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Kunelskaya NL, Baybakova EV, Zaoeva ZO, Guseva AL, Chugunova MA, Manaenkova EA, Vinogradova MV. [Rehabilitation in bilateral vestibulopathy: trends and perspectives]. Vestn Otorinolaringol 2024; 89:59-65. [PMID: 38805465 DOI: 10.17116/otorino20248902159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Abstract
A review of the literature on rehabilitation methods for bilateral vestibulopathy is presented using RSCI, Scopus and PubMed databases. The principles and effectiveness of physical vestibular rehabilitation, vestibular implants, galvanic vestibular stimulation, and biofeedback-based sensory substitution and augmentation systems are described. The advantages and disadvantages of each method and perspectives for their improvement are presented.
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Affiliation(s)
- N L Kunelskaya
- Sverzhevsky Research Clinical Institute of Otorhinolaryngology, Moscow, Russia
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - E V Baybakova
- Sverzhevsky Research Clinical Institute of Otorhinolaryngology, Moscow, Russia
| | - Z O Zaoeva
- Sverzhevsky Research Clinical Institute of Otorhinolaryngology, Moscow, Russia
| | - A L Guseva
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - M A Chugunova
- Sverzhevsky Research Clinical Institute of Otorhinolaryngology, Moscow, Russia
| | - E A Manaenkova
- Sverzhevsky Research Clinical Institute of Otorhinolaryngology, Moscow, Russia
| | - M V Vinogradova
- Pirogov Russian National Research Medical University, Moscow, Russia
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Wuehr M, Eilles E, Lindner M, Grosch M, Beck R, Ziegler S, Zwergal A. Repetitive Low-Intensity Vestibular Noise Stimulation Partly Reverses Behavioral and Brain Activity Changes following Bilateral Vestibular Loss in Rats. Biomolecules 2023; 13:1580. [PMID: 38002261 PMCID: PMC10669117 DOI: 10.3390/biom13111580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/18/2023] [Accepted: 10/22/2023] [Indexed: 11/26/2023] Open
Abstract
Low-intensity noisy galvanic vestibular stimulation (nGVS) can improve static and dynamic postural deficits in patients with bilateral vestibular loss (BVL). In this study, we aimed to explore the neurophysiological and neuroanatomical substrates underlying nGVS treatment effects in a rat model of BVL. Regional brain activation patterns and behavioral responses to a repeated 30 min nGVS treatment in comparison to sham stimulation were investigated by serial whole-brain 18F-FDG-PET measurements and quantitative locomotor assessments before and at nine consecutive time points up to 60 days after the chemical bilateral labyrinthectomy (BL). The 18F-FDG-PET revealed a broad nGVS-induced modulation on regional brain activation patterns encompassing biologically plausible brain networks in the brainstem, cerebellum, multisensory cortex, and basal ganglia during the entire observation period post-BL. nGVS broadly reversed brain activity adaptions occurring in the natural course post-BL. The parallel behavioral locomotor assessment demonstrated a beneficial treatment effect of nGVS on sensory-ataxic gait alterations, particularly in the early stage of post-BL recovery. Stimulation-induced locomotor improvements were finally linked to nGVS brain activity responses in the brainstem, hemispheric motor, and limbic networks. In conclusion, combined 18F-FDG-PET and locomotor analysis discloses the potential neurophysiological and neuroanatomical substrates that mediate previously observed therapeutic nGVS effects on postural deficits in patients with BVL.
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Affiliation(s)
- Max Wuehr
- German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, 81377 Munich, Germany; (M.W.); (E.E.); (M.L.); (M.G.); (R.B.)
| | - Eva Eilles
- German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, 81377 Munich, Germany; (M.W.); (E.E.); (M.L.); (M.G.); (R.B.)
| | - Magdalena Lindner
- German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, 81377 Munich, Germany; (M.W.); (E.E.); (M.L.); (M.G.); (R.B.)
| | - Maximilian Grosch
- German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, 81377 Munich, Germany; (M.W.); (E.E.); (M.L.); (M.G.); (R.B.)
| | - Roswitha Beck
- German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, 81377 Munich, Germany; (M.W.); (E.E.); (M.L.); (M.G.); (R.B.)
