Office Evaluation of Dizziness

Virtual Reality for Vestibular Rehabilitation: A Systematic Review

INTRODUCTION

Vertigo is a debilitating symptom, leading to increased healthcare utilization and lost patient productivity. Vestibular rehabilitation is used to manage the symptomatic manifestations of vestibular disease. However, vestibular rehabilitation is limited by accessibility and time commitment. Recently, virtual reality has been described as a vestibular rehabilitation tool that may circumvent these barriers to treatment. Despite this, the efficacy of virtual reality for vestibular rehabilitation remains unclear. This study aims to review and summarize the current literature on the effectiveness of virtual reality-based vestibular rehabilitation.

METHODS

A systematic review of the MEDLINE, EMBASE, and Alternative and Complementary Medicine databases was conducted for prospective studies describing virtual reality-based vestibular rehabilitation.

RESULTS

Our search identified 382 unique articles. Six randomized controlled trials and four other studies were ultimately included. Study sample sizes ranged from 13 to 70 participants and varied in diagnoses from any unilateral peripheral vertigo to specific pathologies. Different virtual reality interventions were used. Comparator groups ranged from supervised vestibular rehabilitation to independent Cawthorne-Cooksey exercises. Outcomes consisted of validated questionnaires, objective clinical tests, and measurements of balance or reflexes.

CONCLUSION

The studies reviewed in this study are preliminary evidence to suggest the benefit of virtual reality-based vestibular rehabilitation. However, these studies are limited by their inclusion criteria, heterogeneity, comparator design, and evidence-based clinical outcomes. Further research should address these limitations.

The treatment of dizziness by improving cervical lordosis: a Chiropractic BioPhysics® case report

[Purpose] To present the case of the relief of idiopathic dizziness and the reduction of neck pains and headache by the improvement in cervical alignment using Chiropractic BioPhysics^® technique. [Participant and Methods] A 57 year old female presented with 30 years of chronic dizziness, neck pains and headache. Multiple testing ruled out known causes of vertigo. The patient was diagnosed with idiopathic dizziness. The patient scored 56 points on the dizziness handicap inventory. The patient showed a cervical hypolordosis of −13.7° and anterior head translation of 27 mm. The patient underwent a multimodal treatment of spinal manipulation, cervical extension traction, neck exercises as well as initial electrical stimulation. Traction procedures were slowly progressive due to the severity of the dizziness symptoms. [Results] Over a period of 12-months and 115 treatments there was a 20° increase in cervical lordosis. The patient reported significant reduction in neck pains, headache and dizziness frequency and severity. The patient had a 44-point drop on the dizziness handicap inventory; dizziness symptoms were reported to be very rare. A 1.5 year follow-up showed stability of the symptom relief and a negligible score on the dizziness handicap inventory. [Conclusion] Cervical hypolordosis may be an under-diagnosed cause of idiopathic dizziness in some patients.

Dizziness and the Otolaryngology Point of View

Dizziness can be due to pathology from multiple physiologic systems, the most common being vestibular. Dizziness may be categorized as vertigo, disequilibrium, lightheadedness, or oscillopsia. Vertigo is an illusion of motion often caused by asymmetrical vestibular input to the brainstem. To evaluate vertigo, it is essential to include the symptom's quality, timing, frequency, trigger, influence from positional changes, and other associations from the history. Oculomotor, otologic, balance testing, positional testing, and nystagmus testing are equally important components of the examination. Two of the most common diagnoses are readily treated with canalith repositioning maneuvers and vestibular rehabilitation exercises.

Alleviation of posttraumatic dizziness by restoration of the cervical lordosis: a CBP® case study with a one year follow-up

[Purpose] To present the successful treatment of posttraumatic dizziness and neck pains that were initiated in a patient following a whiplash event. [Subject and Methods] A 46 year old male suffered a whiplash event that initiated neck pain and dizziness symptoms. The patient had many positive orthopedic findings and demonstrated a forward head posture and cervical hypolordosis. The patient was treated by Chiropractic BioPhysics^® technique including cervical extension traction, extension exercises and spinal manipulative therapy initially three times a week for 16-weeks, and once a month thereafter. [Results] The patient had a resolution of daily dizziness and neck pain with a concomitant reduction of forward head translation and increase in cervical lordosis. The postural measures were further improved after one year of mostly home-care. [Conclusion] The cervical spine alignment may be an important biomarker for those with dizziness. The correction of cervical lordosis may be an essential requirement for superior clinical outcomes for those with posttraumatic dizziness.

Sleep apnea and risk of vertigo: A nationwide population-based cohort study

OBJECTIVE

To investigate the risk of vertigo in patients with sleep apnea.

STUDY DESIGN

Retrospective cohort study.

METHODS

This study used data from the National Health Insurance Research Database of Taiwan, a population-based database. A total of 5,025 patients who were newly diagnosed with sleep apnea between January 1, 1997, and December 31, 2012, were identified from the Longitudinal Health Insurance Database 2000, a nationally representative database of 1 million randomly selected patients. Moreover, 20,100 patients without sleep apnea were matched at a 1:4 ratio by age, sex, socioeconomic status, and urbanization level. Patients were followed up until death or the end of the study period (December 31, 2013). The primary outcome was the occurrence of vertigo.

RESULTS

Patients with sleep apnea had a significantly higher cumulative incidence of vertigo than those without sleep apnea (P < 0.001). The adjusted Cox proportional hazard model showed that sleep apnea was significantly associated with a higher incidence of vertigo (hazard ratio, 1.71; 95% confidence interval [CI], 1.48-1.97; P < 0.001). Sensitivity and subgroup analyses were performed to adjust for confounders, including head trauma, diabetes mellitus, hypertension, stroke, and obesity. Sleep apnea was demonstrated to be an independent risk factor for vertigo.

CONCLUSION

This is the first nationwide population-based cohort study to investigate the association between sleep apnea and vertigo. The findings strongly support that sleep apnea is an independent risk factor for vertigo. Based on the study results, physicians should be aware of potential vertigo occurrence following sleep apnea.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:763-768, 2017.

Development of the Persian version of the Vertigo Symptom Scale: Validity and reliability

Background:

Vertigo Symptom Scale (VSS) is a proper instrument for assessing the patient status, clarifying the symptoms, and examining the relative impact of the vertigo and anxiety on reported handicap. Our aim is the translation and cross-cultural adaptation of the VSS into Persian language (VSS-P) and investigating its validity and reliability in patients with peripheral vestibular disorders.

Materials and Methods:

VSS was translated into Persian. Cross-cultural adaptation was carried out on 101 patients with peripheral vestibular disorders and 34 participants with no history of vertigo. They completed the Persian versions of VSS, dizziness handicap inventory (DHI), and Beck anxiety inventory (BAI). Internal, discriminant, and convergent validities, internal consistency, and test-retest reliability were determined.

Results:

The VSS-P showed good face validity. Internal validity was confirmed and demonstrated the presence of two vertigo (VSS-VER) and autonomic-anxiety (VSS-AA) subscales. Significant difference between the median scores for patient and healthy groups was reported in discriminate validity (P <0.001). Convergent validity revealed high correlation between both BAI and DHI with VSS-P. There was a high test-retest reliability; with intraclass correlation coefficient of 0.89, 0.86, and 0.91 for VSS-AA, VER, and VSS-P, respectively. The internal consistency was good with Cronbach's alpha 0.90 for VER subscale, 0.86 for VSS-AA subscale, and 0.92 for the overall VSS-P.

Conclusion:

The Persian version of the VSS could be used clinically as a valid and reliable tool. Thus, it is a key instrument to focus on the symptoms associated with dizziness.