Vestibular rehabilitation: advances in peripheral and central vestibular disorders

Can virtual reality replace conventional vestibular rehabilitation tools in multisensory balance exercises for vestibular disorders? A non-inferiority study

BACKGROUND

Vestibular rehabilitation uses multisensory balance exercises to optimize the integration and weighting of sensory inputs, including visual, vestibular, and proprioceptive signals. Head-mounted displays (HMDs) have emerged as a promising tool for these exercises, offering the ability to generate unreliable or conflicting visual stimuli, thereby enhancing vestibular and proprioceptive input weighting. This study aimed to determine whether a virtual reality (VR)-based rehabilitation program using HMDs is non-inferior to a conventional program employing an optokinetic stimulator and slaved environmental surround for multisensory balance exercises.

METHODS

Seventy-six participants with vestibular disorders were randomized into either the VR-based or conventional rehabilitation program for three weeks in a randomized controlled non-inferiority trial with blinded assessment. The non-inferiority margin was set at 5% of the control group's score. Both programs were multidisciplinary and included multisensory balance exercises designed to challenge sensory re-weighting. The primary outcome was the stability score, measured with eyes closed on an unstable platform using posturography, to evaluate postural control. Secondary outcomes included other variables from posturography, perceived disability assessed using the Dizziness Handicap Inventory (DHI), and tolerance to the multisensory balance exercises with unreliable or conflicting visual stimuli, assessed using the Simulator Sickness Questionnaire (SSQ).

RESULTS

The results showed that multisensory balance exercises with unreliable or conflicting visual stimuli were well tolerated in both groups, as indicated by low SSQ scores. Both rehabilitation programs led to significant pre-post improvements in postural control and perceived disability. However, the VR program did not meet the non-inferiority criterion compared to the conventional program. The primary outcome analysis revealed a difference of - 13.36 (95% CI - 29.84 to 3.11), with the lower bound of the confidence interval (- 29.84) falling below the non-inferiority margin of -2.01. Similarly, secondary outcomes, including other variables from posturography and the DHI, also failed to meet the non-inferiority criterion.

CONCLUSION

Although VR rehabilitation shows innovative potential for multisensory balance training, its effectiveness was not demonstrated to be non-inferior to the conventional approach. Therefore, we recommend considering it as a complementary tool rather than a primary device for vestibular rehabilitation. Further research is needed to enhance the efficacy of VR-based rehabilitation for vestibular disorders while maintaining its tolerance. Trial registration NCT03838562.

The effect of using virtual reality on balance in people with persistent postural-perceptual dizziness: A randomized controlled trial

BackgroundPersistent postural-perceptual dizziness (PPPD) represents a relatively new vestibular diagnosis that has garnered attention within the medical community. Consequently, there is a pressing demand for efficacious management strategies.ObjectiveTo assess the comparative effectiveness of virtual reality (VR) versus vestibular rehabilitation therapy (VRT) in improving PPPD symptoms.MethodsWe randomly assigned a cohort of 42 individuals conclusively diagnosed with PPPD to two distinct groups. The experimental group included 21 participants who received a combination of VR and optokinetic stimulation in addition to VRT, while the control group, also made up of 21 individuals, only received optokinetic stimulation in conjunction with VRT. We administered the intervention sessions twice weekly over a span of 6 weeks, resulting in a total of 10-intervention sessions. Additionally, baseline, post-intervention, and follow-up assessments were conducted.ResultsOur analysis revealed that participants in both groups significantly improved with no significant differences between the groups. Individuals undergoing VR interventions demonstrated marked improvements across all of the assessed parameters including the primary outcome measure that were reduced from 41.55 (11.87) to 23.40 (14.17) (p<0.001). Moreover, participants in the control group also displayed notable enhancements in select outcome measures post-intervention including the primary outcome measure that were reduced from 43.60 (12.75) to 26.10 (16.25) (p = 0.001). All participants in both groups maintained significant improvement in the severity of PPPD after 1 year of the. However, the study cannot determine if this change was definitely from the treatment because there was no non-treatment control group.ConclusionsThe study found that the addition of VR to a well-structured VRT did not significantly improve clinical outcomes, indicating a need for further investigation into more effective approaches to yield meaningful clinical benefits. Moreover, adding a control group with no intervention would help revealing a real effect of the intervention.

World-wide survey on the treatment of peripheral vestibular disorders

Objective

The aim of this world-wide survey was to evaluate the currently applied treatment options for the six most frequent peripheral vestibular disorders: benign paroxysmal positional vertigo (BPPV), acute unilateral vestibulopathy (AUVP)/vestibular neuritis, Menière's disease (MD), bilateral vestibulopathy (BVP), vestibular paroxysmia (VP) and superior canal dehiscence syndrome (SCDS).

Background

For the therapy of vestibular disorders, there are four treatment options: vestibular physical therapy (canalith repositioning maneuvers or balance training), pharmacotherapy, surgery, and psychotherapy. Since there are very few state-of-the-art RCTs, the treatment of vestibular disorders is so far not standardized and various methods are applied with heterogeneous efficacy.

Design/methods

A web-based standardized survey questionnaire on the treatment of the six most frequent peripheral vestibular disorders was used to collect data.

Results

234 replies from five continents, 47 countries, 162 cities and 188 centers were received: (% from all 234 replies; multiple answers possible): BPPV: posterior canal BPPV: 71% Epley, 40% Semont, and 12% others. Horizontal canal BPPV canalolithiasis: 58% Lempert (roll-over) maneuver, 33% Gufoni, 7% prolonged rest, and 9% others. Horizontal canal BPPV cupulolithiasis: 35% Gufoni, 27% Lempert (roll-over) maneuver, 9% Zuma, and 7% head shaking: AUVP: 79% pharmacotherapy, namely 47% glucocorticoids, 39% antiemetics, and 24% betahistine; 67% vestibular physical therapy. MD: 85% pharmacotherapy, namely 65% betahistine, 21% diuretics, 20% steroids, 16% antiemetics, 14% gentamicin; 37% surgery. VP: 65% pharmacotherapy, namely 57% anticonvulsants; 7% surgery. BVP: 77% vestibular physical therapy. SCDS: 50% surgery, namely 38.8% canal plugging, 23.3% capping and 15.5% resurfacing.

Conclusion

In this world-wide survey with 234 replies from 188 centers, widely heterogeneous applied treatment options were reported for the six most frequent peripheral vestibular disorders. This study shows in particular that certain drugs are often used despite low or very low evidence. Namely in AUVP, MD and VP well-designed controlled trials with clinically meaningful endpoints are needed.

Evaluation of instability in patients with chronic vestibular syndrome using dynamic stability indicators

Gait abnormalities are common in patients with chronic vestibular syndrome (CVS), and stability analysis and gait feature recognition in CVS patients have clinical significance for diagnosing CVS. This study explored two-dimensional dynamic stability indicators for evaluating gait instability in patients with CVS. The Center of Mass acceleration (COMa) peak of CVS patients was significantly faster than that of the control group (p < 0.05), closer to the back of the body, and slower at the Toe-off (TO) moment, which enlarged the Center of Mass position-velocity combination proportion within the Region of Velocity Stability (ROSv). The sensitivity, specificity, and accuracy of the Center of Mass velocity (COMv) or COMa peaks were 75.0%, 93.7%, and 90.2% for CVS patients and control groups, respectively. The two-dimensional ROSv parameters improved sensitivity, specificity, and accuracy in judging gait instability in patients over traditional dynamic stability parameters. Dynamic stability parameters quantitatively described the differences in dynamic stability during walking between patients with different degrees of CVS and those in the control group. As CVS impairment increases, the patient's dynamic stability decreases. This study provides a reference for the quantitative evaluation of gait stability in patients with CVS.

Knowledge, Barriers, and Future Directions of Vestibular Rehabilitation Practice in Neurorehabilitation: An Italian Survey

Background/Objectives: Vestibular rehabilitation, an evidence-based physical therapy approach, plays a crucial role in managing and recovering from gaze and balance disorders, including those of central origin. This study, targeted at the community of Italian healthcare practitioners, is vital in understanding the application of vestibular rehabilitation in neurological disorders and in identifying knowledge gaps, barriers, and future directions. Methods: This is a cross-sectional study directed at healthcare professionals involved in neurorehabilitation in Italy. The survey consisted of 29 items grouped in 4 sections, which was estimated to take approximately 10 min to complete. The questions covered socio-demographic information, professional information, clinical practice, and future perspectives on vestibular rehabilitation. Results: Out of the 435 respondents, 290 completed the survey. Most of the respondents reported either no (32.87%) or little (42.91%) experience in vestibular rehabilitation. However, most participants (72.98%) recognized the importance of vestibular rehabilitation in treating neurological disorders. The most common condition treated was stroke (46.39%), while balance training (52.69%) and visual input exercises (26.35%) were the two most frequently used strategies. The main barriers to implementing vestibular rehabilitation in clinical practice were equipment cost and insufficient skills. Conclusions: Vestibular physical therapy is a promising complementary approach in neurorehabilitation. However, the study reveals a perceived lack of basic training in vestibular assessment and therapy. This suggests that more efforts are needed to bridge this knowledge gap and make necessary equipment more accessible.

