Feasibility and safety of an immersive virtual reality-based vestibular rehabilitation programme in people with multiple sclerosis experiencing vestibular impairment: a protocol for a pilot randomised controlled trial

Introduction: Vestibular system damage in patients with multiple sclerosis (MS) may have a central and/or peripheral origin. Subsequent vestibular impairments may contribute to dizziness, balance disorders and fatigue in this population. Vestibular rehabilitation targeting vestibular impairments may improve these symptoms. Furthermore, as a successful tool in neurological rehabilitation, immersive virtual reality (VRi) could also be implemented within a vestibular rehabilitation intervention. Methods and analysis: This protocol describes a parallel-arm, pilot randomised controlled trial, with blinded assessments, in 30 patients with MS with vestibular impairment (Dizziness Handicap Inventory ≥16). The experimental group will receive a VRi vestibular rehabilitation intervention based on the conventional Cawthorne-Cooksey protocol; the control group will perform the conventional protocol. The duration of the intervention in both groups will be 7 weeks (20 sessions, 3 sessions/week). The primary outcomes are the feasibility and safety of the vestibular VRi intervention in patients with MS. Secondary outcome measures are dizziness symptoms, balance performance, fatigue and quality of life. Quantitative assessment will be carried out at baseline (T0), immediately after intervention (T1), and after a follow-up period of 3 and 6 months (T2 and T3). Additionally, in order to further examine the feasibility of the intervention, a qualitative assessment will be performed at T1. Ethics and dissemination: The study was approved by the Andalusian Review Board and Ethics Committee, Virgen Macarena-Virgen del Rocio Hospitals (ID 2148-N-19, 25 March 2020). Informed consent will be collected from participants who wish to participate in the research. The results of this research will be disseminated by publication in peer-reviewed scientific journals

Advantages and limitations of virtual reality for balance assessment and rehabilitation

International audienceVirtual reality (VR) is now commonly used in many domains because of its ability to provide a standardized, reproducible and controllable environment. In balance assessment, it can be used to control stimuli presented to patients and thus accurately evaluate their progression or compare them to different populations in standardized situations. In balance rehabilitation, VR allows the creation of new generation tools and at the same time the means to assess the efficiency of each parameter of these tools in order to optimize them. Moreover, with the development of low-cost devices, this rehabilitation can be continued at home, making access to these tools much easier, in addition to their entertaining and thus motivating properties. Nevertheless, and even more with low-cost systems, VR has limits that can alter the results of the studies that use it: the latency of the system (the delay cumulated on each step of the process from data acquisition on the patients to multimodal outputs); and distance perception, which tends to be underestimated in VR. After having described why VR is an essential tool for balance assessment and rehabilitation and illustrated this statement with a case study, this review discusses the previous works in the domain with regards to the technological limits of V

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

The Effect of Cervical Muscle Fatigue on Postural Stability during Immersion Virtual Reality

The visual system is part of the nervous system that enables an individual to scan their environment and assess distance to and from objects. The information captured form our navigating environment is communicated to the brain, which in turn makes the decision on how we respond to spatial orientation. This is particularly useful in helping with balance and determining direction of movement. Our posture and visual stability rely heavily on an efficient and processing of visual, vestibular, and proprioception afferent input. Erroneous sensory information from defective sensory organs may cause a person to experience feelings of lightheadedness, spinning and whirling sensations, and difficulty in maintaining straight posture. Few studies have examined the synergy between cervical spine proprioception and the vestibular ocular reflex (VOR) and as such, their impact on human VOR is less understood. The purpose of this study therefore was to investigate how motion sensitivity is impacted by neck muscle fatigue in normal healthy participants. The overall aim of the present work was to investigate whether impaired somatosensory information from the cervical spine, caused by neck muscle fatigue, would negatively impact postural stability in healthy young participants. Results indicated that healthy young participants who were fatigued had significantly poorer postural stability than those who were not fatigued (p\u3c 0.001). In Conclusion, our research suggests that when assessing motion sensitivity in patients complaining of dizziness with a history of neck trauma, one may consider that VOR dysfunction could have a cervical origin due to somatosensory disturbance, which may lead to poor postural stability

