Auditory evoked potentials and vestibular evoked myogenic potentials in evaluation of brainstem lesions in multiple sclerosis

OBJECTIVE: The aim of this study was to determine the roles of magnetic resonance imaging (MRI), auditory evoked potentials (AEP) and vestibular evoked myogenic potentials (VEMP) in the evaluation of brainstem involvement in multiple sclerosis (MS). ----- PATIENTS AND METHODS: Altogether 32 patients with the diagnosis of MS participated in the study. The following data was collected from all patients: age, gender, Expanded Disability Status Scale (EDSS) score, brainstem functional system score (BSFS) (part of the EDSS evaluating brainstem symptomatology), and involvement of the brainstem on the brain MRI. AEP and ocular VEMP (oVEMP) and cervical VEMP (cVEMP) were studied in all patients. ----- RESULTS: BSFS, MRI, AEP, oVEMP and cVEMP involvement of the brainstem was evident in 9 (28.1%), 14 (43.8%), 7 (21.9%), 12 (37.5%) and 10 (31.0%) patients, respectively. None of the tests used showed statistically significant advantage in the detection of brainstem lesions. When combining oVEMP and cVEMP 18 (56.3%) patients showed brainstem involvement. This combination showed brainstem involvement in greater percentage than BSFS or AEP, with statistical significance (p=0.035 and p=0.007, respectively). ----- CONCLUSION: VEMP is a reliable method in detection of brainstem involvement in MS. It is comparable with MRI, but superior to clinical examination or AEP

Συμπτώματα και έκβαση σε ασθενείς με μη αντιρροπούμενη μονόπλευρη αιθουσαία ανεπάρκεια