Vestibular Infant Screening-Rehabilitation (VIS-REHAB): protocol for a randomised controlled trial on Vestibular Rehabilitation Therapy (VRT) in vestibular-impaired children

INTRODUCTION

A vestibular deficit can have a substantial impact on the overall development of children. Therefore, it is of utmost importance that vestibular-impaired problems are treated early and effectively through Vestibular Rehabilitation Therapy (VRT). Although VRT is sufficiently proven and standardised in adults, there remains a lack of research examining its efficacy in children. To assess the effectiveness of VRT in vestibular-impaired children, the Vestibular Infant Screening-Rehabilitation (VIS-REHAB) protocol was developed with the following objectives: (1) to investigate the short-term effect of a combined postural control and gaze stabilisation protocol, compared with receiving no therapy and (2) to investigate the most important factors that may influence the effect of and outcome after application of the VIS-REHAB protocol in a group of vestibular-impaired children. This study aims to address lingering questions in the existing literature in a standardised manner, with the ultimate objective to establish evidence-based rehabilitation guidelines.

METHODS AND ANALYSIS

The VIS-REHAB study is a two-parallel group, superiority, randomised controlled crossover trial with 1:1 allocation ratio. The study includes patients aged 3-17 years old with identified peripheral vestibular dysfunction. Primary and secondary outcome measures assess gaze stability, postural stability, motor performance and quality of life. The effectiveness of the VIS-REHAB protocol will be evaluated through parallel group and crossover analyses using analysis of covariance (ANCOVA). Additionally, prespecified subgroup analyses will be conducted to assess influencing factors that may impact the outcome and effect of VIS-REHAB.

ETHICS AND DISSEMINATION

At the start of the VIS-REHAB study, an amendment will be submitted to the ethics committee of Ghent University Hospital for the following applications: (EC2018/0435), (EC2018/0959), (EC2015/1441) and (EC2015/1442). The trial is registered at Clinical Trials (clinicaltrials.gov) with registry name VIS-REHAB and identifier NCT06177132. All research findings will be disseminated in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT06177132.

An overview of the current and emerging treatment options for vestibular migraine

INTRODUCTION

Vestibular migraine is a relatively common syndrome characterized by the occurrence of vertigo and other vestibular symptoms, frequently -but not always- accompanied by migraine symptoms, such as headache, photophobia, and phonophobia.

AREAS COVERED

The authors review the acute or abortive treatment during an attack and prophylactic treatment of vestibular migraines, including pharmacological and non-pharmacological options.

EXPERT OPINION

Since its recognition as an independent clinical entity is recent, studies concerning its different treatment alternatives are still scarce, and the level of evidence of published studies is generally low. For acute treatment, although available data are conflicting, triptans are usually tried first. Neurostimulating devices can also be considered for acute treatment of vestibular migraine. Regarding the preventive treatment of vestibular migraine, based on the results of two randomized clinical trials and its pharmacological properties, flunarizine should be considered as the first treatment option. Second-line preventive treatments encompass propranolol, topiramate, venlafaxine, and valproic acid. Among non-pharmacological options, vestibular rehabilitation seems to be a sound prophylactic treatment option.

The Unveiled Potential of Telehealth Practice in Vestibular Rehabilitation: A Comparative Randomized Study

Background and Objectives: Unilateral vestibular hypofunction (UVH) in cases of insufficient central nervous system compensation leads to chronic dizziness. A customized vestibular rehabilitation (VR) program is more beneficial than a generic set of exercises for patients with chronic UVH. The purpose of the present study is to compare a customized remotely supervised VR program with a customized unsupervised VR program in chronic UVH patients. Methods: Participants were randomly allocated into two groups (Group A and Group B) and received an individualized 6-week home-based VR program that included adaptation and habituation exercises, balance and gait training. All individuals' VR program implementation was evaluated weekly, allowing for exercise modifications. Moreover, Group A received additional remote supervision via phone communication (twice per week). The effectiveness of each VR program was evaluated using the scores of the Mini-BESTest, the Functional Gait Assessment (FGA), and the Dizziness Handicap Inventory (DHI). Results: At the 6-week assessment, participants in Group A had significantly better scores in objective and subjective evaluated parameters than those in Group B (p < 0.001). Group A also showed better compliance with the VR program. On the contrary, participants' conformity in their individualized exercises was not affected by gender, duration of symptoms, or BMI (p > 0.05). Conclusions: Our clinical study highlights the advantages of using telephone communication, with a structured design and implementation, to assist individuals in successfully following a VR protocol.

Limits of Stability during a Therapeutic Exercise Intervention for Instability: Progression, Responders' and Non-Responders' Analysis and Predictors

Background/Objectives: Instability is one of the main symptoms in patients with vestibular and neurological disorders and therapeutic exercise interventions are increasing in popularity as a form of treatment. Additionally, the limits of stability measurement are known to be a good tool for balance evaluation and monitoring of these interventions. The aim of this work is to better understand how a specific protocol provokes changes on this variable and to study the characteristics of those who do and do not respond to it. Methods: A retrospective study was developed with the data of 40 patients treated in the Otorhinolaryngology department in Clínica Universidad de Navarra (Madrid, Spain). They had an initial reduction in limits of stability, completed the proposed protocol with home-based and hospital-based exercises and with frequent limits of stability remeasurement, and were assisted to a follow-up retest after 1-2 months. Results: A progressive improvement in limits of stability measure was developed through the intervention and was partially retained at follow-up visit. Several differences were found between those patients who improved with the treatment (responders) and those who did not improve (non-responders). More specifically an initial measure of the limits of stability was able to differentiate those groups with a cut-off data of 56 cm2. Conclusions: The proposed protocol was able to induce motor learning in patients included in this study with good retention after 1-2 months. Furthermore, there is some variability in how patients respond to the treatment. Age and diagnosis should be considered and an interesting cut-off data for clinal decision making was found.

Application of clinical indicators in evaluating vestibular compensation efficacy in benign recurrent vestibular vertigo patients with short-term personalized vestibular rehabilitation

BACKGROUND

Short-term personalized vestibular rehabilitation (ST-PVR) can establish stable vestibular compensation. However, there is a lack of a clear definition for clinical indicators that can dynamically reflect the progress of vestibular rehabilitation (VR).

OBJECTIVE

To explore the clinical indicators suitable for evaluating the effectiveness of ST-PVR in treating benign recurrent vertigo (BRV).

METHODS

In total, 50 patients diagnosed with BRV were enrolled. All patients received the ST-PVR treatment program. At 2 and 4 weeks after rehabilitation, subjective scales, including the visual analogue scale (VAS), dizziness handicap inventory scale (DHI), activities-specific balance confidence scale (ABC) and generalized anxiety disorder (GAD-7) were assessed. Objective vestibular function tests were performed. VR grading was determined.

RESULTS

At 2 weeks after rehabilitation, significant enhancements were observed in VAS, DHI, ABC, GAD-7, UW, vHIT results, and VR grading scores (p < 0.05). The sensory organization test (SOT) results demonstrated statistically significant improvements at 2 weeks and 4 weeks after rehabilitation (p < 0.05).

CONCLUSION AND SIGNIFICANCE

Both subjective scales and partial examination results in objective assessment can serve as indicators to dynamically monitor the compensatory process of vestibular function in patients with BRV. The VR efficacy grading score, which incorporates the above indicators, allows for quantification of the changes that occur during the vestibular rehabilitation process.

Effect of vestibular rehabilitation games in patients with persistent postural perceptual dizziness and its relation to anxiety and depression: prospective study

PURPOSE

To evaluate the efficacy of vestibular rehabilitation therapy (VRT) for management of patients with persistent postural perceptual dizziness (PPPD) utilizing subjective and objectives outcome measures and to study the effect of degree of both anxiety and depression in patients on the response of vestibular rehabilitation therapy.

METHODS

Thirty-three PPPD patients participated in this study. Selection of patients was based on the diagnostic criteria for PPPD stated by Barany society in the International Classification of Vestibular Disorders (2017). Every patient was subjected to history taking, anxiety and depression assessment, Arabic version of Dizziness Handicap Inventory (DHI), and sensory organization test (SOT). All patients received vestibular rehabilitations therapy. Assessment of VRT outcome was conducted after 6 weeks of VRT.

RESULTS

The mean patients' age was 40.9 ± 16.3 years, and nearly equal gender distribution. Vestibular migraine was the most precipitating condition (24.2%) in patients with PPPD. (39.4%) of patients had abnormal scores of anxiety and depression tests, all patients had from moderate to severe degrees of handicap caused by dizziness as measured by DHI, most of patients had abnormal findings in all conditions of SOT. After vestibular rehabilitation therapy, DHI and SOT scores showed significant improvement after VRT. More improvement was found among the group with no anxiety and depression.