Vestibular rehabilitation for peripheral vestibular hypofunction: An updated clinical practice guideline from the Academy of Neurologic Physical Therapy of the American Physical Therapy Association

BACKGROUND: Uncompensated vestibular hypofunction can result in symptoms of dizziness, imbalance, and/or oscillopsia, gaze and gait instability, and impaired navigation and spatial orientation; thus, may negatively impact an individual\u27s quality of life, ability to perform activities of daily living, drive, and work. It is estimated that one-third of adults in the United States have vestibular dysfunction and the incidence increases with age. There is strong evidence supporting vestibular physical therapy for reducing symptoms, improving gaze and postural stability, and improving function in individuals with vestibular hypofunction. The purpose of this revised clinical practice guideline is to improve quality of care and outcomes for individuals with acute, subacute, and chronic unilateral and bilateral vestibular hypofunction by providing evidence-based recommendations regarding appropriate exercises. METHODS: These guidelines are a revision of the 2016 guidelines and involved a systematic review of the literature published since 2015 through June 2020 across 6 databases. Article types included meta-analyses, systematic reviews, randomized controlled trials, cohort studies, case-control series, and case series for human subjects, published in English. Sixty-seven articles were identified as relevant to this clinical practice guideline and critically appraised for level of evidence. RESULTS: Based on strong evidence, clinicians should offer vestibular rehabilitation to adults with unilateral and bilateral vestibular hypofunction who present with impairments, activity limitations, and participation restrictions 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) to promote gaze stability. Based on moderate to strong evidence, clinicians may offer specific exercise techniques to target identified activity limitations and participation restrictions, including virtual reality or augmented sensory feedback. Based on strong evidence and in consideration of patient preference, clinicians should offer supervised vestibular rehabilitation. Based on moderate to weak evidence, clinicians may prescribe weekly clinic visits plus a home exercise program of gaze stabilization exercises consisting of a minimum of: (1) 3 times per day for a total of at least 12 minutes daily for individuals with acute/subacute unilateral vestibular hypofunction; (2) 3 to 5 times per day for a total of at least 20 minutes daily for 4 to 6 weeks for individuals with chronic unilateral vestibular hypofunction; (3) 3 to 5 times per day for a total of 20 to 40 minutes daily for approximately 5 to 7 weeks for individuals with bilateral vestibular hypofunction. Based on moderate evidence, clinicians may prescribe static and dynamic balance exercises for a minimum of 20 minutes daily for at least 4 to 6 weeks for individuals with chronic unilateral vestibular hypofunction and, based on expert opinion, for a minimum of 6 to 9 weeks for individuals with bilateral vestibular hypofunction. Based on moderate evidence, clinicians may use achievement of primary goals, resolution of symptoms, normalized balance and vestibular function, or plateau in progress as reasons for stopping therapy. Based on moderate to strong evidence, clinicians may evaluate factors, including time from onset of symptoms, comorbidities, cognitive function, and use of medication that could modify rehabilitation outcomes. DISCUSSION: Recent evidence supports the original recommendations from the 2016 guidelines. There is strong evidence that vestibular physical therapy provides a clear and substantial benefit to individuals with unilateral and bilateral vestibular hypofunction. LIMITATIONS: The focus of the guideline was on peripheral vestibular hypofunction; thus, the recommendations of the guideline may not apply to individuals with central vestibular disorders. One criterion for study inclusion was that vestibular hypofunction was determined based on objective vestibular function tests. This guideline may not apply to individuals who report symptoms of dizziness, imbalance, and/or oscillopsia without a diagnosis of vestibular hypofunction. DISCLAIMER: These recommendations are intended as a guide to optimize rehabilitation outcomes for individuals undergoing vestibular physical therapy. The contents of this guideline were developed with support from the American Physical Therapy Association and the Academy of Neurologic Physical Therapy using a rigorous review process. The authors declared no conflict of interest and maintained editorial independence.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A369)