- Pharmaceutical Radiochemistry, TUM School of Natural Sciences, TU Munich, 85748 Garching, Germany
| | - Sibylle Ziegler
- Department of Nuclear Medicine, LMU University Hospital, LMU Munich, 81377 Munich, Germany;
| | - Andreas Zwergal
- German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, 81377 Munich, Germany; (M.W.); (E.E.); (M.L.); (M.G.); (R.B.)
- Department of Neurology, LMU University Hospital, LMU Munich, 81377 Munich, Germany
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Unidirectional Vertical Vestibuloocular Reflex Adaptation in Humans Using 1D and 2D Scenes. Otol Neurotol 2022; 43:e1039-e1044. [PMID: 36075099 DOI: 10.1097/mao.0000000000003684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
HYPOTHESIS The vertical vestibuloocular reflex (VOR) in response to pitch head impulses can be optimally trained to increase in one direction using a two-dimensional (2D) visual training target with minimal effect on the horizontal VOR. BACKGROUND We modified the incremental VOR adaptation (IVA) technique, shown to increase the horizontal VOR in patients with vestibular hypofunction, to drive vertical VOR adaptation in healthy control subjects. METHODS We measured the horizontal and vertical active (self-generated) and passive (imposed) head impulse VOR gains (eye velocity/head velocity) before and after 15 minutes of unidirectional downward IVA training. IVA training consisted of two sessions, one using a single-dot one-dimensional (1D) target, the other a grid-of-dots 2D target. RESULTS The downward head impulse VOR gain significantly increased because of training by 13.3%, whereas the upward VOR gain did not change. The addition of extraretinal (2D) feedback did not result in greater adaptation, i.e., 1D and 2D gain increases were 15.5% and 10.6%, respectively. The vertical VOR gain increase resulted in a 3.2% decrease in horizontal VOR gain. CONCLUSION This preliminary study is the first to show that physiologically relevant (high frequency) unidirectional increases in vertical VOR gain are possible with just 15 minutes of training. This study sets the basis for future clinical trials examining vertical IVA training in patients, which may provide the first practical rehabilitation treatment to functionally improve the vertical VOR.
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Cole KR, Goodman K, Volland L. Reporting of exercise dose and dosage and outcome measures for gaze stabilisation in the literature: a scoping review. BMJ Open 2022; 12:e049560. [PMID: 35121596 PMCID: PMC8819788 DOI: 10.1136/bmjopen-2021-049560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES The concept of this review is to examine and quantify the reporting of parameters of dose (duration, speed, head excursion) and dosage (daily and weekly frequency, duration) for gaze stabilisation exercises and to report on outcome measures used to assess change in gaze stabilisation following intervention. This review includes any population completing gaze stabilisation exercises. DESIGN Scoping review. METHODS We searched key terms in the following databases: PubMed, CINAHL, Scopus and Cochrane. Two researchers reviewed titles, abstracts and full-text articles for inclusion. Data retrieved included: patient diagnosis, specific interventions provided, dose and dosage of gaze stabilisation interventions and outcome measures. RESULTS From the initial 1609 results, 138 studies were included. Data extraction revealed that only 13 studies (9.4%) reported all parameters of dose and dosage. Most studies used other interventions in addition to gaze stabilisation exercises. Half of the studies did not use a clinical or instrumented outcome measure of gaze stability, using only patient-reported outcome measures. Clinical tests of gaze stability were used in 21.1% of studies, and instrumented measures of gaze stability were used in 14.7% of studies. CONCLUSIONS Full reporting of the dose and dosage of gaze stabilisation interventions is infrequent, impairing the ability to translate current evidence into clinical care. Most studies did not use a clinical or instrumented measure of gaze stabilisation as outcome measures, questioning the validity of intervention effects. Improved reporting and use of outcome measures are necessary to establish optimal intervention parameters for those with gaze stability impairments.