CONCLUSION

VRT were effective in improving balance abnormalities in patients with PPPD evidenced by subjectively by DHI scores and objectively by SOT results. PPPD patients with concomitant psychiatric disorders; anxiety and depression experienced the least degree of improvement.

Vestibular dysfunction in Parkinson's disease: a neglected topic

Dizziness and postural instability are frequently observed symptoms in patient with Parkinson's disease (PD), potentially linked to vestibular dysfunction. Despite their significant impact on quality of life, these symptoms are often overlooked and undertreated in clinical practice. This review aims to summarize symptoms associated with vestibular dysfunction in patients with PD and discusses vestibular-targeted therapies for managing non-specific dizziness and related symptoms. We conducted searches in PubMed and Web of Science using keywords related to vestibular dysfunction, Parkinson's disease, dizziness, and postural instability, alongside the reference lists of relevant articles. The available evidence suggests the prevalence of vestibular dysfunction-related symptoms in patients with PD and supports the idea that vestibular-targeted therapies may be effective in improving PD symptoms.

A diagnostic framework to identify vestibular involvement in multi-sensory neurological disease

BACKGROUND AND PURPOSE

Identifying vestibular causes of dizziness and unsteadiness in multi-sensory neurological disease can be challenging, with problems typically attributed to central or peripheral nerve involvement. Acknowledging vestibular dysfunction as part of the presentation provides an opportunity to access targeted vestibular rehabilitation, for which extensive evidence exists. A diagnostic framework was developed and validated to detect vestibular dysfunction, benign paroxysmal positional vertigo or vestibular migraine. The specificity and sensitivity of the diagnostic framework was tested in patients with primary mitochondrial disease.

METHODS

Adults with a confirmed diagnosis of primary mitochondrial disease were consented, between September 2020 and February 2022. Participants with and without dizziness or unsteadiness underwent remote physiotherapy assessment and had in-person detailed neuro-otological assessment. The six framework question responses were compared against objective neuro-otological assessment or medical notes. The output was binary, with sensitivity and specificity calculated.

RESULTS

Seventy-four adults completed the study: age range 20-81 years (mean 48 years, ±SD 15.05 years); ratio 2:1 female to male. The framework identified a vestibular diagnosis in 35 participants, with seven having two diagnoses. The framework was able to identify vestibular diagnoses in adults with primary mitochondrial disease, with a moderate (40-59) to very high (90-100) sensitivity and positive predictive value, and moderate to high (60-74) to very high (90-100) specificity and negative predictive value.

CONCLUSIONS

Overall, the clinical framework identified common vestibular diagnoses with a moderate to very high specificity and sensitivity. This presents an opportunity for patients to access effective treatment in a timely manner, to reduce falls and improve quality of life.

Post-stroke dizziness, depression and anxiety

OBJECTIVE

Vestibular and psychiatric disorders are very closely related. Previous research shows that the discomfort and dysfunction caused by dizziness in patients can affect psychological processes, leading to anxiety and depression, and the irritation of anxiety and depression can aggravate the discomfort of dizziness. But the causal relationship between dizziness in the recovery period of stroke and Post-stroke depression (PSD) / Post-stroke anxiety (PSA) is not clear. Identifying the causal relationship between them can enable us to conduct more targeted treatments.

METHODS

We review the epidemiology and relationship of dizziness, anxiety, and depression, along with the related neuroanatomical basis. We also review the pathophysiology of dizziness after stroke, vestibular function of patients experiencing dizziness, and the causes and mechanisms of PSD and PSA. We attempt to explore the possible relationship between post-stroke dizziness and PSD and PSA.

CONCLUSION

The treatment approach for post-stroke dizziness depends on its underlying cause. If the dizziness is a result of PSD and PSA, addressing these psychological factors may alleviate the dizziness. This can be achieved through targeted treatments for PSD and PSA, such as psychotherapy, antidepressants, or anxiolytics, which could indirectly improve dizziness symptoms. Conversely, if PSA and PSD are secondary to vestibular dysfunction caused by stroke, a thorough vestibular function assessment is crucial. Identifying the extent of vestibular impairment allows for tailored interventions. These could include vestibular rehabilitation therapy and medication aimed at vestibular restoration. By improving vestibular function, secondary symptoms like anxiety and depression may also be mitigated.

Vestibular compensation: Neural mechanisms and clinical implications for the treatment of vertigo

After unilateral peripheral vestibular lesions, the neural activity of neurons in the ipsi-lesional medial vestibular nucleus (ipsi-MVe) are markedly decreased, resulting in static and dynamic asymmetries of the vestibulo-ocular and vestibulo-spinal reflexes. Consequently, static vestibular symptoms such as spontaneous nystagmus and postural deviation and dynamic vestibular symptoms such as oscillopsia and swaying gait are induced. However, these behavioral asymmetries gradually recover after the lesion. Progressive balance restoration is termed vestibular compensation, which is divided into two phases: static and dynamic. Static vestibular compensation is further divided into initial and late processes. In the initial process of static vestibular compensation after unilateral labyrinthectomy (UL) in rats, plastic changes in the cerebello-vestibular and vestibular commissural inhibitory pathways suppress neurons in the contra-lesional MVe (contra-MVe), resulting in the restoration of symmetrical resting activity of MVe neurons on both sides at low levels. The declining frequency of spontaneous nystagmus after UL is an index of the initial process, and short-term administration of diazepam, a GABAA receptor agonist, has been shown to accelerate the initial process in rats. Accordingly, short-term administration of diazepam is recommended for the treatment of acute vertigo in patients with unilateral vestibular dysfunction. In the late process of static vestibular compensation after UL in rats, the resting activity of ipsi-MVe neurons gradually recovers due to changes in cell membrane properties, resulting in the reinforcement of balanced intervestibular nuclear activities to nearly normal levels without the suppression of contra-MVe neurons. The declining number of MK801-induced Fos-positive neurons in contra-MVe after UL is an index of the late process, and long-term administration of betahistine, a histamine H3 receptor antagonist, has been shown to accelerate the late process in rats. Accordingly, long-term administration of betahistine is recommended for the treatment of subacute vertigo in patients who were not compensated for unilateral vestibular dysfunction. In the process of dynamic vestibular compensation after UL, the sensitivity of ipsi-MVe neurons to head velocity and acceleration is restored due to synaptic changes such as long-term potentiation and sprouting of commissures, resulting in the restoration of the dynamic vestibulo-ocular and vestibulo-spinal reflexes. To facilitate dynamic vestibular compensation, early ambulation and subsequent vestibular rehabilitation exercise are recommended for the treatment of chronic vertigo in patients with uncompensated unilateral vestibular dysfunction. Although vestibular compensation after bilateral vestibular loss is not expected, vestibular rehabilitation with a sensory-substitution strategy can improve imbalance in patients with bilateral vestibular lesions.

[The six most frequent peripheral vestibular syndromes]

Three forms of peripheral vestibular disorders, each with its typical symptoms and clinical signs, can be differentiated functionally, anatomically and pathophysiologically: 1. inadequate unilateral paroxysmal stimulation or rarely inhibition of the peripheral vestibular system, e. g., BPPV, Menière's disease, vestibular paroxysmia or syndrome of the third mobile windows; 2. acute unilateral vestibulopathy leading to an acute vestibular tone imbalance manifesting as an acute peripheral vestibular syndrome; and 3. loss or impairment of function of the vestibular nerve and/or labyrinth: bilateral vestibulopathy. For all of these diseases, current diagnostic criteria by the Bárány-Society are available with a high clinical and scientific impact, also for clinical trials. The treatment depends on the underlying disease. It basically consists of 5 principles: 1. Explaining the symptoms and signs, pathophysiology, aetiology and treatment options to the patient; this is important for compliance, adherence and persistence. 2. Physical therapy: A) For BPPV specific liberatory maneuvers, depending on canal involved. Posterior canal: The new SémontPLUS maneuver is superior to the regular Sémont and Epley maneuvers; horizontal canal: the modified roll-maneuver; anterior canal the modified Yacovino-maneuver; 3. Symptomatic or causative drug therapy. There is still a deficit of placebo-controlled clinical trials so that the level of evidence for pharmacotherapy is most often low. 4. Surgery, mainly for the syndrome of the third mobile windows. 5. Psychotherapeutic measures for secondary functional dizziness.

Efficacy of vestibular rehabilitation and its facilitating and hindering factors from real-world clinical data

Background and purpose

Customized vestibular rehabilitation improved dizziness and imbalance in several randomized controlled trials. In the present study, we determined the efficacy of customized vestibular rehabilitation using real-world observational data.

Methods

In this retrospective observational study, we recruited 64 patients (median age = 60, interquartile range = 48-66.3) who completed the customized vestibular rehabilitation from January to December 2022. The outcomes of rehabilitation were evaluated using the dizziness handicap inventory (DHI) or vestibular disorders activities of daily living scale (VADL). The factors associated with outcomes were assessed with a generalized linear model, of which covariates included patients' age, sex, duration of illness, type of vestibular disorders, initial DHI and VADL scores, exercise compliance, and initial hospital anxiety and depression scale (HADS) scores.

