proof of concept randomised controlled study results

BACKGROUND: Dizziness and imbalance are common symptoms that are often inadequately diagnosed or managed, due to a lack of dedicated specialists. Decision Support Systems (DSS) may support first-line physicians to diagnose and manage these patients based on personalised data. AIM: To examine the diagnostic accuracy and application of the EMBalance DSS for diagnosis and management of common vestibular disorders in primary care. METHODS: Patients with persistent dizziness were recruited from primary care in Germany, Greece, Belgium and the UK and randomised to primary care clinicians assessing the patients with (+ DSS) versus assessment without (- DSS) the EMBalance DSS. Subsequently, specialists in neuro-otology/audiovestibular medicine performed clinical evaluation of each patient in a blinded way to provide the "gold standard" against which the + DSS, - DSS and the DSS as a standalone tool (i.e. without the final decision made by the clinician) were validated. RESULTS: One hundred ninety-four participants (age range 25-85, mean = 57.7, SD = 16.7 years) were assigned to the + DSS (N = 100) and to the - DSS group (N = 94). The diagnosis suggested by the + DSS primary care physician agreed with the expert diagnosis in 54%, compared to 41.5% of cases in the - DSS group (odds ratio 1.35). Similar positive trends were observed for management and further referral in the + DSS vs. the - DSS group. The standalone DSS had better diagnostic and management accuracy than the + DSS group. CONCLUSION: There were trends for improved vestibular diagnosis and management when using the EMBalance DSS. The tool requires further development to improve its diagnostic accuracy, but holds promise for timely and effective diagnosis and management of dizzy patients in primary care. TRIAL REGISTRATION NUMBER: NCT02704819 (clinicaltrials.gov)

Dizziness and balance disorders in the elderly

Background: Patients in the geriatric age are characterized by the presence of degenerative changes, significantly affecting their daily functioning. One of the most common symptoms accompanying the elderly include dizziness and balance disorders. This is an extremely important issue, because even every third patient can report such ailments. Often, especially in the group of geriatric patients, these problems are related to disorders in the circulatory system, and more specifically to orthostatic hypotension. Material and methods: Analysis of available literature, articles in the Google Scholar and PubMed database using keywords: geriatrics, dizziness, balance disorders. Results: In the treatment of dizziness and disorders of the balance we distinguish pharmacological and non-pharmacological methods where kinesitherapy (exercises) looms large. In the case of pharmacological treatment, attention should be focused on causal therapy because symptomatic treatment can cause side effects and should therefore be used as soon as possible. In many cases, pharmacological treatment can be fully replaced by normal and individually conducted physiotherapeutic procedures. Training to which a patient is subjected should consist of many elements, which, however, will be adapted to the conditions that can meet a patient in everyday life. In diagnostics of the above-mentioned problems, research on stabilometric platforms is becoming more and more important. Increasingly, also in the rehabilitation of patients with a problem with equilibrium, modern technology in the form of virtual reality is used. Conclusions: Dizziness and balance disorders can result in many problems, which is why correct diagnosis and effective treatment are so important, especially because it is a problem for more and more people. Greater importance should be attached to prevention. Although modern forms of fighting these disorders are being introduced, there is still a need for further research on their effectiveness

Vestibular rehabilitation in multiple sclerosis: study protocol for a randomised controlled trial and cost-effectiveness analysis comparing customised with booklet based vestibular rehabilitation for vestibulopathy and a 12 month observational cohort study of the symptom reduction and recurrence rate following treatment for benign paroxysmal positional vertigo

BACKGROUND: Symptoms arising from vestibular system dysfunction are observed in 49-59% of people with Multiple Sclerosis (MS). Symptoms may include vertigo, dizziness and/or imbalance. These impact on functional ability, contribute to falls and significant health and social care costs. In people with MS, vestibular dysfunction can be due to peripheral pathology that may include Benign Paroxysmal Positional Vertigo (BPPV), as well as central or combined pathology. Vestibular symptoms may be treated with vestibular rehabilitation (VR), and with repositioning manoeuvres in the case of BPPV. However, there is a paucity of evidence about the rate and degree of symptom recovery with VR for people with MS and vestibulopathy. In addition, given the multiplicity of symptoms and underpinning vestibular pathologies often seen in people with MS, a customised VR approach may be more clinically appropriate and cost effective than generic booklet-based approaches. Likewise, BPPV should be identified and treated appropriately. METHODS/ DESIGN: People with MS and symptoms of vertigo, dizziness and/or imbalance will be screened for central and/or peripheral vestibulopathy and/or BPPV. Following consent, people with BPPV will be treated with re-positioning manoeuvres over 1-3 sessions and followed up at 6 and 12 months to assess for any re-occurrence of BPPV. People with central and/or peripheral vestibulopathy will be entered into a randomised controlled trial (RCT). Trial participants will be randomly allocated (1:1) to either a 12-week generic booklet-based home programme with telephone support or a 12-week VR programme consisting of customised treatment including 12 face-to-face sessions and a home exercise programme. Customised or booklet-based interventions will start 2 weeks after randomisation and all trial participants will be followed up 14 and 26 weeks from randomisation. The primary clinical outcome is the Dizziness Handicap Inventory at 26 weeks and the primary economic endpoint is quality-adjusted life-years. A range of secondary outcomes associated with vestibular function will be used. DISCUSSION: If customised VR is demonstrated to be clinically and cost-effective compared to generic booklet-based VR this will inform practice guidelines and the development of training packages for therapists in the diagnosis and treatment of vestibulopathy in people with MS. TRIAL REGISTRATION: ISRCTN Number: 27374299 Date of Registration 24/09/2018 Protocol Version 15 25/09/2019

m- and e-Health applications in diagnosis and rehabilitation of balance disorders - Εφαρμογές m- και e-health για τη διάγνωση και αποκατάσταση διαταραχών ισορροπίας