Εισαγωγή Η εμφάνιση μονόπλευρης αιθουσαίας ανεπάρκειας έχει ως αποτέλεσμα μια σειρά ενοχλητικών συμπτωμάτων για τους ασθενείς. Οι περισσότεροι από αυτούς αναρρώνουν καλώς και επανέρχονται σε ένα φυσιολογικό τρόπο ζωής. Πολλοί όμως δεν αναρρώνουν επαρκώς και βιώνουν τη συμπτωματολογία μιας μη αντιρροπούμενης αιθουσαίας βλάβης. Οι κύριες αιτίες μονόπλευρης αιθουσαίας βλάβης είναι νοσήματα του αιθουσαίου συστήματος (αιθουσαία νευρίτιδα, νόσος Meniere, καλοήθης παροξυσμικός ίλιγγος θέσης), ιατρικές πράξεις (χειρουργική αφαίρεση ακουστικού νευρινώματος, ενδοτυμπανική έγχυση γενταμυκίνης), κατάγματα κροταφικού οστού. Η μη αντιρροπούμενη αιθουσαία ανεπάρκεια είναι το επακόλουθο της μη επαρκούς ανάρρωσης ασθενών με κάποιο από τα ανωτέρω νοσήματα, οι οποίοι παραπονούνται κυρίως για συμπτώματα αστάθειας, αταξίας βάδισης και ταλαντοψίας. Η ανάρρωση ενέχει, πέραν από τεστ λειτουργίας του αιθουσαίου συστήματος, και υποκειμενικές συνιστώσες. Είναι πιθανό οι μετρήσεις στα τεστ να βελτιωθούν αλλά ο ασθενής να είναι ακόμα δυσαρεστημένος από την ποιότητα ζωής του. Αυτό οδηγεί στη χρήση ερωτηματολογίων για την ποσοτικοποίηση των υποκειμενικών συμπτωμάτων στα αρχικά στάδια της νόσου και στην έκβασή της, μετά από θεραπευτική παρέμβαση. Η κύρια παρέμβαση στη μονόπλευρη αιθουσαία ανεπάρκεια είναι οι ασκήσεις αιθουσαίας αποκατάστασης. Μεθοδολογία Οριοθετημένη ανασκόπηση της αρθρογραφίας σε βάθος δεκαετίας (2011-2020) σε 3 βάσεις δεδομένων: PubMed, Cochrane Library, Google Scholar με τις κατάλληλες λέξεις-κλειδιά. Επιλογή άρθρων στην αγγλική γλώσσα. Αποτελέσματα Μετά τον έλεγχο συνάφειας των άρθρων με το θέμα της εργασίας, συμπεριλήφθηκαν 30 άρθρα. Σε όλα, οι ασθενείς ήταν ενήλικες που έπασχαν από μονόπλευρη αιθουσαία ανεπάρκεια, με βάση κριτήρια νυσταγμογραφίας με διακλυσμούς ή v-HIT, και με σχετιζόμενη συμπτωματολογία. Η θεραπευτική προσέγγιση ήταν οι ασκήσεις αιθουσαίας αποκατάστασης. Ως μέτρα έκβασης χρησιμοποιήθηκαν ερωτηματολόγια υποκειμενικών συμπτωμάτων ζάλης και ποιότητας ζωής (DHI, ABCscale, dVAS, PSIL, UCLA-DQ, SF-36), ερωτηματολόγια ψυχολογικής κατάστασης (HADS), μετρήσεις φυσικής λειτουργίας (DGI, DVA, SVV) και ισορροπίας. Από τις μελέτες διατυπώθηκαν αποτελέσματα ως προς : τη χρησιμότητα και αποτελεσματικότητα των ασκήσεων στην αντιρρόπηση, τη σύγκριση μεταξύ διαφορετικών πρωτοκόλλων ασκήσεων, την ποσοτικοποίηση των συμπτωμάτων με αξιολογημένα μέτρα έκβασης, τους παράγοντες που πιθανό να επηρεάζουν την κατάληξη. Οι περισσότεροι συγγραφείς συμφωνούν στα κάτωθι : Συνιστάται η προσφορά ασκήσεων αποκατάστασης στους ασθενείς. Ο συνδυασμός τύπων ασκήσεων και η επίβλεψη από εξειδικευμένο φυσιοθεραπευτή επιδρούν θετικά στην έκβαση. Η χρήση της εικονικής πραγματικότητας είναι ενθαρρυντική καθώς σχετίζεται με τη μεγαλύτερη εμπλοκή και συμμόρφωση των ασθενών. Το φύλο και η ηλικία δεν επηρεάζουν την συνολική έκβαση, ενώ οι ψυχολογικοί παράγοντες φαίνεται να παίζουν ρόλο. Συμπεράσματα Η συμπτωματολογία της μη αντιρροπούμενης αιθουσαίας υπαισθησίας φαίνεται ότι δύναται να βελτιωθεί με τη χρήση κατάλληλων τεχνικών και προγραμμάτων αιθουσαίας αποκατάστασης, έτσι ώστε η έκβασή της να αντανακλάται στη βελτίωση των σκορ των μέτρων έκβασης, υποδηλώνοντας καλύτερη ποιότητα ζωής. Η ετερογένεια των άρθρων, τα μικρά δείγματα ασθενών και τα συστηματικά σφάλματα, καθιστούν αναγκαίες περισσότερες μελέτες, που θα καταδεικνύουν τις μεταβλητές που ευθύνονται ή προβλέπουν τη μη αντιρρόπηση, και που θα υποδεικνύουν την κατάλληλη θεραπευτική μέθοδο.Introduction Unilateral vestibular hypofunction results in a series of dramatic symptoms. Although most patients recover well and have a good quality of life, some unfortunately experience an uncompensated vestibular loss. Main causes of unilateral vestibular deficit are vestibular diseases (vestibular neuritis, Meniere disease, benign paroxysmal positional vertigo), iatrogenic (removal of vestibular schwannoma, intratympanic injection of gentamycin) and trauma (temporal bone fractures). Uncompensated vestibular hypofunction is the outcome of non compensation from the aforementioned diseases and consists of disequilibrium, gait ataxia and oscillopsia. Apart from functional tests of vestibular system, the assessment of the extent of recovery involves subjective components. It is quite likely to encounter symptomatic patients even when vestibular tests are improving. This leads to the use of questionnaires for the quantification of severity of symptoms before and after therapeutic intervention. The main intervention in unilateral vestibular deficit is vestibular rehabilitation exercises. Material and method Scoping review of English literature from 2011 to 2020 on 3 online databases (PubMed, Cochrane Library, Google Scholar) using key-words. Results After evaluation of the relevant articles, thirty of them were included in the scoping review. In all 30 articles, the patients were adults suffering from unilateral vestibular hypofunction, based on nystagmography with calorics or v-HIT related criteria and relevant symptoms. Intervention tested was a range of vestibular rehabilitation exercises. Outcome measures used were questionnaires of subjective symptoms of vertigo/dizziness and psychological state, as well as measures of physical activity and posture. Formulated results: Usefulness and efficiency of exercises in compensation, comparing different exercises protocols, quantification of symptoms with validated outcome measures, possible variables that affect the outcome. Most authors agree to the following: Clinicians should offer vestibular rehabilitation to patients with unilateral vestibular hypofunction and supervised rehabilitation shows better outcomes. The use of virtual reality is promising, because of the motivation offered. The gender and age do not affect the outcome, whereas psychological aspects play an important role. Conclusion Symptoms of uncompensated unilateral vestibular hypofunction seem to be improved with the use of appropriate strategies and programs of vestibular rehabilitation, so that the outcome can be reflected in the improved scores of questionnaires. The heterogeneity of the articles, the small patients sample and systematic bias necessitate further studies, in order to demonstrate possible causes of poor compensation and suggest the most appropriate therapeutic intervention