Results

After the median of 6 (4-6) weeks of rehabilitation, DHI and VADL scores significantly improved in patients with either peripheral or central vestibular disorders (Wilcoxon signed-rank test, p < 0.05). The initial DHI and VADL scores showed a positive while the sum of HADS scores showed a negative correlation with the outcome. In contrast, the age, sex, duration of illness, types of vestibular disorders, and exercise compliance did not affect the outcome.

Discussion and conclusion

Customized vestibular rehabilitation is effective for central as well as peripheral disorders, especially when the symptoms are severe and the psychological distress is mild.

Effects of Transcranial Direct Current Stimulation on Clinical Features of Dizziness and Cortical Activation in a Patient with Vestibular Migraine

BACKGROUND

Vestibular migraine (VM) is common migraine that occurs in patients with dizziness. Vestibular rehabilitation for managing VM generally remains unclear. Recently, it has been reported that transcranial direct current stimulation (tDCS) has positive effects in alleviating dizziness. This study investigated the effects of tDCS on dizziness and cortical activation in a patient with VM.

METHODS

We recruited a male patient aged 31 years with no dizziness. The patient watched a video to induce dizziness using a virtual reality device. The study applied the intervention using tDCS for 4 weeks and measured 4 assessments: functional near-infrared spectroscopy (fNIRS), quantitative electroencephalography (qEEG), dizziness handicap inventory, and visual vertigo analog scale.

RESULTS

We showed the activation in the middle temporal gyrus and inferior temporal gyrus (ITG) of the left hemisphere and in the superior temporal gyrus and ITG of the right hemisphere in the pre-intervention. After the intervention, the activation of these areas decreased. In the results of qEEG, excessive activation of C3, P3, and T5 in the left hemisphere and C4 in the right hemisphere before intervention disappeared after the intervention.

CONCLUSIONS

This study indicated that tDCS-based intervention could be considered a viable approach to treating patients with vestibular dysfunction and dizziness caused by VM.

Effect of health education based on information-motivation-behavioral skills model on patients with unilateral vestibular dysfunction

BACKGROUND

Vestibular dysfunction (VH) is a common concomitant symptom of late peripheral vestibular lesions, which can be trauma, poisoning, infection, heredity, and neurodegeneration, but about 50% of the causes are unknown. The study uses the information-motivation-behavioral skills (IMB) model for health education, effectively improve the quality of life, increase their self-confidence, reduce anxiety and depression, and effectively improve the psychological state of patients.

AIM

To explore the effect of health education based on the IMB model on the degree of vertigo, disability, anxiety and depression in patients with unilateral vestibular hypofunction.

METHODS

The clinical data of 80 patients with unilateral vestibular hypofunction from January 2019 to December 2021 were selected as the retrospective research objects, and they were divided into the control group and the observation group with 40 cases in each group according to different nursing methods. Among them, the control group was given routine nursing health education and guidance, and the observation group was given health education and guidance based on the IMB model. The changes in self-efficacy, anxiety and depression, and quality of life of patients with unilateral VH were compared between the two groups.

RESULTS

There was no significant difference in General Self-Efficacy Scale (GSES) scale scores between the two groups of patients before nursing (P > 0.05), which was comparable; after nursing, the GSES scale scores of the two groups were higher than those before nursing. The nursing group was higher than the control group, and the difference was statistically significant (P < 0.05). There was no significant difference in the scores of Hospital Anxiety and Depression Scale (HADS) and anxiety and depression subscales between the two groups before nursing (P > 0.05). After nursing, the HADS score, anxiety, and depression subscale scores of the two groups of patients were lower than those before nursing, and the nursing group was lower than the control group, and the difference was statistically significant (P < 0.05). After nursing, the Dizziness Handicap Inventory (DHI) scale and DHI-P, DHI-E and DHI-F scores in the two groups were decreased, and the scores in the nursing group were lower than those in the control group, and the difference was statistically significant (P < 0.05).

CONCLUSION

Health education based on the IMB model can effectively improve patients' quality of life, increase self-efficacy of patients with unilateral vestibular hypofunction, enhance patients' confidence, enable patients to resume normal work and life as soon as possible, reduce patients' anxiety and depression, and effectively improve patients' psychological status.

Cross-cultural adaptation and construct validity of the Chinese Version of Visual Vertigo Analogue Scale by using structural equation modeling

BACKGROUND

Visual vertigo (VV) is a disease characterized by various visual signal-induced discomforts, including dizziness, unsteady balance, activity avoiding, and so forth. Distinguishing it from other kinds of dizziness is important because it needs the combination of visual training and vestibular rehabilitation together. However, there is no appropriate tool to diagnose VV in China, thus we would like to introduce an effective tool to China.

OBJECTIVE

The aim of this study was to establish the reliability and validity of the Chinese version of visual vertigo analogue scale (VVAS-CH) and to achieve its cross-cultural adaptation in order to promote its further usage in China.

METHODS

A total of 1681 patients complaining of vertigo or dizziness were enrolled and they were asked to complete the VVAS-CH. The cross-cultural adaptation, reliability and construct validity of the VVAS-CH were determined.

RESULTS

Split-half reliability was 0.939, showing a good reliability. Factor analysis identified only one common factor for the nine items that explained 64.83% of the total variance. Most fit indices reached acceptable levels, proving the good fit of the VVAS-CH model.

CONCLUSIONS

The VVAS-CH validated in this study can be used as an effective tool for diagnosing and evaluating VV in patients whose native language is Chinese.

Association of self-efficacy, risk attitudes, and time preferences with functioning in older patients with vertigo, dizziness, and balance disorders in a tertiary care setting-Results from the MobilE-TRA2 cohort

Introduction

The functional burden of vertigo, dizziness, and balance problems (VDB) might depend on the personality traits of the patients affected. The aim of this study thus was to investigate the impact of self-efficacy, risk attitudes, and time preferences on functioning in older patients with VDB before and after treatment in a specialized tertiary care center.

Methods

Data for this study was obtained from the MobilE-TRA2 cohort study, conducted at a specialized tertiary care center in Germany. Patients aged 60 and older were assessed during their initial stay at the care center and 3 months later, using self-administered questionnaires. Self-efficacy was measured on a scale from 1 (very low) to 5 (very high). Health-related risk attitudes were inquired using an 11-point scale. Time preferences were measured by evaluating patients' willingness to postpone a reward in favor of a greater benefit on an 11-point Likert scale. Functioning was evaluated using the Dizziness Handicap Inventory, representing functional, emotional, and physical aspects of functional disability caused by VDB. Mixed-effects regression models were used to analyze the association between the selected personality traits and functioning over time. Interaction terms with time were incorporated for each personality trait, enabling the assessment of their influence on functioning 3 months following the initial observation period.

Results

An overall of 337 patients (53% women, median age at baseline = 70 years) were included. Patients with higher self-efficacy (Beta = -3.82, 95%-CI [-6.56; -1.08]) and higher willingness to take risks (Beta = -1.31, 95%-CI [-2.31; -0.31]) reported better functioning during their initial visit at the care center. Self-efficacy significantly predicted functioning after 3 months for overall functioning (Beta = -4.21, 95%-CI [-6.57; -1.84]) and all three domains.

Conclusion

Our findings suggest that patients with high self-efficacy and high willingness to take risks may exhibit better coping mechanisms when faced with the challenges of VDB. Promoting self-efficacy may help patients to better manage the duties accompanying their treatment, leading to improved functioning. These insights may inform the development of personalized treatment aimed at reducing the functional burden of VDB in older patients.

Improvement of vertigo symptoms after 2 months of Vertigoheel treatment: a case series in patients with bilateral vestibulopathy and functional dizziness

Background

Dizziness is a common leading symptom in bilateral vestibulopathy (BVP) and functional dizziness (FD), with significant negative effects on functional ability and quality of life. Vertigoheel is a widely used non-prescription drug for the treatment of vertigo. In order to generate systematic data for Vertigoheel in BVP and FD, we conducted a non-interventional study assessing vertigo symptoms.

Methods

This study was conducted as an open-label, prospective, monocentric, non-interventional case series (ClinicalTrials.gov identifier NCT05897853). Patients with BVP and FD received Vertigoheel according to market approval for an observational period of 2 months. Change from baseline after 2 months was assessed for the following endpoints: Dizziness Handicap Inventory (DHI) as the primary endpoint, quality of life (QoL) by EQ-5D-5L, and body sway by static posturography. Patients with FD were additionally assessed for depression and anxiety by PHQ-9 and GAD-7 questionnaires. Patients with BVP were assessed for vestibular function by video head impulse testing and caloric testing. Adverse events and other safety-related observations were evaluated.