Vestibular Rehabilitation: Conventional and Virtual Reality-Based Methods

The vestibular system is responsible for sensing the velocity and acceleration of angular and linear movements of the head and sensitivity to gravity in maintaining balance with its peripheral and central structures. It performs this function through vestibular reflexes. When peripheral vestibular diseases occur unilaterally or bilaterally, the functions of vestibular reflexes are affected, resulting in deterioration in eye movements compatible with head movements and anti-gravity muscle activity coordination, which ensures upright posture against gravity. Dizziness and/or imbalance persist in patients in whom the central compensation process cannot be completed, resulting in restrictions in the patient’s independent movements, daily activities, and quality of life. In the middle and long term, these restrictions cause sedentary life, fear of falling, loss of general condition, emotional problems, and social isolation. In patients diagnosed with unilateral peripheral vestibular disease, vestibular rehabilitation methods based on exercise and living environment arrangements are used as valid and reliable methods to support central compensation mechanisms and to eliminate movement restrictions. Along with conventional exercises, virtual reality-based vestibular rehabilitation systems on stable or unstable platforms are also used for this purpose. In this chapter, the essential principles of conventional and virtual reality-based vestibular rehabilitation methods take place

Vibrotactile Sensory Augmentation and Machine Learning Based Approaches for Balance Rehabilitation

Vestibular disorders and aging can negatively impact balance performance. Currently, the most effective approach for improving balance is exercise-based balance rehabilitation. Despite its effectiveness, balance rehabilitation does not always result in a full recovery of balance function. In this dissertation, vibrotactile sensory augmentation (SA) and machine learning (ML) were studied as approaches for further improving balance rehabilitation outcomes. Vibrotactile SA provides a form of haptic cues to complement and/or replace sensory information from the somatosensory, visual and vestibular sensory systems. Previous studies have shown that people can reduce their body sway when vibrotactile SA is provided; however, limited controlled studies have investigated the retention of balance improvements after training with SA has ceased. The primary aim of this research was to examine the effects of supervised balance rehabilitation with vibrotactile SA. Two studies were conducted among people with unilateral vestibular disorders and healthy older adults to explore the use of vibrotactile SA for therapeutic and preventative purposes, respectively. The study among people with unilateral vestibular disorders provided six weeks of supervised in-clinic balance training. The findings indicated that training with vibrotactile SA led to additional body sway reduction for balance exercises with head movements, and the improvements were retained for up to six months. Training with vibrotactile SA did not lead to significant additional improvements in the majority of the clinical outcomes except for the Activities-specific Balance Confidence scale. The study among older adults provided semi-supervised in-home balance rehabilitation training using a novel smartphone balance trainer. After completing eight weeks of balance training, participants who trained with vibrotactile SA showed significantly greater improvements in standing-related clinical outcomes, but not in gait-related clinical outcomes, compared with those who trained without SA. In addition to investigating the effects of long-term balance training with SA, we sought to study the effects of vibrotactile display design on people’s reaction times to vibrational cues. Among the various factors tested, the vibration frequency and tactor type had relatively small effects on reaction times, while stimulus location and secondary cognitive task had relatively large effects. Factors affected young and older adults’ reaction times in a similar manner, but with different magnitudes. Lastly, we explored the potential for ML to inform balance exercise progression for future applications of unsupervised balance training. We mapped body motion data measured by wearable inertial measurement units to balance assessment ratings provided by physical therapists. By training a multi-class classifier using the leave-one-participant-out cross-validation method, we found approximately 82% agreement among trained classifier and physical therapist assessments. The findings of this dissertation suggest that vibrotactile SA can be used as a rehabilitation tool to further improve a subset of clinical outcomes resulting from supervised balance rehabilitation training. Specifically, individuals who train with a SA device may have additional confidence in performing balance activities and greater postural stability, which could decrease their fear of falling and fall risk, and subsequently increase their quality of life. This research provides preliminary support for the hypothesized mechanism that SA promotes the central nervous system to reweight sensory inputs. The preliminary outcomes of this research also provide novel insights for unsupervised balance training that leverage wearable technology and ML techniques. By providing both SA and ML-based balance assessment ratings, the smart wearable device has the potential to improve individuals’ compliance and motivation for in-home balance training.PHDMechanical EngineeringUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttps://deepblue.lib.umich.edu/bitstream/2027.42/143901/1/baotian_1.pd