Manual therapy with and without vestibular rehabilitation for cervicogenic dizziness: a systematic review

<p>Abstract</p> <p>Background</p> <p>Manual therapy is an intervention commonly advocated in the management of dizziness of a suspected cervical origin. Vestibular rehabilitation exercises have been shown to be effective in the treatment of unilateral peripheral vestibular disorders, and have also been suggested in the literature as an adjunct in the treatment of cervicogenic dizziness. The purpose of this systematic review is to evaluate the evidence for manual therapy, in conjunction with or without vestibular rehabilitation, in the management of cervicogenic dizziness.</p> <p>Methods</p> <p>A comprehensive search was conducted in the databases Scopus, Mantis, CINHAL and the Cochrane Library for terms related to manual therapy, vestibular rehabilitation and cervicogenic dizziness. Included studies were assessed using the Maastricht-Amsterdam criteria.</p> <p>Results</p> <p>A total of fifteen articles reporting findings from thirteen unique investigations, including five randomised controlled trials and eight prospective, non-controlled cohort studies were included in this review. The methodological quality of the included studies was generally poor to moderate. All but one study reported improvement in dizziness following either unimodal or multimodal manual therapy interventions. Some studies reported improvements in postural stability, joint positioning, range of motion, muscle tenderness, neck pain and vertebrobasilar artery blood flow velocity.</p> <p>Discussion</p> <p>Although it has been argued that manual therapy combined with vestibular rehabilitation may be superior in the treatment of cervicogenic dizziness, there are currently no observational and experimental studies demonstrating such effects. A rationale for combining manual therapy and vestibular rehabilitation in the management of cervicogenic dizziness is presented.</p> <p>Conclusion</p> <p>There is moderate evidence to support the use of manual therapy, in particular spinal mobilisation and manipulation, for cervicogenic dizziness. The evidence for combining manual therapy and vestibular rehabilitation in the management of cervicogenic dizziness is lacking. Further research to elucidate potential synergistic effects of manual therapy and vestibular rehabilitation is strongly recommended.</p

Effects of Dual (Cognitive) Tasking on Free Walking in Patients with a Peripheral Vestibular Disorder