Results

Of 41 patients with FD and 13 with BVP, two with FD and none with BVP dropped out before the follow-up visit. Both patient groups showed significantly improved disability caused by dizziness after 2 months: In BVP, the DHI decreased on average by 13.2 points from 45.4 to 32.2 (p < 0.001). In FD, the DHI decreased on average by 12.0 points from 46.5 to 34.5 (p < 0.001). In patients with FD, significant improvements were also observed for the secondary endpoints QoL, anxiety, and depression. No significant change was observed for posturography readouts. In patients with BVP, there were no statistically significant improvements for the secondary endpoints QoL, posturography, or vestibular function within the observation period. The study found no evidence of a safety risk.

Conclusion

The study provides evidence for Vertigoheel's clinical safety and limited evidence - because of the non-interventional design - for its effectiveness in BVP and FD that are considered disease entities with high medical need for new treatment options. The results may serve as the basis for randomized placebo-controlled trials.

Contextual sensory integration training vs. traditional vestibular rehabilitation: a pilot randomized controlled trial

BACKGROUND

We created a clinical virtual reality application for vestibular rehabilitation. Our app targets contextual sensory integration (C.S.I.) where patients are immersed in safe, increasingly challenging environments while practicing various tasks (e.g., turning, walking). The purpose of this pilot study was to establish the feasibility of a randomized controlled trial comparing C.S.I. training to traditional vestibular rehabilitation.

METHODS

Thirty patients with vestibular dysfunction completed the Dizziness Handicap Inventory (DHI), Activities-Specific Balance Confidence Scale (ABC), Visual Vertigo Analog Scale (VVAS), Functional Gait Assessment (FGA), Timed-Up-and-Go (TUG), and Four-Square Step Test (FSST). Following initial assessment, the patients were randomized into 8 weeks (once per week in clinic + home exercise program) of traditional vestibular rehabilitation or C.S.I. training. Six patients had to stop participation due to the covid-19 pandemic, 6 dropped out for other reasons (3 from each group). Ten patients in the traditional group and 8 in the C.S.I group completed the study. We applied an intention to treat analysis.

RESULTS

Following intervention, we observed a significant main effect of time with no main effect of group or group by time interaction for the DHI (mean difference - 18.703, 95% CI [-28.235, -9.172], p = 0.0002), ABC (8.556, [0.938, 16.174], p = 0.028), VVAS, (-13.603, [-25.634, -1.573], p = 0.027) and the FGA (6.405, [4.474, 8.335], p < 0.0001). No changes were observed for TUG and FSST.

CONCLUSION

Patients' symptoms and function improved following either vestibular rehabilitation method. C.S.I training appeared comparable but not superior to traditional rehabilitation.

TRIAL REGISTRATION

This study (NCT04268745) was registered on clincaltrials.gov and can be found at https://clinicaltrials.gov/ct2/show/NCT04268745 .

Differences between physical therapist ratings, self-ratings, and posturographic measures when assessing static balance exercise intensity

Introduction

In order for balance therapy to be successful, the training must occur at the appropriate dosage. However, physical therapist (PT) visual evaluation, the current standard of care for intensity assessment, is not always effective during telerehabilitation. Alternative balance exercise intensity assessment methods have not previously been compared to expert PT evaluations. The aim of this study was therefore to assess the relationship between PT participant ratings of standing balance exercise intensity and balance participant self-ratings or quantitative posturographic measures.

Methods

Ten balance participants with age or vestibular disorder-related balance concerns completed a total of 450 standing balance exercises (three trials each of 150 exercises) while wearing an inertial measurement unit on their lower back. They provided per-trial and per-exercise self-ratings of balance intensity on a scale from 1 (steady) to 5 (loss of balance). Eight PT participants reviewed video recordings and provided a total of 1,935 per-trial and 645 per-exercise balance intensity expert ratings.

Results

PT ratings were of good inter-rater reliability and significantly correlated with exercise difficulty, supporting the use of this intensity scale. Per-trial and per-exercise PT ratings were significantly correlated with both self-ratings (r = 0.77-0.79) and kinematic data (r = 0.35-0.74). However, the self-ratings were significantly lower than the PT ratings (difference of 0.314-0.385). Resulting predictions from self-ratings or kinematic data agreed with PT ratings approximately 43.0-52.4% of the time, and agreement was highest for ratings of a 5.

Discussion

These preliminary findings suggested that self-ratings best indicated two intensity levels (i.e., higher/lower) and sway kinematics were most reliable at intensity extremes.

Effectiveness of Vestibular Rehabilitation in Improving Health Status and Balance in Patients with Fibromyalgia Syndrome: A Single-Blind Randomized Controlled Trial

BACKGROUND

Fibromyalgia Syndrome (FMS) is a highly prevalent health problem whose main symptom is widespread pain, although it presents as other manifestations, such as loss of balance, that seem to mainly affect visuo-vestibular information.

OBJECTIVE

to compare the effects of a Vestibular Rehabilitation (VR) program versus those of a Conventional Physical Exercise (CPE) program on the health status of patients with FMS.

METHODS

A single-blind randomized controlled trial was performed. Patients with FMS were randomly assigned to VR or CPE programs. The protocols were performed in 40 min group sessions, twice weekly, for 16 sessions. Perceived health status, static and dynamic balance, verticality perception, confidence in balance, sensitization and kinesiophobia were measured at baseline, post-treatment and at the three-month follow-up and analyzed using an intention-to-treat approach.

RESULTS

Forty-eight subjects were randomly assigned, of whom thirty-five completed the planned VR (n = 19) or CPE (n = 16) program. At the three-month follow-up, there were differences in physical health status measured with the SF-12 (mean = -4.36, SE = 1.88, p = 0.027), balance during walking (mean = 1.90, SE = 0.57, p = 0.002), the perception of verticality in degrees (mean = 3.61, SE = 1.51, p = 0.024) and the anteroposterior position of the center of pressure (mean = -7.88, SE = 2.80, p = 0.009), as well as a decrease in the number of falls (mean = 0.98, SE = 0.44, p = 0.033), favoring the VR group.

CONCLUSIONS

Vestibular Rehabilitation can be as beneficial as conventional exercise in improving the state of health in patients with Fibromyalgia Syndrome, providing additional improvements in physical health status, body balance, the perception of verticality and the number of falls.

Relationships between the Pittsburgh Sleep Quality Index (PSQI) and vertigo outcome

OBJECTIVE

This retrospective cohort study aimed to investigate the association of sleep characteristics measured by the Pittsburgh Sleep Quality Index (PSQI) with the vertigo outcome in vertiginous patients with comorbid cardiometabolic diseases.

METHODS

Four hundred and thirteen patients with comorbid cardiometabolic diseases who consecutively visiting vertigo and dizziness clinic were enrolled between October 2018 and January 2020 in a tertiary teaching medical center. Regression analyses and stratified analyses were used to explore the relationship between PSQI and vertigo outcome, which was measured by the visual analogue scale (VAS) score.

RESULTS

In the study sample, 73.8% (305/413) were defined as 'poor sleep' (PSQI>5). Participants with better recovery tended to have better baseline PSQI global score, PSQI sleep quality, PSQI sleep onset latency, PSQI daytime dysfunction, less severe baseline vertigo symptoms indicated by VAS, Vertigo Symptom Scale (VSS) and Dizziness Handicap Inventory (DHI) scores. Moreover, baseline PSQI global score and PSQI daytime dysfunction score were independently associated with the vertigo VAS scores at the last follow-up.

CONCLUSION

The present results clearly indicated that poor sleep is common and inversely associated with vertigo outcome in vertiginous patients with co-morbid cardiometabolic diseases. Therefore, sleep deserves greater attention in the total medical care in specific subgroup of vertiginous patients.

Different Vestibular Rehabilitation Modalities in Unilateral Vestibular Hypofunction: A Prospective Study

OBJECTIVE

To assess the effectiveness of three vestibular rehabilitation protocols in patients with chronic unilateral vestibular hypofunction.

STUDY DESIGN

Prospective randomized trial.

SETTING

Audiology-neurootology laboratory in a general public hospital.

PATIENTS

Eighty-one patients were randomly allocated into three groups: adaptation exercises (AEs), habituation exercises (HEs), and combined exercises (AE-HEs).

INTERVENTIONS

Each patient completed an 8-week vestibular rehabilitation program with exercise, depending on their allocation group.

MAIN OUTCOME MEASURES

Evaluations performed at baseline, 4 weeks, and 8 weeks with (a) Functional Gait Assessment (FGA), (b) Mini-BESTest, (c) Vestibular Rehabilitation Benefit Questionnaire, and (d) Dizziness Handicap Inventory.

RESULTS

FGA and Mini-BESTest scores showed significant improvement between the baseline and 8-week scores in all groups (p < 0.001), except for the FGA score in the HE group. The AE-HE group showed better scores for all measurements at 4 weeks and had significantly better FGA and Mini-BESTest scores than the AE group and better FGA scores than the HE group. The Vestibular Rehabilitation Benefit Questionnaire and Dizziness Handicap Inventory scores in the AE-HE group were significantly better (p ≤ 0.001) than those in the HE group at 8 weeks.