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Affiliation(s)
- Keith R Cole
- Health, Human Function, and Rehabilitation Science, The George Washington University, Washington, DC, USA
| | - Karen Goodman
- Health, Human Function, and Rehabilitation Science, The George Washington University, Washington, DC, USA
| | - Lena Volland
- Department of Clinical Research and Leadership, The George Washington University, Washington, DC, USA
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Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Updated Clinical Practice Guideline From the Academy of Neurologic Physical Therapy of the American Physical Therapy Association. J Neurol Phys Ther 2021; 46:118-177. [PMID: 34864777 PMCID: PMC8920012 DOI: 10.1097/npt.0000000000000382] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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's 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).
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Abstract
OBJECTIVES Oscillopsia is a disabling condition for patients with bilateral vestibular hypofunction (BVH). When the vestibulo-ocular reflex is bilaterally impaired, its ability to compensate for rapid head movements must be supported by refixation saccades. The objective of this study is to assess the relationship between saccadic strategies and perceived oscillopsia. DESIGN To avoid the possibility of bias due to remaining vestibular function, we classified patients into two groups according to their gain values in the video head impulse test. One group comprised patients with extremely low gain (0.2 or below) in both sides, and a control group contained BVH patients with gain between 0.2 and 0.6 bilaterally. Binary logistic regression (BLR) was used to determine the variables predicting oscillopsia. RESULTS Twenty-nine patients were assigned to the extremely low gain group and 23 to the control group. The BLR model revealed the PR score (saccades synchrony measurement) to be the best predictor of oscillopsia. Receiver operating characteristic analysis determined that the most efficient cutoff point for the probabilities saved with the BLR was 0.518, yielding a sensitivity of 86.6% and specificity of 84.2%. CONCLUSIONS BVH patients with higher PR values (nonsynchronized saccades) were more prone to oscillopsia independent of their gain values. We suggest that the PR score can be considered a useful measurement of compensation.
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Kim KJ, Gimmon Y, Millar J, Brewer K, Serrador J, Schubert MC. The Instrumented Timed "Up & Go" Test Distinguishes Turning Characteristics in Vestibular Hypofunction. Phys Ther 2021; 101:6189156. [PMID: 33774661 DOI: 10.1093/ptj/pzab103] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 01/22/2021] [Accepted: 02/28/2021] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Deficits in vestibular function increase the risk for falls while turning. However, the clinical assessment of turning in patients with vestibular dysfunction is lacking, and evidence is limited that identifies the effectiveness of vestibular physical therapy in improving turning performance. The purpose of this study was to quantify walking and turning performance during the instrumented Timed "Up & Go" (TUG) test using body-worn inertial measurement units (IMUs). Novel instrumented TUG parameters were investigated for ability to distinguish patients with unilateral vestibular deafferentation (UVD) from control groups and discriminate the differences in turning parameters of patients with UVD following vestibular physical therapy. METHODS Thirty-eight individuals were recruited following UVD surgery: 26 age-matched veteran controls with reports of dizziness not from a peripheral vestibular origin, and 12 age-matched healthy controls. Participants were donned with IMUs and given verbal instructions to complete the TUG test as fast as safely possible. The IMU-instrumented and automated assessment of the TUG test provided component-based TUG parameters, including the novel walk:turn ratio. Among the participants with UVD, 19 completed an additional instrumented TUG testing after vestibular physical therapy. RESULTS The walk:turn time ratio showed that turning performance in patients with UVD before rehabilitation is significantly more impaired than both the individuals with nonperipheral conditions and healthy controls. Vestibular rehabilitation significantly improved turning performance and "normalized" their walk:turn time ratio compared with healthy controls. The duration of the straight walking component in individuals with UVD before vestibular physical therapy, however, was not significantly different compared with that component in people after vestibular physical therapy and in healthy controls. CONCLUSION The IMU-instrumented TUG test can be used to distinguish individuals with vestibular deafferentation and to objectively quantify the change in their turning performance after vestibular physical therapy. IMPACT The IMU-based instrumented TUG parameters have the potential to quantify the efficacy of vestibular physical therapy and be adopted in the clinic.
