Vestibular rehabilitation: advances in peripheral and central vestibular disorders

Vestibular Dysfunction and Gross Motor Milestone Acquisition in Children With Hearing Loss: A Systematic Review

OBJECTIVE

To describe the impact of vestibular dysfunction on gross motor development in children with hearing loss.

DATA SOURCES

MEDLINE (PubMed), Embase (Elsevier), Web of Science (Clarivate), and the Cumulative Index of Nursing and Allied Health Literature (EBSCO).

REVIEW METHODS

A systematic review was reported in concordance with the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses). Articles on children with hearing loss who underwent at least 1 instrumented measure of vestibular function and had gross motor milestones assessed were included. The Downs and Black checklist was used to assess risk of bias and methodological quality.

RESULTS

Eleven articles were included in the systematic review. Three articles stratified quantitative results of gross motor milestone acquisition by severity of vestibular impairment. Over half of studies were case series published within the last 5 years. This systematic review showed that children with hearing loss and severe, bilateral vestibular dysfunction demonstrate delayed gross motor milestones. However, it was difficult to draw conclusions on whether milder forms of vestibular dysfunction significantly affect gross motor milestone acquisition in children with hearing loss. The reason is that most studies were of low to moderate quality, used different assessment methods, and contained results that were descriptive in nature.

CONCLUSIONS

This emerging area would benefit from future research, such as higher-quality studies to assess vestibular function and gross motor milestones. This would allow for better characterization of the impacts of vestibular impairment, especially milder forms, in children with hearing loss.

The Effects of Stochastic Galvanic Vestibular Stimulation on Body Sway and Muscle Activity

Objective: This study aimed to investigate whether galvanic vestibular stimulation with stochastic noise (nGVS) modulates the body sway and muscle activity of the lower limbs, depending on visual and somatosensory information from the foot using rubber-foam.

Methods: Seventeen healthy young adults participated in the study. Each subject maintained an upright standing position on a force plate with/without rubber-foam, with their eyes open/closed, to measure the position of their foot center of pressure. Thirty minutes after baseline measurements under four possible conditions (eyes open/closed with/without rubber-foam) performed without nGVS (intensity: 1 mA, duration: 40 s), the stimulation trials (sham-nGVS/real-nGVS) were conducted under the same conditions in random order, which were then repeated a week or more later. The total center of pressure (COP) path length movement (COP-TL) and COP movement velocity in the mediolateral (Vel-ML) and anteroposterior (Vel-AP) directions were recorded for 30 s during nGVS. Furthermore, electromyography activity of the right tibial anterior muscle and soleus muscle was recorded for the same time and analyzed.

Results: Three-way analysis of variance and post-hoc multiple comparison revealed a significant increment in COP-related parameters by nGVS, and a significant increment in soleus muscle activity on rubber. There was no significant effect of eye condition on any parameter.

Conclusions: During nGVS (1 mA), body sway and muscle activity in the lower limb may be increased depending not on the visual condition, but on the foot somatosensory condition.

Vestibular rehabilitation therapy in combination with transcranial direct current stimulation (tDCS) for treatment of chronic vestibular dysfunction in the elderly: a double-blind randomized controlled trial

Introduction

Dizziness and imbalance are common dysfunctions in the elderly. Vestibular rehabilitation therapy is an effective method to alleviate chronic dizziness in patients with vestibular dysfunction. Transcranial direct current stimulation has reportedly improved balance function in patients with vestibular dysfunction.

Objective

This study was conducted to investigate the therapeutic efficacy of vestibular rehabilitation combined with transcranial direct current stimulation in elderly patients with vestibular dysfunction.

Methods

In a double-blinded randomized controlled trial, 36 elderly patients with chronic vestibular dysfunction were randomly assigned to either vestibular rehabilitation and transcranial direct current stimulation (n = 18) or vestibular rehabilitation alone (n = 18) group. The transcranial stimulation protocol consisted of multisession bifrontal electrical stimulation of the dorsolateral prefrontal cortex (2 mA intensity and 20 min duration), followed by rehabilitation exercises. The vestibular rehabilitation protocol consisted of habituation and adaptation exercises combined with gait exercises during a three week period. The primary outcome of this study was the dizziness handicap inventory score, and the secondary outcomes were activities-specific balance confidence and Beck anxiety inventory scores.