CONCLUSIONS

The AE-HE group showed faster improvement and significantly better outcomes for static balance, dynamic postural stability, and self-perceived disability than the single-exercise protocols in chronic unilateral vestibular hypofunction.

Can Virtual Reality-Assisted Therapy Offer Additional Benefits to Patients With Vestibular Disorders Compared With Conventional Vestibular Physical Therapy? A Meta-analysis

OBJECTIVE

To determine whether virtual reality-assisted therapy (VRAT) significantly improves the treatment of peripheral or central vestibular disorders when compared with conventional vestibular physical therapy (CVPT) alone. Indicators of vestibular symptoms are used to determine this.

DATA SOURCES

Two reviewers independently searched PubMed, EMBASE, ClinicalTrials.gov, Web of Science, and the Cochrane Collaboration database from January 2010 to January 2022 for studies reporting on VRAT in vestibular disorders.

STUDY SELECTION

Randomized controlled trials (RCTs) were included that mainly focused on the following measures: the Dizziness Handicap Inventory (DHI), Simulator Sickness Questionnaire, visual analog scale, and balance measures such as the Activities-specific Balance Confidence Scale (ABC), timed Up and Go test, sensory organization test, and center of pressure. The primary outcome was assessment of symptomatic changes before and after VRAT.

DATA EXTRACTION

Two authors independently conducted the literature search and selection. After screening, meta-analysis was performed on the RCTs using RevMan 5.3 software.

DATA SYNTHESIS

The results showed that VRAT produced significantly greater improvement than CVPT alone in scores of DHI-Total (standardized mean difference [SMD]: -7.09, 95% confidence interval [CI]: [-12.17, -2.00], P=.006), DHI-Functional (SMD=-3.66, 95% CI: [-6.34, -0.98], P=.007), DHI-Physical (SMD=-3.14, 95% CI: [-5.46, -0.83], P=.008), and DHI-Emotional (SMD=-3.10, 95% CI: [-5.13, -1.08], P=.003). ABC scores did not show improvement (SMD: 0.58, 95% CI: [-3.69, 4.85], P=.79). Subgroup analysis showed that DHI-Total between-group differences were insignificant for central vestibular disorders (SMD=-1.47, 95% CI: [-8.71, -5.78], P=.69), although peripheral disorders showed significant improvements (SMD=-9.58, 95% CI: [-13.92, -5.25], P<.0001). However, the included studies showed high heterogeneity (I²>75%).

CONCLUSIONS

VRAT may offer additional benefits for rehabilitation from vestibular diseases, especially peripheral disorders, when compared with CVPT alone. However, because of high heterogeneity and limited data, additional studies with a larger sample size and more sensitive and specific measurements are required to conclusively determine the evidence-based utility of virtual reality.

Instrumental and Non-Instrumental Measurements in Patients with Peripheral Vestibular Dysfunctions

Vestibular dysfunction is a disturbance of the body's balance system. The control of balance and gait has a particular influence on the quality of life. Currently, assessing patients with these problems is mainly subjective. New assessment options using wearables may provide complementary and more objective information. Posturography makes it possible to determine the extent and type of posture dysfunction, which makes it possible to plan and monitor the effectiveness of physical rehabilitation therapy. This study evaluates the effectiveness of non-instrumental clinical tests and the instrumental mobile posturography MediPost device for patients with unilateral vestibular disorders. The study group included 40 patients. A subjective description of the symptoms was evaluated using a questionnaire about the intensity of dizziness using the Dizziness Handicap Inventory (DHI) and Vertigo Syndrome Scale-short form (VSS-sf). The clinical protocol contained clinical tests and MediPost measurements using a Modified Clinical Test of Sensory Interaction on Balance. All patients underwent vestibular rehabilitation therapy (VRT) for four weeks. The non-instrumental measurement results were statistically significant, and the best was in the Timed Up and Go test (TUG). In MediPost, condition 4 was the most valuable. This research demonstrated the possibilities of using an instrumental test (MediPost) as an alternative method to assess balance.

The combined effect of gaze stability and balance exercises using telerehabilitation in individuals with vestibular disorders during the COVID-19 pandemic: A pilot study

BACKGROUND

Vestibular rehabilitation is recognized as the most effective intervention to relieve symptoms of dizziness and imbalance related to vestibular disorders.

OBJECTIVE

This study aimed to examine the combined effect of gaze stability and balance exercises using telerehabilitation in individuals with vestibular disorders during the COVID-19 pandemic.

METHODS

This pilot study was a quasi-experimental, single-group design pre- to post-telerehabilitation intervention. Individuals with vestibular disorders between the ages of 25-60 participated in this study (n = 10). Participants underwent four weeks of combined gaze stability and balance exercises using telerehabilitation at their homes. The Arabic version of the Activities-Specific Balance Confidence scale (A-ABC), Berg Balance Scale (BBS), and the Arabic version of the Dizziness Handicap Inventory (A-DHI) were assessed pre- and post-vestibular telerehabilitation. Wilcoxon signed rank test was used to examine the magnitude of difference pre- and post-intervention scores of outcome measures. The effect size (r) for the Wilcoxon signed rank was calculated.

RESULTS

After four weeks of vestibular telerehabilitation, there was an improvement in BBS and A-DHI outcome measures (p < .001), with moderate effect size for both scales (r = 0.6). However, A-ABC showed no significant improvement among participants.

CONCLUSION

This pilot study found that the combined effect of gaze stability and balance exercises using telerehabilitation appear to be effective in improving balance and activities of daily living in individuals with vestibular disorders.

Differences in Body Balance According to Body Mass Classification among Brazilian Jiu-Jitsu Athletes

Background: Body weight is an important aspect in the development of components of physical fitness that can affect athletic performance. The purpose of this study was to examine the differences in body balance of Brazilian Jiu-Jitsu (BJJ) athletes according to body mass classification: underweight/normal weight (UW/NW); overweight/obese (OW/OB). Material and Methods: The study was conducted among 69 BJJ athletes (age 23.26 ± 3.53) and 93 non-practicing adults (age 21.73 ± 2.32). This study was based on a quantitative assessment of body balance on the Zebris PDM platform during two tests, i.e., with eyes open and closed. Results: The total path of the center of pressure (COP TTL) was significantly higher in participants with UW/NW compared to those with OW/OB, both in participants from the study group and control group (p < 0.001). COP TTL was significantly lower in UW/NW BJJ athletes than in participants in the control group with the same BMI category (987.4 mm vs. 1238.5 mm and 1080.59 mm vs. 1280.70 mm, respectively) (p < 0.001). Conclusions. BJJ training is associated with a better balance in terms of COP TTL in the case of people with normal or underweight. The presence of excess body weight has a positive effect on lower COP TTL values in both practicing and non-practicing people.

Categorizing individuals based on the severity of Visual Vertigo Analogue Scale symptoms

BACKGROUND

The Visual Vertigo Analogue Scale (VVAS) assesses visual vertigo. Instead of the original scoring methods (positive VVAS > 1), we propose categorizing patients as having No (0), Mild (0.1-40), Moderate (40.01-70), or Severe (70.01-100) symptoms.

OBJECTIVE

Our primary aim was to validate an alternative interpretation of the VVAS by exploring the relationship between categories of visual vertigo symptoms and measures of activity and participation, dizziness handicap, anxiety, and depression. We aimed to describe the severity of visual vertigo reported by patients in different vestibular diagnostic categories.

METHODS

Participants with vestibular disorders (n = 250) completed the VVAS, Vestibular Activities and Participation (VAP) Measure, Dizziness Handicap Inventory (DHI), and the Hospital Anxiety and Depression Scale (HADS).

RESULTS

Patients with central disorders were more symptomatic than those with peripheral vestibular disorders. As evaluated by one-way ANOVA, the scores on the VAP, HADS, and DHI significantly differed among mild, moderate, severe, and no visual vertigo categories (p < 0.001). As VVAS severity increased, activity and participation decreased (r = 0.582, p < 0.001); dizziness handicap increased (r = 0.597, p < 0.001, n = 199); anxiety increased (r = 0.405, p < 0.001); and depression increased (r = 0.521, p < 0.001).

CONCLUSIONS

The findings of this study support the use of an alternative VVAS interpretation method of categorizing symptoms as none, mild, moderate, and severe visual vertigo.

Group Vestibular Rehabilitation Program: A Cost-Effective Outpatient Management Option for Dizzy Patients

OBJECTIVES

This study was performed to evaluate the effectiveness of our novel group vestibular rehabilitation therapy (G-VRT) and to analyze the factors affecting outcomes.

STUDY DESIGN

Retrospective case series.

SETTING

Tertiary referral center.

PATIENTS

Patients with chronic dizziness who received G-VRT between December 2019 and July 2020.

INTERVENTION

The G-VRT program consisted of a 1-hour physical therapy session by an otologist in a small group setting.