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Affiliation(s)
- Kyoung Jae Kim
- Human Physiology, Performance, Protection and Operation (H-3PO) Laboratory, NASA Johnson Space Center/KBR, Houston, Texas, USA.,Department of Physical Therapy, University of Miami Miller School of Medicine, Coral Gables, Florida, USA
| | - Yoav Gimmon
- Department of Physical Therapy, Faculty of Social Welfare and Health Studies, University of Haifa, Haifa, Israel.,Department of Otolaryngology-Head and Neck Surgery, Sheba Medical Center, Tel-Hashomer, Israel.,Laboratory of Vestibular NeuroAdaptation, Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Jennifer Millar
- Laboratory of Vestibular NeuroAdaptation, Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.,Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kelly Brewer
- Department of Veteran Affairs, Veterans Biomedical Institute, War Related Illness and Injury Study Center, East Orange, New Jersey, USA
| | - Jorge Serrador
- Department of Rehabilitation and Movement Sciences, Rutgers School of Health Professions, Newark, New Jersey, USA.,Department of Pharmacology, Physiology and Neuroscience, Rutgers Biomedical Health Sciences, Newark, New Jersey, USA
| | - Michael C Schubert
- Laboratory of Vestibular NeuroAdaptation, Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.,Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Rodriguez Montesdeoca I, Ramos de Miguel A, González JCF, Barreiro SB, Pérez Fernández N, Vanspauwen R, Ramos-Macias A. Differences in Vestibular-Evoked Myogenic Potential Responses by Using Cochlear Implant and Otolith Organ Direct Stimulation. Front Neurol 2021; 12:663803. [PMID: 34113311 PMCID: PMC8185293 DOI: 10.3389/fneur.2021.663803] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/08/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: Several studies have demonstrated the possibility to obtain vestibular potentials elicited with electrical stimulation from cochlear and vestibular implants. The objective of this study is to analyze the vestibular-evoked myogenic potentials (VEMPs) obtained from patients implanted with cochlear and vestibulo-cochlear implant. Material and Methods: We compared two groups: in the first group, four cochlear implant (CI) recipients with present acoustic cVEMPs before CI surgery were included. In the second group, three patients with bilaterally absent cVEMPs and bilateral vestibular dysfunction were selected. The latter group received a unilateral cochleo-vestibular implant. We analyze the electrically elicited cVEMPs in all patients after stimulation with cochlear and vestibular electrode array stimulation. Results: We present the results obtained post-operatively in both groups. All patients (100%) with direct electrical vestibular stimulation via the vestibular electrode array had present cVEMPs. The P1 and N1 latencies were 11.33-13.6 ms and 18.3-21 ms, respectively. In CI patients, electrical cVEMPs were present only in one of the four subjects (25%) with cochlear implant ("cross") stimulation, and P1 and N1 latencies were 9.67 and 16.33, respectively. In these patients, the responses present shorter latencies than those observed acoustically. Conclusions: Electrically evoked cVEMPs can be present after cochlear and vestibular stimulation and suggest stimulation of vestibular elements, although clinical effect must be further studied.
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Affiliation(s)
- Isaura Rodriguez Montesdeoca
- Department of Otolaryngology, Head and Neck Surgery, Complejo Hospitalario Universitario Insular Materno Infantil de Gran Canaria, Las Palmas, Spain
| | - Angel Ramos de Miguel
- Hearing and Balance Laboratory, Las Palmas de Gran Canaria University (SIANI), Las Palmas, Spain
| | - Juan Carlos Falcon González
- Department of Otolaryngology, Head and Neck Surgery, Complejo Hospitalario Universitario Insular Materno Infantil de Gran Canaria, Las Palmas, Spain
| | - Silvia Borkoski Barreiro
- Department of Otolaryngology, Head and Neck Surgery, Complejo Hospitalario Universitario Insular Materno Infantil de Gran Canaria, Las Palmas, Spain
| | | | - Robby Vanspauwen
- European Institute for Otorhinolaryngology Head and Neck Surgery, Gasthuiszusters Antwerpen Hospitals Antwerp, Wilrijk, Belgium
| | - Angel Ramos-Macias
- Department of Otolaryngology, Head and Neck Surgery, Complejo Hospitalario Universitario Insular Materno Infantil de Gran Canaria, Las Palmas, Spain.,Hearing and Balance Laboratory, Las Palmas de Gran Canaria University (SIANI), Las Palmas, Spain