Stroboscopic Augmented Reality as an Approach to Mitigate Gravitational Transition Effects During Interplanetary Spaceflight

During interplanetary spaceflight, periods of extreme gravitational transitions will occur such as transitions between hypergravity, hypogravity, and microgravity. Following gravitational transitions, rapid sensorimotor adaptation or maladaptation may occur which can affect gaze control and weaken dynamic visual acuity in astronauts. A reduction in dynamic visual acuity during spaceflight could possibly impact or impair mission critical activities (e.g., control of extraterrestrial machinery/vehicles and other important tasks). Stroboscopic visual training is an emerging visual tool that has been terrestrially observed to enhance visual performance and perception by performing tasks under conditions of intermittent vision. This technique has also been seen to increase the dynamic visual acuity for individuals terrestrially. To mitigate the decreased dynamic visual acuity that is observed in astronauts following gravitational transitions, stroboscopic vision training may serve as a potential countermeasure. We describe the effects of gravitational transitions on the vestibulo-ocular system and dynamic visual acuity, review terrestrial stroboscopic visual training, and report the novel development of stroboscopic augmented reality as a possible countermeasure for G-transitions in future spaceflight

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)

Concussion history among Icelandic female athletes : mental health, cognition and possible concussion biomarkers

Concussion symptoms are complex. They are non-specific to a concussion, and there is no gold standard for diagnosis and evaluation. For most, symptoms will resolve in days or weeks following a concussion. However, symptoms can become more serious, lasting for months or even years, considerably affecting quality of life. Long-lasting concussion symptoms can include worse mental health and cognitive function, impaired sleep, and ocular and vestibular problems. Sports are a significant risk factor for concussions. Previous concussions, medical history and background, age and gender are also factors influencing the prevalence and the sequela of concussion and progression of symptoms. Despite being underrepresented in the concussion literature, many studies have found that women are more at risk of sustaining a concussion and have more severe symptoms. All of the participants in this study were Icelandic female athletes, retired and still active. All had been playing at the highest level in their sport in Iceland. The aims of this Thesis were to 1) examine the usefulness of self-report of concussion history and test if different methods of obtaining self-report would affect the report given and the relationship with an outcome variable; 2) examine concussion history and symptoms among retired and still active female athletes and the relationship with mental health and cognitive abilities; 3) validate self-reported concussion history and symptoms by assessing phycological responses and physical markers in a virtual reality environment. Self-reported history varied according to the method used to elicit concussion history. This change indicates a lack of concussion knowledge and that detailed questioning might be preferable when asking for a self-report of concussion history. This change and how groups were formed depending on concussion count affected the relationship with current symptoms. History of concussion was connected to poorer impulse control, more current post-concussion symptoms and more problems with sleep, as well as more anxiety and depression symptoms. Retired athletes with a concussion history tended to have a worse outcome. When evaluating concussion symptoms and responses in a virtual reality environment, biological signals showed discriminative powers when comparing those with and without a concussion history. This supports their use as possibleiv biomarkers for concussion. The Random forest algorithm predicted concussion history with over 