MAIN OUTCOME MEASURES

Dizziness Handicap Inventory, visual analog scale, functional level scales, and video head impulse test, as well as the compliance to the program, were evaluated.

RESULTS

All scores of dizziness questionnaires were significantly improved after G-VRT ( p < 0.001). The overall vestibule-ocular reflex gain calculated by video head impulse test increased compared to the initial scores, whereas the average PR scores of all three semicircular canals significantly decreased from the initial scores, indicating enhanced vestibular compensation ( p < 0.05). Enrolled patients showed high compliance to the program.

CONCLUSION

G-VRT program is a cost-effective and efficient way to provide relief for chronic dizzy patients. Further case-control studies in a larger group, as well as comparative studies with generic or customized vestibular exercise, will be needed to validate the clinical value of G-VRT.

Central vestibular dysfunction: don't forget vestibular rehabilitation

INTRODUCTION

Vestibular rehabilitation (VR) is now a subject of active studies and has been shown to be effective for multiple vestibular disorders, peripheral or central. VR is a physical therapy that helps train the central nervous system to compensate for vestibular dysfunction. There is moderate to strong evidence that VR is safe and effective for the management of peripheral vestibular dysfunction. Nonetheless, the studies on how VR works on central vestibular dysfunction remains scanty.

AREAS COVERED

This article addressed the rehabilitation strategies and possible mechanisms, including how central vestibular function might improve upon rehabilitation. In addition, it provides some examples concerning the effect of VR on central vestibular dysfunction.

EXPERT OPINION

VR works on the vestibular system through repetition of specific physical exercises that activate central neuroplastic mechanisms to achieve adaptive compensation of the impaired functions. VR has become a mainstay in the management of patients with dizziness and balance dysfunction. Individualized VR programs are a safe and effective treatment option for a large percentage of patients with central vestibular disease reporting imbalance and dizziness. Exploration of various treatment strategies and possible mechanisms will help develop the best and personalized VR treatment for patients with central vestibular dysfunction.

Dysfunctions of the vestibular organ in patients with migrainous vertigo in the results of objective tests of the equilibrium system

<b>Introduction:</b> Migrainous vertigo (MV) is one of the most common causes of episodic vertigo. Diagnostic criteria for MV are described in the appendix to the third edition of the International Classification of Headache Disorders (Beta Version). The dysfunction exerts its impact on certain peripheral and central structures within the vestibular system. </br></br> <b>Aim:</b> The aim of the study was to assess the function of the central and peripheral vestibular system in patients with MV based on the results of objective clinical tests including videonystagmography (VNG) and cervical vestibular evoked myogenic potentials (cVEMP) depending on the duration of the disease. </br></br> <b>Material and methods:</b> A query of the medical records of patients receiving vertigo treatment at the Department of Otolaryngo-logy of the Centre of Postgraduate Medical Education over the last four years returned a total of 84 cases of patients diagnosed with MV; the patients were assigned to either of the following two groups: study group I (SG1) – 42 patients with MV in whom the symp-tom onset had occurred within one year prior to hospital admission, and study group II (SG2) – 42 patients who had been suffering from vertigo for about 10 years. </br></br> <b>Results:</b> Patients in both groups (SG1 and SG2) were diagnosed with all three types of vestibular dysfunction (central, peri-pheral and mixed), with peripheral vestibular dysfunction being the predominant finding. A thorough analysis of the dura-tion of vestibular attacks revealed that the patients suffering from MV for a longer period of time (SG2) suffered from vertigo attacks which were longer than those in the patients with the shorter lasting-disorder (SG1). The duration of vertigo episodes was also estimated to be prolonged in peripheral and mixed types of vestibular disorders. The percentage of individuals with peripheral and mixed vestibular disorders increased significantly with increasing MV episode durations.

Utility of the Novel MediPost Mobile Posturography Device in the Assessment of Patients with a Unilateral Vestibular Disorder

Balance disorders are a growing problem worldwide. Thus, there is an increasing need to provide an inexpensive and feasible alternative to standard posturographic platforms (SP) used for the assessment of balance and to provide a possible solution for telemonitoring of patients. A novel mobile posturography (MP) MediPost device was developed to address these issues. This prospective study used a Modified Clinical Test of Sensory Interaction on Balance to evaluate healthy individuals and patients with a unilateral vestibular disorder through SP and MP simultaneously. The control group included 65 healthy volunteers, while the study group included 38 patients diagnosed with a unilateral vestibular deficit. The angular velocity values obtained from both methods were compared by intraclass correlation coefficients (ICC) and Bland−Altman plot analysis. Diagnostic capabilities were measured in terms of sensitivity and specificity. The ICC between the two methods for conditions 2−4 was indicative of excellent reliability, with the ICC > 0.9 (p < 0.001), except for Condition 1 (standing stance, eyes open) ICC = 0.685, p < 0.001, which is indicative of moderate reliability. ROC curve analysis of angular velocity for condition 4 represents the most accurate differentiating factor with AUC values of 0.939 for SP and 0.953 for MP. This condition also reported the highest sensitivity, specificity, PPV, and NPV values with 86.4%, 87.7%, 80%, and 90.5% for SP, and 92.1%, 84.6%, 77.8%, and 94.8% for MP, respectively. The newly developed MediPost device has high sensitivity and specificity in distinguishing between healthy individuals and patients with a unilateral vestibular deficit.

Estimating the minimal clinically important difference for balance and gait outcome measures in individuals with vestibular disorders

BACKGROUND

Vestibular Rehabilitation Therapists (VRT) utilize outcome measures to quantify gait and balance abilities in individuals with vestibular disorders (IVD). The minimal clinically important difference (MCID) in gait and balance outcome measures for IVD is unknown.

OBJECTIVE

The purpose of this study is to estimate the MCID of the Activities-specific Balance Confidence Scale (ABC), Functional Gait Assessment (FGA), and Gait Speed (GS) using distribution and anchor-based methods relative to the Dizziness Handicap Inventory (DHI) in IVD.

METHODS

Data were collected using a retrospective chart review from two outpatient Vestibular Rehabilitation (VR) clinics. Data included demographic characteristics, diagnosis, VR course, and pre and post outcome measures including DHI, ABC, FGA, and GS. The DHI was used to classify subjects as "responders" or "non-responders" in order to calculate MCID values.

RESULTS

The total number of subjects analyzed for each outcome measure was 222 for the ABC, 220 for FGA, and 237 for GS. Subjects made statistically significant improvements in ABC, DHI, FGA, and GS (p <  0.001) from pre to post VR. The MCID calculated for ABC, FGA, and GS using the anchor-based approach was 18.1%, 4 points, and 0.09 m/s respectively. The MCIDs calculated using distribution-based approach for the ABC ranged between 7.5-23.5%, FGA ranged between 1.31-4.15 points, and GS ranged between 0.07 m/s-0.22 m/s.

CONCLUSIONS

The anchor-based calculations of the MCID of 18.1%, 4 points, and 0.09 m/s for ABC, FGA, and GS respectively for IVD should be used over distribution-based calculations. This is due to strength of DHI as the anchor and statistical analysis. VRT and researches can use these values to indicate meaningful changes in gait and balance function in IVD.

Feasibility and Preliminary Effects of a 1-Week Vestibular Rehabilitation Day Camp in Children with Developmental Coordination Disorder

AIM

This pilot study investigated the feasibility and preliminary effects of an intensive 1-week day camp program for children with Developmental Coordination Disorder (DCD) that focused on vestibular rehabilitation.

METHODS

Ten participants (6-10 years) were assessed twice pre-intervention, post intervention, and at 8-week follow-up. Videonystagmography, Video Head Impulse Tests (vHIT), and Modified Emory Clinical Vestibular Chair Test (m-ECVCT) test were assessed at baseline. Outcomes measures were gaze stability (Dynamic Visual Acuity; DVA), functional gait (Functional Gait Assessment; FGA), balance (Sensory Organization Test), motor function (Bruininks-Oseretsky Test), and participation (Miller Function and Participation).

RESULTS

No abnormal results were detected from the videonystagmography, vHIT and m-ECVCT. There was a 100% attendance rate at the camp and assessment sessions. FGA scores significantly improved following intervention and changes were maintained at follow-up. The number of children with abnormal DVA scores decreased from 3 to 1 to 0 between pre-intervention, post-intervention, and follow-up. There were no significant changes in any of the other outcomes following intervention.

CONCLUSIONS

Intensive vestibular rehabilitation delivered in a day camp format is feasible and show positive preliminary effects on functional gait and dynamic visual acuity in children with DCD.

The diagnosis of central vestibular disorders based on the complementary examination of the vestibulospinal reflex

OBJECTIVES

Stance and gait unsteadiness along with vertigo contribute to a central vestibular disorder. For objective analysis ultrasound-computer-craniocorpography (US-COMP-CCG) can be used. Aim of the study was to characterize the unsteadiness in central vestibular disorders and discuss the possible diagnostic usage of US-COMP-CCG.