Results

For the dizziness handicap score, the repeated-measures analysis of variance showed a significant main effect of “time”, “stimulation” and stimulation × time interaction effect. There was a significant reduction in the overall dizziness handicap score with “time” for both the groups, which was more pronounced in the vestibular rehabilitation and electrical stimulation group. In terms of activities-specific balance confidence change scores, we found a significant main effect of “time” and “stimulation” main factors, but this effect for stimulation × time interaction was not significant. For the Beck anxiety score, we observed a significant main effect of “time”, but no evidence for the main effect of the “stimulation” factor.

Conclusion

Bifrontal transcranial direct current stimulation in combination with vestibular rehabilitation therapy is a promising approach to improve chronic vestibular symptoms in the elderly.

A Dynamic Bayesian Network Approach to Behavioral Modelling of Elderly People during a Home-based Augmented Reality Balance Physiotherapy Programme

In this study, we propose a dynamic Bayesian network (DBN)-based approach to behavioral modelling of community dwelling older adults at risk for falls during the daily sessions of a hologram-enabled vestibular rehabilitation therapy programme. The component of human behavior being modelled is the level of frustration experienced by the user at each exercise, as it is assessed by the NASA Task Load Index. Herein, we present the topology of the DBN and test its inference performance on real-patient data.Clinical Relevance- Precise behavioral modelling will provide an indicator for tailoring the rehabilitation programme to each individual's personal psychological needs.

Benign paroxysmal positional vertigo, dizziness, and health-related quality of life among older adults in a population-based setting

Purpose

Dizziness may affect quality of life in a negative way and contribute to falls. The aim of this study was to investigate and compare 75 years old with dizziness caused by benign paroxysmal positional vertigo (BPPV) to those with general dizziness/impaired balance (non-BPPV related) and to those reporting no dizziness, regarding health-related quality of life (HRQL), falls, tiredness, and walking speed in a population-based setting.

Method

A cross-sectional population-based sample, including 671 75 years old (398 women, 273 men), was investigated for BPPV, dizziness symptoms, falls, and walking speed. HRQL was assessed using the 36-item Short Form-36 Health Survey (SF-36).

Result

A total of 67 persons (10%) had symptoms of BPPV with 11 (1.6%) having nystagmus when tested for BPPV. Having BPPV as well as general dizziness/impaired balance was associated with reduced HRQL, more tiredness, enhanced number of falls, and lower walking speed. Furthermore, the risk of having BPPV increased fourfold if symptoms of dizziness when turning in bed was reported.

Conclusion

Having problems with dizziness is common among senior citizens where BPPV can be an unrecognized cause of dizziness that may impact HRQL and overall well-being. As BPPV is common among older adults, and is potentially curable through reposition maneuvers, it is important to liberally test for, and treat the condition. Information about dizziness when turning in bed can help to pinpoint persons with enhanced risk for BPPV also on a population-based level.

A review on the alterations in the brain of persistent postural-perceptual dizziness patients and non-pharmacological interventions for its management

Persistent postural perceptual dizziness (PPPD) is a relatively newer term, and this term is included in the International Classification of Diseases in its 11th revision. The typical features of PPPD include the presence of persistent dizziness, non-spinning vertigo, and unsteadiness, and these symptoms are exacerbated during upright posture, movement, or visual stimuli. Moreover, the structural changes have also been identified in the brains of PPPD patients, particularly in visual, vestibular, and limbic areas. These include a decrease in the volume and gyration of gray matter, a decrease in the blood flow to the cortex region, and alterations in the structural and functional connectivity, particularly in the visual-vestibular networks. Moreover, the impairment in sensory processing is restricted not only to the vestibular and visual regions; instead, there is a generalized impairment in the sensory processing, and thus, there is a multisensory dimension of sensory impairment. Selective serotonin uptake inhibitors and serotonin-norepinephrine reuptake inhibitors are the mainstay drugs for the management of PPPD patients. However, a significant proportion of PPPD patients do not show improvement in response to standard drug therapy. The employment of alternative and complementary treatment strategies, including vestibular rehabilitation therapy, cognitive behavioral therapy, and non-invasive vagal nerve stimulation, is effective in the management of PPPD patients. The present review discusses the alterations in the brains of PPPD patients along with the possible non-pharmacological treatment options in these types of patients.