This thesis examines the effect of dual tasking on dynamic balance in patients with unilateral peripheral vestibular disorders, both in indoor laboratory and in outdoor urban environments. A novel dual-tasking the functional gait assessment test (FGA) and an outdoor urban walking task around London Bridge using an accelerometer device were used to examine the effect of dual tasking on walking velocity and acceleration of various body segments. In addition, behavioural assessment using the dys-executive syndrome tests battery (BADs) was undertaken to assess participants’ cognitive abilities and their impact on performance under the dual task condition. The above measures were first applied to healthy participants assigned to young and old age groups (Chapter 3). Although both study groups had reduced FGA scores under the dual tasking condition, the older healthy group had significantly lower scores that may increase their risk of falls. The trunk medio-lateral (ML) acceleration was significantly reduced in older healthy adults, and the trunk attenuation rate (TAR) was reduced in dual tasking. Case control trials were carried out to compare the performance of patients diagnosed with unilateral peripheral vestibular disorders (UVD) relative to healthy age matched controls, while carrying indoor assessment (Chapter 4) and outdoor assessment tasks (Chapter 5). The addition of cognitive tasks adversely affected the FGA scores in both groups, though UVD group had a significantly higher risk of falls (in Chapter 4). Cognitive scores were significantly lower in the UVD group in three sub-tests of the BADs test battery. Walking velocity was significantly reduced in the patients group under single and dual task conditions (Chapter 5). Cognitive tasking resulted in significant reduction in the anterior-posterior (AP) and vertical (V) acceleration of the UVD group. ML head acceleration was significantly higher than ML Trunk Acceleration in UVD with dual tasking. In conclusion, our novel approach of implementing a dual tasking paradigm while walking in an outdoor environment showed that dual tasking interferes with postural stability. This will most likely put patients at risk of falls in multitasking situations commonly encountered in everyday life. This finding could be used to inform patient rehabilitation programmes currently in use

Tatalaksana Benign Paroxysmal Positional Vertigo (BPPV) Posterior dengan Paresis Kanal Unilateral

Pendahuluan: Benign paroxysmal positional vertigo (BPPV) posterior dan paresis kanal unilateral merupakan dua kasus yang berbeda. BPPV menyebabkan gangguan keseimbangan perifer yang sering ditandai oleh sensasi pusing berputar dan bersifat sementara, sedangkan paresis kanal akan  menyebabkan gangguan stabilitas postural. Keterlibatan kanal posterior pada BPPV paling sering dijumpai. Diagnosis BPPV ditegakkan berdasarkan anamnesis, pemeriksaan keseimbangan sederhana dan Dix-Hallpike dan ENG untuk peresis kanal. Manuver Epley merupakan tatalakasan dari BPPV posterior dan rehabilitasi vestibular tatalaksana paresis kanal. Laporan Kasus: Seorang laki-laki berusia 36 tahun dengan diagnosis BPPV kanal posterior kanan dagan paresis kanal kiri. Diagnosis ditegakkan berdasarkan anamnesis pusing berputar dipengaruhi oleh perubahan posisi, pada Dix-Hallpike  dengan nistagmus torsional ke atas-kanan dan hasil Electronistagmografi (ENG) dengan unilateral weakness (UW) 50% kiri. Pasien diterapi dengan canalith repositioning procedure dengan manuver Epley dan terapi adaptasi dikombinasi substitusi. Kesimpulan: BPPV kanal posterior dan paresis kanal kiri ditandai dengan gejala pusing berputar dipengaruhi posisi, ditemukan nistagmus torsional ke atas-kanan pada Dix-Hallpike dan UW 50% kiri. Penatalaksanaan BPPV posterior dengan manuver Epley dan paresis kanal kiri ditatalaksana dengan latihan adaptasi dan substitusiKata kunci: Benign Paroxysmal Positional Vertigo, manuver Dix-Hallpike, manuver Epley, paresis kanal unilateral, rehabilitasi vestibular

Effects of vestibular rehabilitation in patients with unilateral vestibular hypofunction

Purpose: To investigate the effect of physiotherapy on the balance parameters and fall risk in patients with unilateral vestibular hypofunction (UVH). Patients and Methods: Thirty patients diagnosed with UVH were included in the study. The number of falls, Visual Analog Scale, Modified Clinical Test for Sensory Interaction in Tandem and Balance, and dynamic visual acuity assessments was performed before and after treatment. The patients were included in an individual treatment program for 8 weeks. Physiotherapy sessions were given at 2-week intervals. Along with the level of development of the treatment applied to the patients, it was requested perform a home exercise program with ten repetitions three times a day. Results: After 8 weeks of vestibular rehabilitation, it was observed that the balance parameters of the participants improved and the number of falls decreased. Statistically significant results were obtained in the Eyes-closed Tandem test (P = 0.001). Significant changes occurred in the modified Clinical Test results for Sensory Interaction in Balance from 0.37 +/- 0.19 s to 0.93 +/- 0.11 s (P = 0.001). Vestibular symptoms and dynamic visual acuity scores also improved after treatment (P = 0.001). Conclusion: It was concluded that the physiotherapy program applied to our patients with UVH positively affected fall risk and significantly improved balance parameters