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Mahfuz MM, Millar JL, Schubert MC. Repeated video head impulse testing in patients is a stable measure of the passive vestibulo-ocular reflex. J Otol 2020; 16:128-137. [PMID: 34220981 PMCID: PMC8241694 DOI: 10.1016/j.joto.2020.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 12/15/2020] [Accepted: 12/15/2020] [Indexed: 10/29/2022] Open
Abstract
Objectives The video head impulse test (vHIT) is used as a measure of compensation yet it's stability in patients with vestibular pathology is unknown. Methods 144 patients (n = 72 female, mean 54.46 ± 15.8 years) were grouped into one of three primary diagnoses (Peripheral, Central, or Mixed). Subjects were further categorized based on sex (male versus female), ear (left versus right; ipsilesional versus contralesional), age (six groups ranging from 19 to 84 years), and duration between visits (five groups, mean 191.46 ± SE 29.42 days, median 55.5 days). The gain of the VOR during passive head rotation was measured for each semicircular canal (horizontal, anterior, posterior). Results There was no difference in the VOR gain within any semicircular canal between the two visits (horizontal: p = 0.179; anterior: p = 0.628; posterior: p = 0.613). However, the VOR gain from the horizontal canals was higher than the vertical canals for each visit (p < 0.001). Patients diagnosed with peripheral vestibular pathology had significantly lower (p ≤ 0.001) horizontal semicircular canal gains at each visit. There was no difference in VOR gain between sex (p = 0.215) or age groupings (p = 0.331). Test-retest reliability of vHIT in patient subjects is good (ICC = 0.801) and the VOR gain values across two separate visits were significant and positively correlated (r = 0.67) regardless of sex, ear, age, or duration between visits. Conclusion The vHIT is a stable measure of VOR gain over two different times across a variety of vestibular patients with no influence of age or sex.
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Affiliation(s)
- M Muntaseer Mahfuz
- Laboratory of Vestibular NeuroAdaptation, Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Jennifer L Millar
- Laboratory of Vestibular NeuroAdaptation, Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University, Baltimore, MD, 21205, USA.,Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Michael C Schubert
- Laboratory of Vestibular NeuroAdaptation, Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University, Baltimore, MD, 21205, USA.,Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD, 21205, USA
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Retinal Image Slip Must Pass the Threshold for Human Vestibulo-Ocular Reflex Adaptation. J Assoc Res Otolaryngol 2020; 21:277-285. [PMID: 32232608 DOI: 10.1007/s10162-020-00751-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 03/12/2020] [Indexed: 10/24/2022] Open
Abstract
We sought to determine whether repeated vestibulo-ocular reflex (VOR) adaptation training to increase the VOR gain (eye/head velocity) had a lasting effect in normal subjects and whether there was a retinal image slip tolerance threshold for VOR adaptation. We used the unilateral incremental VOR adaptation technique and horizontal active (self-generated, predictable) head impulses as the vestibular stimulus. Both active and passive (imposed, unpredictable) head impulse VOR gains were measured before and after unilateral incremental VOR adaptation training. The adapting side was pseudo-randomized for left or right. We tested ten normal subjects over one block (10 sessions over 12 days) of VOR adaptation training and testing, immediately followed by a second block (5 sessions over 19 days) of testing only without training. Our findings show robust short-term VOR adaptation of ~ 10 % immediately after each 15-min training session, but that the daily pre-adaptation gain was most different on days 1 and 2, and for subsequent training days before saturating to ~ 5 % greater than the pre-adaptation gain on day 1. This increase was partially retained for 19 days after regular training stopped. The data suggest that stable vision in normal subjects is maintained when there is < 5 % deviation in VOR gain from the original baseline, which corresponds to < 9°/s retinal image slip. Below this threshold, there is poor adaptive drive to return the gain to its original baseline value.