[Reliability and validity of chinese version of vestibular rehabilitation benefit questionnaire]

Objective:To translate the English version of vestibular rehabilitation benefit questionnaire （VRBQ） into Chinese, and to test its reliability and validity. Method:The VRBQ was forward and backward-translated according to the Brislin model. Cultural adaption was done by expert discussion and pilot study. The scale was applied to 158 patients to test its reliability and validity. Result:The Cronbach's α coefficient was 0.90, and the test-retest reliability was 0.98, the total scale responsiveness is 2.066. Chinese version of VRBQ consisted of 22 items. Four factors were extracted by factor analysis, which could explain 73.341% of the total variance. Conclusion:The Chinese version of VRBQ is reliable and valid, therefore can be used to evaluate the quality of life and rehabilitation efficacy of patients with vestibular dysfunction in Chinese cultural background.

Contextual sensory integration training via head mounted display for individuals with vestibular disorders: a feasibility study

Purpose: Virtual reality (VR) interventions can simulate real-world sensory environments. The purpose of this study was to test the feasibility of a novel VR application (app) developed for a Head Mounted Display (HMD) to target dizziness, imbalance and sensory integration in a functional context for patients with vestibular disorders. Here we describe the design of the app as well as self-reported and functional outcomes in vestibular patients before and after participating in vestibular rehabilitation using the app.Material and methods: Our app includes a virtual street, airport, subway or a park. The clinician controls the visual and auditory load including several levels of direction, amount and speed of virtual pedestrians. Clinicians enrolled 28 patients with central (mild-traumatic brain injury [mTBI] or vestibular migraine) and peripheral vestibular disorders. We recorded the Simulator Sickness Questionnaire, Visual Vertigo Analogue Scale (VVAS), Dizziness Handicap Inventory (DHI), Activities-Specific Balance Confidence Scale (ABC), 8-foot up and go (8FUG) and Four-Step Square Test (FSST) before and after the intervention.Results: Within the 15 patients who completed the study, 12 with peripheral hypofunction showed significant improvements on the VVAS (p = 0.02), DHI (p = 0.008) and ABC (p = 0.02) and a small significant improvement on the FSST (p = 0.015). Within-session changes in symptoms were minimal. Two patients with mTBI showed important improvements, but one patient with vestibular migraine, did not.Conclusion: HMD training within increasingly complex immersive environments appears to be a promising adjunct modality for vestibular rehabilitation. Future controlled studies are needed to establish effectiveness.IMPLICATIONS FOR REHABILITATIONVirtual Reality allows for gradual introduction of complex semi-real visual environments.Within VR training patients can re-learn to maintain balance when presented with a sensory conflict in a safe environment.Head Mounted Display training appears to be a promising adjunct modality for vestibular rehabilitation.Portability and affordability of the hardware and software enhance the potential clinical outreach.

Vestibular Disorders

BACKGROUND

Recent research findings have improved the understanding of the diagnosis, pathophysiology, genetics, etiology, and treatment of peripheral, central, and functional vestibular vertigo syndromes.

METHOD

A literature search, with special attention to the current classification, treatment trials, Cochrane analyses, and other meta-analyses.

RESULTS

There are internationally accepted diagnostic criteria for benign positional paroxysmal vertigo, Menière's disease, bilateral vestibulopathy, vestibular paroxysmia, and functional dizziness. Whether an acute vestibular syndrome is central or peripheral can usually be determined rapidly on the basis of the history and the clinical examination. "Cere - bellar vertigo" is a clinically important entity. For bilateral vestibulopathy, balance training is an effective treatment. For Menière's disease, preventive treatment with betahistine (48 mg and 144 mg per day) is not superior to placebo. For vestibular paroxysmia, oxcarbazepine has been shown to be effective. Treatments that are probably effective for functional dizziness include vestibular rehabilitation, cognitive behavioral therapy, and serotonin reuptake inhibitors.

CONCLUSION

The diagnostic assessment of vestibular syndromes is much easier for clinicians now that it has been internationally standardized. There is still a lack of randomized, controlled trials on the treatment of, for example, Menière's disease, vestibular migraine, and "cerebellar vertigo."