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

Locomotor Sensory Organization Test: How Sensory Conflict Affects the Temporal Structure of Sway Variability During Gait

When maintaining postural stability temporally under increased sensory conflict, a more rigid response is used where the available degrees of freedom are essentially frozen. The current study investigated if such a strategy is also utilized during more dynamic situations of postural control as is the case with walking. This study attempted to answer this question by using the Locomotor Sensory Organization Test (LSOT). This apparatus incorporates SOT inspired perturbations of the visual and the somatosensory system. Ten healthy young adults performed the six conditions of the traditional SOT and the corresponding six conditions on the LSOT. The temporal structure of sway variability was evaluated from all conditions. The results showed that in the anterior posterior direction somatosensory input is crucial for postural control for both walking and standing; visual input also had an effect but was not as prominent as the somatosensory input. In the medial lateral direction and with respect to walking, visual input has a much larger effect than somatosensory input. This is possibly due to the added contributions by peripheral vision during walking; in standing such contributions may not be as significant for postural control. In sum, as sensory conflict increases more rigid and regular sway patterns are found during standing confirming the previous results presented in the literature, however the opposite was the case with walking where more exploratory and adaptive movement patterns are present

Head Position Variability During Single and Dual-task Tandem Gait Concussion Testing Protocol

The tandem gait (TG) test is commonly administered to evaluate and diagnose possible sports-related concussions. To date, head position is not controlled for, nor has its potential influence been studied during TG testing. PURPOSE: Examine the difference in the mediolateral (ML) sway and velocity and time to complete between two head positions of cervical neutral and cervical flexion during single and dual-task tandem gait. METHODS: 25 apparently healthy subjects (age=21.9±1.41 years) performed tandem gait walking along a 3-meter piece of tape affixed to an instrumented walkway (30 Hz, Tekscan Strideway, Tekscan Inc., South Boston, MA). Each participant completed 3 randomized trials of 2 different head positions, cervical neutral (CN) and cervical flexion (CF). The time to complete and center of pressure (COP), filtered using empirical mode decomposition, were measured during the tasks and analyzed by the 1st pass (FP), turn (T), and 2nd (SP) using a custom MATLAB code. The time to complete the task and average mean excursion in the ML direction, velocity in the ML direction, were ensemble averaged and compared using a repeated measures ANOVA. RESULTS: A significant difference was found for single-task FP mean excursion ML (CN=1.78±0.54cm, CF=1.49±0.38cm; p=0.007), SP mean excursion ML (CN=1.72±0.44cm, CF=1.53±0.39cm; p=0.03). A significant difference was found for dual-task FP mean excursion ML (CN=1.80±0.37cm, CF=1.52±0.40cm; p=0.002), SP mean excursion ML (CN=2.00±0.50cm, CF=1.58±0.34cm; p<0.001), and T mean excursion ML (CN=2.81±0.80cm; CF=2.29±0.58cm; p=0.004) by head position. There was no significant difference was found in single-task or dual-task trials in the ML velocity or time by head position. CONCLUSION: The results of this study suggest that during a fixed head position of CN during dual-task TG, the COP ML sway increases during the FP, SP, and T when the participants are unable to look around. Secondly, there is an increase in COP ML sway during single-task TG when controlling head position. This research provides preliminary evidence that fixed head positions may alter the clinical application of concussion TG testing

Vestibular rehabilitation with Dynamic posturography

[ES] La rehabilitación vestibular es fundamental en el tratamiento de la inestabilidad actuando sobre la compensación se mejora el equilibrio y la calidad de vida del paciente. En este artículo, nos centraremos en la utilidad y en los aspectos practicos de la posturografía dinámica computarizada en el diseño de un programa de rehabilitación vestibula