Υπόβαθρο: Η ισορροπία είναι μια αρχέγονη ανθρώπινη αίσθηση που απαιτεί πολυαισθητηριακή ολοκλήρωση από το αιθουσαίο, το οπτικό και το ιδιοδεκτικό σύστημα και συμμετοχή της παρεγκεφαλίδας και αρκετών άλλων νευρωνικών κυκλωμάτων. Επιπλέον, εμπλέκονται ένας αριθμός αντανακλαστικών, όπως το αιθουσοοφθαλμικό και το αιθουσονωτιαίο αντανακλαστικό, μαζί με πολλές άλλες ανώτερες εγκεφαλικές λειτουργίες. Υπό συγκεκριμένες συνθήκες, μια περιφερική ή κεντρική βλάβη μπορεί να συμβεί στο σύστημα οδηγώντας σε αστάθεια και συμπτωματολογία ιλίγγου. Από τη 1940, όταν οι Cooksey και Cawthorne ξεκίνησαν να διερευνούν την αποκατάσταση μετά από τέτοιες βλάβες, πολλά πράγματα έχουν αλλάξει στο πεδίο της αποκατάστασης ισορροπίας και κατά τις τελευταίες δεκαετίες οι νέες τεχνολογίες έχουν ενσωματωθεί σε αυτή την προσπάθεια. Σήμερα, ένας μεγάλος αριθμός από εφαρμογές mHealth, eHealth και εικονικής πραγματικότητας έχον αναπτυχθεί με σκοπό να συνεισφέρουν στη διάγνωση ή/και αποκατάσταση ασθενών με αιθουσαίες διαταραχές. Μεθοδολογία: Η ηλεκτρονική βάση δεδομένων MEDLINE διερευνήθηκε για σχετικές εργασίες από την 1η Ιανουαρίου 2015 έως την 15η Απριλίου 2021. Οι συμπεριληφθείσες στην ανασκόπηση εργασίες καθορίστηκαν βάσει συγκεκριμένων κριτηρίων ένταξης και αποκλεισμού. Αποτελέσματα: Ένας συνολικός αριθμός από 187 εργασίες προέκυψε μετά την αρχική στρατηγική αναζήτησης, από τις οποίες 43 κρίθηκαν επιλέξιμες και συμπεριλήφθηκαν σε αυτή την ανασκόπηση. Χωρίστηκαν σε 5 μείζονες κατηγορίες και συζητήθηκαν περαιτέρω. Συζήτηση: Οι κονσόλες παιχνιδιών, όπως το Nintendo Wii, το Nintendo Wii Fit και το Sony PlayStation 2 EyeToy, και οι εφαρμογές Internet έχουν χρησιμοποιηθεί τα τελευταία χρόνια για να συνδράμουν στη διάγνωση και αποκατάσταση ασθενών με διαταραχές ισορροπίας. Καθώς αναδύονται νέες τεχνολογίες και τα smartphones γίνονται βασικό μέρος της καθημερινότητας μας, η αιθουσαία διάγνωση και αποκατάσταση θα βασίζονται όλο και περισσότερο σε εφαρμογές για γυαλιά εικονικής πραγματικότητας, για smartphones και για εξελιγμένες πλατφόρμες.Background: Balance is a primary human sense which requires multisensory integration from the vestibular, the visual and the proprioceptive systems and involvement of the cerebellum and several other neural circuits. Additionally, a number of reflexes, such as the vestibuloocular and the vestibulospinal reflexes, along with many other higher cerebral functions are engaged. Under certain circumstances, a peripheral or central lesion can occur to the system leading to instability and vertigo symptomatology. Since the 1940s, when Cooksey and Cawthorne began to investigate rehabilitation following such lesions, many things have changed in the field of balance rehabilitation and during the last decades modern technologies have been incorporated in this effort. Nowadays, a great amount of mHealth, eHealth and Virtual Reality applications have been developed aiming to contribute in diagnosis or/and rehabilitation of patients with vestibular disorders. Methods: The electronic database MEDLINE was searched for relevant studies from January 1, 2015 up to April 15, 2021. The papers included in this review were determined according to certain inclusion and exclusion criteria. Results: A total number of 187 studies occurred after the initial search strategy, out of which 43 were considered eligible and included in this review. They were subdivided into 5 major categories and further discussed. Discussion: Gaming consoles, such as the Nintendo Wii, Nintendo Wii Fit and Sony PlayStation 2 EyeToy and Internet-based applications have been implemented during the last years to assist in the diagnosis and rehabilitation of patients with balance disorders. As novel technologies emerge and smartphones become an essential part of our everyday lives, vestibular diagnosis and rehabilitation will rely more and more on head-mounted display, mobile phone and sophisticated platform applications