Effectiveness of Vestibular Training for Balance and Dizziness Rehabilitation in People with Multiple Sclerosis: A Systematic Review and Meta-Analysis

Postural instability and dizziness are commonly observed in people with multiple sclerosis (PwMS). The aim of this systematic review was to evaluate the evidence for the use of vestibular rehabilitation, in comparison with other exercise interventions or no intervention, to treat balance impairments and dizziness in PwMS. An electronic search was conducted by two independent reviewers in the following databases: MEDLINE (Pubmed), Scopus, the Physiotherapy Evidence Database (PEDro), Web of Science (WOS), Lilacs, CINHAL and the Cochrane Database of Systematic Reviews (CDSR). A quality assessment was performed using the PEDro scale and the Cochrane Risk of Bias Tool. When possible, the data were pooled in a meta-analysis (95%CI). This systematic review followed the PRISMA guideline statement and was registered in the PROSPERO database (CRD42019134230). Seven studies were included, with a total of 321 participants analysed. Compared with no intervention, vestibular rehabilitation was more effective for balance development (SMD = 2.12; 95% CI = 0.49, 3.75; p = 0.01; I² = 89%) and dizziness symptoms improvement (SMD = −17.43; 95% CI = −29.99, −4.87; p= 0.007; I²= 66%). Compared with other exercise interventions, improvements in favour of the experimental group were observed, but statistical significance for the differences between groups was not reached.

Preclerkship Point-of-Care Ultrasound: Image Acquisition and Clinical Transferability

INTRODUCTION

The integration of point-of-care ultrasound (POCUS) in preclerkship medical education is currently popular and based on the notion that POCUS may improve diagnostic and procedural skills in medical students. However, empirical evidence demonstrating that POCUS can enhance clinical skills in preclerkship students has been lacking. We sought to evaluate anatomical sonographic knowledge and ultrasound generation capabilities associated with the implementation of a 3-h echocardiography training camp led by 2 emergency physicians and using a flipped classroom design.

METHODS

Preclerkship students from the University of Ottawa (n = 32) were recruited to participate. A flipped classroom model was adopted, providing students with a 3-chaptered peer-designed, expert validated ultrasound manual before the workshop, to maximize scanning times (2 h of reading). A pretest Likert-type design was used to assess student perception of the ultrasound tool. Similarly, a pretest/post-test model was used to assess sonographic anatomical identification. In addition, a subsequent Objective Structured Clinical Examination (OSCE) test was done 3 weeks after the hands-on session, to evaluate image generation (4 cardiac views: parasternal long, parasternal short, subxiphoid, and apical 4 chambers), understanding of knobology and structural labeling.

RESULTS

For the sonographic anatomy, there was a statistically significant increase (P < .001) between pretest (average = 12.12) and post-test (average = 18.85). The OSCE, which also ascertained knowledge retention, found that 81% of students were able to generate all 4 cardiac views perfectly, 6% were able to obtain 3 views, 10% obtained 2 views and 3% successfully generated a single view. The most challenging scan to generate was the apical 4-chamber view.

CONCLUSION

The positive outcomes stemming from this study reinforces the notion that formal curricular integration of POCUS at the preclerkship level has tangible benefits for medical students.

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.

Efficacy of intergrating vestibular rehabilitation and cognitive behaviour therapy in persons with persistent dizziness in primary care- a study protocol for a randomised controlled trial

Background

Dizziness is a common complaint, and the symptom often persists, together with additional complaints. A treatment combining Vestibular Rehabilitation (VR) and Cognitive Behaviour Therapy (CBT) is suggested. However, further research is necessary to evaluate the efficacy of such an intervention. The objective of this paper is to present the design of a randomised controlled trial aiming at evaluating the efficacy of an integrated treatment of VR and CBT on dizziness, physical function, psychological complaints and quality of life in persons with persistent dizziness.

Methods/design

The randomised controlled trial is an assessor-blinded, block-randomised, parallel-group design, with a 6- and 12-month follow-up. The study includes 125 participants from Bergen (Norway) and surrounding areas. Included participants present with persistent dizziness lasting for at least 3 months, triggered or exacerbated by movement. All participants receive a one-session treatment (Brief Intervention Vestibular Rehabilitation; BI-VR) with VR before being randomised into a control group or an intervention group. The intervention group will further be offered an eight-session treatment integrating VR and CBT. The primary outcomes in the study are the Dizziness Handicap Inventory and preferred gait velocity.

Discussion

Previous studies combining these treatments have been of varying methodological quality, with small samples, and long-term effects have not been maintained. In addition, only the CBT has been administered in supervised sessions, with VR offered as home exercises. The current study focusses on the integrated treatment, a sufficiently powered sample size, and a standardised treatment programme evaluated by validated outcomes using a standardised assessment protocol.

Trial registration

www.clinicaltrials.gov, ID: NCT02655575. Registered on 14 January 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3660-5) contains supplementary material, which is available to authorized users.