90% accuracy. Overall, the findings support the use of self-report while assessing concussion history and symptoms among female athletes with the appropriate framework. However, the limitations of self-report and how they can affect results are also recognised. In addition, results suggest that concussion history is connected to worse mental health and poorer impulse control. The findings also highlight the use of a multimodal approach to concussion assessment and support the use of several biological measures as possible biomarkers for concussion. Results also underline the importance of including technology from different fields in concussion assessmentEinkenni sem hafa verið kennd við heilahristing eru flókin, þau eru ekki sértæk fyrir heilahristing og það er engin ein algild leið til þess að greina og meta heilahristing. Flestir jafna sig á einkennum á nokkrum dögum eða vikum. Hins vegar, geta einkenni orðið mjög slæm, varað í nokkra mánuði eða ár og haft mikil áhrif á lífsgæði. Langtímaafleiðingar eftir heilahristing geta verið verri líðan og hugræn geta, verri svefn og vandi með augnhreyfingar og jafnvægi. Íþróttir eru einn þeirra áhættuþátta sem hefur mikið vægi þegar kemur að heilahristing, þó ekki fylgi öllum íþróttum jafn mikil áhætta. Fyrri heilahristingssaga, heilsa og bakgrunnur hafa jafnframt áhrif, en einnig aldur og kyn. Allt eru þetta þættir sem hafa áhrif á algengi og afleiðingar heilahristings. Þrátt fyrir að konur eru ekki eins mikið rannsakaðar og karlar gefa margar rannsóknir til kynna að konur séu í meiri hættu á því að fá heilahristing og glími við alvarlegri einkenni. Allir þátttakendur í þessari rannsókn voru íslenskar íþróttakonur sem annað hvort voru enn að æfa og keppa í efstu deildum í sinni íþrótt, eða voru hættar. Markmið þessa verkefnis voru að 1) skoða gagnsemi þess að fá þátttakendur sjálfa til að greina frá heilahristingssögu sinni ásamt því að meta hvort mismunandi aðferðir við að fá fram heilahristingssögu hafi áhrif á það sem er uppgefið og tengsl við fylgibreytur; 2) skoða heilahristingssögu og einkenni meðal íþróttakvenna, sem eru hættar og þeirra sem eru enn virkar, og meta samband við líðan og hugræna getu; 3) staðfesta mat á eigin heilahristingssögu og einkennum með því að skoða svörun og líffræðileg merki sem safnað var í sýndarveruleika. Mat á heilahristingssögu breyttist á milli aðstæðna og var háð því hvaða upplýsingar voru gefnar og hvernig þáttakandi var beðinn um að rifja upp. Þessi breyting bendir til þekkingarleysis á heilahristing og að nákvæmari spurningar um heilahristingssögu séu mikilvægur hluti af gagnasöfnun þegar nota á sjálfsmat. Þessi breyting og það hvernig hópar voru myndaðir út frá fjölda heilahristinga hafði áhrif þegar tengslin við fylgibreytu voru metin. Tengsl voru á milli heilahristingssögu og stýrifærni, núverandi heilahristingseinkenna, meiri svefnvanda, og kvíða-og þunglyndiseinkenna. Þeim íþróttakonum sem áttu sögu um heilahristing og voru hættar keppni gekk í mörgum vi tilvikum verr en öðrum hópum. Merki frá nemum sem mældu líffræðilega svörun við áreiti í sýndarveruleika gáfu ennfremur til kynna að hægt var að greina á milli þeirra sem greindu frá sögu um heilahristing og þeirra sem ekki greindu frá heilahristingssögu. Niðurstöður stiðja því að hægt sé nota þessi merki sem viðmið við mat á heilahristingseinkennum. Með notkun Random forest reikniritsins var hægt að spá fyrir um heilahristingssögu með yfir 90% nákvæmni. Þegar á heildina er litið gefa niðurstöður þessa verkefnis til kynna að hægt sé að styðjast við sjálfsmat á einkennum og heilahristingssögu. Þó er mikilvægt að vera meðvitaður um þær takmarkanir sem kunna að fylgja þessari aðferð og áhrifum á niðurstöður. Að auki benda niðurstöður til þess að tengsl séu á milli heilahristingssögu og verri andlegrar heilsu og að hluta til stýrifærni. Niðurstöður undirstrika einnig mikilvægi þessa að notast við fleiri en eina mælingu við mat á einkennum og mikilvægi þess að nýta aðferðir sem koma úr ólíkum áttum við mat á heilahristing. Með því opnast fleiri möguleikar á mögulegum greiningarviðmiðum fyrir heilahristin