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Millar JL, Gimmon Y, Roberts D, Schubert MC. Improvement After Vestibular Rehabilitation Not Explained by Improved Passive VOR Gain. Front Neurol 2020; 11:79. [PMID: 32153490 PMCID: PMC7044341 DOI: 10.3389/fneur.2020.00079] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 01/22/2020] [Indexed: 01/13/2023] Open
Abstract
Gaze stability exercises are a critical component of vestibular rehabilitation for individuals with vestibular hypofunction and many studies reveal the rehabilitation improves functional performance. However, few studies have examined the vestibular physiologic mechanisms (semicircular canal; otolith) responsible for such recovery after patients with vestibular hypofunction complete gaze and gait stability exercises. The purpose of this study was to compare behavioral outcome measures (i.e., visual acuity during head rotation) with physiological measures (i.e., gain of the vestibulo-ocular reflex) of gaze stability following a progressive vestibular rehabilitation program in patients following unilateral vestibular deafferentation surgery (UVD). We recruited n = 43 patients (n = 18 female, mean 52 ± 13 years, range 23-80 years) after unilateral deafferentation from vestibular schwannoma; n = 38 (25 female, mean 46.9 ± 15.9 years, range 22-77 years) age-matched healthy controls for dynamic visual acuity testing, and another n = 28 (14 female, age 45 ± 17, range 20-77 years) healthy controls for video head impulse testing. Data presented is from n = 19 patients (14 female, mean 48.9 ± 14.7 years) with UVD who completed a baseline assessment ~6 weeks after surgery, 5 weeks of vestibular physical therapy and a final measurement. As a group, subjective and fall risk measures improved with a meaningful clinical relevance. Dynamic visual acuity (DVA) during active head rotation improved [mean ipsilesional 38.57% ± 26.32 (n = 15/19)]; mean contralesional 39.96% ± 22.62 (n = 12/19), though not uniformly. However, as a group passive yaw VOR gain (mean ipsilesional pre 0.44 ± 0.18 vs. post 0.44 ± 0.15; mean contralesional pre 0.81 ± 0.19 vs. post 0.85 ± 0.09) did not show any change (p ≥ 0.4) after rehabilitation. The velocity of the overt compensatory saccades during ipsilesional head impulses were reduced after rehabilitation; no other metric of oculomotor function changed (p ≥ 0.4). Preserved utricular function was correlated with improved yaw DVA and preserved saccular function was correlated with improved pitch DVA. Our results suggest that 5 weeks of vestibular rehabilitation using gaze and gait stability exercises improves both subjective and behavioral performance despite absent change in VOR gain in a majority of patients, and that residual otolith function appears correlated with such change.
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Affiliation(s)
- Jennifer L Millar
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Laboratory of Vestibular NeuroAdaptation, Department of Otolaryngology - Head and Neck Surgery, Baltimore, MD, United States
| | - Yoav Gimmon
- Laboratory of Vestibular NeuroAdaptation, Department of Otolaryngology - Head and Neck Surgery, Baltimore, MD, United States.,Department of Physical Therapy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Dale Roberts
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Michael C Schubert
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Laboratory of Vestibular NeuroAdaptation, Department of Otolaryngology - Head and Neck Surgery, Baltimore, MD, United States
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Inertial sensor-based measures of gait symmetry and repeatability in people with unilateral lower limb amputation. Clin Biomech (Bristol, Avon) 2020; 72:102-107. [PMID: 31862603 DOI: 10.1016/j.clinbiomech.2019.12.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 10/03/2019] [Accepted: 12/12/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND People with lower limb amputation often walk with asymmetrical gait patterns potentially leading to long-term health problems, ultimately affecting their quality of life. The ability to discreetly detect and quantify the movement of bilateral thighs and shanks using wearable sensor technology can provide additional insight into how a person walks with a lower limb prosthesis. This study investigated segmental symmetry and segmental repeatability of people with unilateral lower limb amputation, examining performance of the prosthetic and intact limbs. METHODS Gyroscope signals were recorded from four inertial measurement units worn on bilateral lower limb segments of subjects with unilateral lower limb amputation during the 10-m walk test. Raw angular velocity signals were processed using dynamic time warping and application of algorithms resulting in symmetry measures comparing similarity of prosthetic to intact limb strides, and repeatability measures comparing movement of one limb to its consecutive strides. FINDINGS Biomechanical differences in performance of the prosthetic and intact limb segments were detected with the segmental symmetry and segmental repeatability measures in 128 subjects. More asymmetries and less consistent movements of the lower limbs were exhibited by subjects with transfemoral amputation versus transtibial amputation (p < .004, Cohen's d = 0.65-1.1). INTERPRETATION Sensor-based measures of segmental symmetry and segmental repeatability were found to be reliable in detecting discreet differences in movement of the prosthetic versus intact lower limbs in amputee subjects. These measures provide a convenient tool for enhanced prosthetic gait analysis with the potential to focus rehabilitative and prosthetic interventions.
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Fornos AP, van de Berg R, Armand S, Cavuscens S, Ranieri M, Crétallaz C, Kingma H, Guyot JP, Guinand N. Cervical myogenic potentials and controlled postural responses elicited by a prototype vestibular implant. J Neurol 2019; 266:33-41. [PMID: 31396689 PMCID: PMC6722147 DOI: 10.1007/s00415-019-09491-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 07/28/2019] [Accepted: 07/29/2019] [Indexed: 02/04/2023]
Abstract
Gaze stabilization and postural control are two key functions of the vestibular system. In consequence, oscillopsia and chronic imbalance are the two main complaints of patients presenting with a severe bilateral vestibular function loss. The vestibular implant is emerging as a promising treatment for this group of patients whose quality of life is significantly impaired. Although the final aim of the vestibular implant should be to restore vestibular function as a whole, until now the research has focused mainly on the restoration of the vestibulo-ocular reflex to improve gaze stabilization. In this study, we aimed to explore whether the vestibulo-collic and vestibulo-spinal pathways could be activated and controlled with the electrical stimuli provided by our vestibular implant prototype. This was first explored and demonstrated with recordings of electrically elicited cervical vestibular evoked myogenic potentials (ecVEMPs). ecVEMPs with characteristics similar to the classical acoustically elicited cervical vestibular evoked myogenic potentials (cVEMPs) were successfully evoked in five out of the eight tested patients. Amplitudes of the electrically elicited N–P complex varied, ranging from 44 to 120 µV. Mean latencies of the N and P waves were of 9.71(± 1.17) ms and 17.24 ms (± 1.74), respectively. We also evaluated the possibility of generating controlled postural responses using a stepping test. Here, we showed that controlled and consistent whole-body postural responses can be effectively obtained with rapid changes in the “baseline” (constant rate and amplitude) electrical activity delivered by the vestibular implant in two out of the three tested subjects. Furthermore, obtained amplitude of body rotations was significantly correlated with the intensity of stimulation and direction of body rotations correlated with the side of the delivered stimulus (implanted side). Altogether, these data suggest that the vestibular implant could also be used to improve postural control in patients with bilateral vestibulopathy.
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Affiliation(s)
- Angelica Perez Fornos
- Division of Otorhinolaryngology Head and Neck Surgery, Geneva University Hospitals and University of Geneva, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland
| | - Raymond van de Berg
- Division of Balance Disorders, Department of ENT, Maastricht University Medical Centre, Maastricht, The Netherlands
- Faculty of Physics, Tomsk State University, Tomsk, Russia
| | - Stéphane Armand
- Willy Taillard Laboratory of Kinesiology, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Samuel Cavuscens
- Division of Otorhinolaryngology Head and Neck Surgery, Geneva University Hospitals and University of Geneva, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland
| | - Maurizio Ranieri
- Division of Otorhinolaryngology Head and Neck Surgery, Geneva University Hospitals and University of Geneva, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland
| | - Céline Crétallaz
- Division of Otorhinolaryngology Head and Neck Surgery, Geneva University Hospitals and University of Geneva, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland
| | - Herman Kingma
- Division of Balance Disorders, Department of ENT, Maastricht University Medical Centre, Maastricht, The Netherlands
- Faculty of Physics, Tomsk State University, Tomsk, Russia
| | - Jean-Philippe Guyot
- Division of Otorhinolaryngology Head and Neck Surgery, Geneva University Hospitals and University of Geneva, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland
| | - Nils Guinand
- Division of Otorhinolaryngology Head and Neck Surgery, Geneva University Hospitals and University of Geneva, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland.
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Gaze stabilisation exercises in vestibular rehabilitation: review of the evidence and recent clinical advances. J Neurol 2019; 266:11-18. [DOI: 10.1007/s00415-019-09459-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 07/04/2019] [Accepted: 07/06/2019] [Indexed: 10/26/2022]
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