METHODS AND RESULTS

Hundred-and-ninety patients (70 male and 120 female, mean age ± SD, 58.94 ± 15.27) suffering from central vestibular disorder and 230 healthy control patients (78 male and 152 female, mean age ± SD, 50.94 ± 15.27) were enrolled. Stance and gait analysis was according to vestibulospinal tests of US-COMPCCG. IBM SPSS V24 software was used for statistical analysis. Mann-WhitneyU test and Chi-square test were used, along with sensitivity and specificity categorization. The significance level was p < 0.05. According to schematic and statistical analysis instability and postural sway were increased in the vertigo population and statistically significant difference was shown. Upon categorical analysis significant correlation was detected [standing test: longitudinal sway (p < 0.00001), lateral sway (p < 0.00001), forehead covering area parameters (p = 0.0001); stepping test: longitudinal deviation (p = 0.05), lateral sway (p = 0.011) parameters].

CONCLUSIONS

Clinicians should consider that postural instability is prominently present in this population and might be of a diagnostic importance.

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

INTRODUCTION

Vestibular system damage in patients with multiple sclerosis (MS) may have a central and/or peripheral origin. Subsequent vestibular impairments may contribute to dizziness, balance disorders and fatigue in this population. Vestibular rehabilitation targeting vestibular impairments may improve these symptoms. Furthermore, as a successful tool in neurological rehabilitation, immersive virtual reality (VRi) could also be implemented within a vestibular rehabilitation intervention.

METHODS AND ANALYSIS

This protocol describes a parallel-arm, pilot randomised controlled trial, with blinded assessments, in 30 patients with MS with vestibular impairment (Dizziness Handicap Inventory ≥16). The experimental group will receive a VRi vestibular rehabilitation intervention based on the conventional Cawthorne-Cooksey protocol; the control group will perform the conventional protocol. The duration of the intervention in both groups will be 7 weeks (20 sessions, 3 sessions/week). The primary outcomes are the feasibility and safety of the vestibular VRi intervention in patients with MS. Secondary outcome measures are dizziness symptoms, balance performance, fatigue and quality of life. Quantitative assessment will be carried out at baseline (T0), immediately after intervention (T1), and after a follow-up period of 3 and 6 months (T2 and T3). Additionally, in order to further examine the feasibility of the intervention, a qualitative assessment will be performed at T1.

ETHICS AND DISSEMINATION

The study was approved by the Andalusian Review Board and Ethics Committee, Virgen Macarena-Virgen del Rocio Hospitals (ID 2148-N-19, 25 March 2020). Informed consent will be collected from participants who wish to participate in the research. The results of this research will be disseminated by publication in peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT04497025.

Comparison of Incremental Vestibulo-ocular Reflex Adaptation Training Versus x1 Training in Patients With Chronic Peripheral Vestibular Hypofunction: A Two-Year Randomized Controlled Trial

BACKGROUND AND PURPOSE

A crossover, double-blinded randomized controlled trial to investigate once-daily incremental vestibulo-ocular reflex (VOR) adaptation (IVA) training over 2 years in people with stable and chronic peripheral vestibular hypofunction.

METHODS

Twenty-one patients with peripheral vestibular hypofunction were randomly assigned to intervention-then-control (n = 12) or control-then-intervention (n = 9) groups. The task consisted of either x1 (control) or IVA training, once daily every day for 15 minutes over 6-months, followed by a 6-month washout, then repeated for arm 2 of the crossover. Primary outcome: vestibulo-ocular reflex gain. Secondary outcomes: compensatory saccades, dynamic visual acuity, static balance, gait, and subjective symptoms. Multiple imputation was used for missing data. Between-group differences were analyzed using a linear mixed model with repeated measures.

RESULTS

On average patients trained once daily 4 days per week. IVA training resulted in significantly larger VOR gain increase (active: 20.6% ± 12.08%, P = 0.006; passive: 30.6% ± 25.45%, P = 0.016) compared with x1 training (active: -2.4% ± 12.88%, P = 0.99; passive: -0.6% ± 15.31%, P = 0.68) (P < 0.001). The increased IVA gain did not significantly reduce with approximately 27% persisting over the washout period. x1 training resulted in greater reduction of compensatory saccade latency (P = 0.04) and increase in amplitude (P = 0.02) compared with IVA training. There was no difference between groups in gait and balance measures; however, only the IVA group had improved total Dizziness Handicap Inventory (P = 0.006).

DISCUSSION AND CONCLUSIONS

Our results suggest IVA improves VOR gain and reduces perception of disability more than conventional x1 training. We suggest at least 4 weeks of once-daily 4 days-per-week IVA training should be part of a comprehensive vestibular rehabilitation program.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A356).

Audiologists should not fail with falls: A call to commit to prevention of falls in older adults

Globally, falls are a serious economic and public health concern. While all age groups are impacted by falls, the threats to morbidity and mortality are most severe in older adults. Recent literature has linked hearing loss, and related issues such as an increase in sedentary behaviour, to a greater risk of falls. Therefore, this opinion article aims to raise audiologists’ awareness of falls in ageing patients or clients, and calls for change in terms of having these rehabilitation professionals embrace identification and management of fall risk.

Exploratory fall risk and preventive intervention in acute vestibular neuritis

Objective

To analyze recovery from dizziness in patients with acute vestibular neuritis (AVN) after applying the “Dizziness & Fall Risk Assessment and Intervention (DFRAI)”.

Methods

This prospective study involved patients with AVN who underwent a survey of dizziness and fall risk. The patients received medical treatment and customized vestibular rehabilitation, and vestibular function was evaluated at the initial attack and 3 months later.

Results

Forty-one patients underwent subjective questionnaire assessments, which showed significant improvement in visual analog scale-dizziness handicap inventory-fear of falling (VAS-DHI-FOF) results from the initial vertigo attack to 3 months later. In the sensory organization test (SOT), the initial composite score was 63 ± 13.1, which improved to 77.5 ± 4.9 3 months later. In caloric testing, the canal paresis (CP) score was 42.9 ± 35.2, which improved to 29.9 ± 23.5 3 months later.

Conclusions

Subjective improvement in dizziness and objective recovery of vestibular function were confirmed. DFRAI is a comprehensive solution for dizziness, and appropriate application of the DFRAI is expected to have a positive effect on recovery from dizziness and fall prevention in patients with AVN.

Advantages of Short-term Personalized Vestibular Rehabilitation at Home Guided by Professional Therapist for Treatment of Decompensated Vestibular Vertigo

OBJECTIVE

Patients suffered a lot from decompensated vestibular vertigo. Pharmacotherapy and vestibular rehabilitation training have been proven to be effective in prompting vestibular compensation. Routine rehabilitation training is faced with the challenges of patients' compliance, completion, the average recuperation time and so on. This study is aimed to investigate advantages of short-term personalized vestibular rehabihitation at home guided by professional therapist.

METHODS

A short-term personalized vestibular rehabilitation program (ST-PVR) was designed for patients with decompensated vestibular vertigo in this study.

RESULTS

Patients experiencing the ST-PVR program showed significant improvement of Self-Rating Anxiety Scale (SAS), Dizziness Handicap Inventory (DHI), Activities-Specific Balance Confidence Scale (ABC) scores by the second follow-up (at 2nd week after treatment, P<0.05). However-improvement in the medication group occurred slightly later, DHI for 1 month and SAS for 2 months after treatment (P<0.05). Also, the improvement in the onset time of unilateral weakness (UW) at 2nd week after treatment in the personalized vestibular rehabilitation (PVR) group was faster than that in the medication group.

CONCLUSION

In general, the short-term PVR program showed great advantages by prompting vestibular compensation quickly and putting forward future direction for clinical treatment on decompensated vestibular vertigo.

Validated argentine version of the visual vertigo analogue scale

BACKGROUND

Visual vertigo (VV), triggered by environmental or dynamic visual stimuli and repetitive visual patterns, can affect daily life activities. The Visual Vertigo Analogue Scale (VVAS) is a valid and reliable self-administered questionnaire to assess VV, which has been culturally adapted to the Argentine population but has not been validated.

OBJECTIVE

To validate the Argentine version of VVAS (VVAS-A) by confirming its psychometric properties in patients with vestibular disorders.

METHODS

Vestibular patients (n = 82) completed the VVAS-A and the Dizziness Handicap Inventory Argentine version (DHI-A) during their initial visit and one week later. The VVAS-A's internal consistency, test retest reliability, ceiling and floor effects, and construct validity were determined. Test-retest data (n = 71) was used to calculate reliability using the intraclass correlation coefficient (ICC 2.1).

RESULTS

A ceiling effect was observed in 12 patients (14.6%). Internal consistency was acceptable (Cronbach's alpha: 0.91). The reliability was r = 0.764 [CI 95%: 0.7 -0.86]). Correlations were observed between the VVAS-A and the total DHI-A score (rho = 0.571), the DHI-A physical subscale (rho: 0.578), and DHI-A functional and emotional subscales of the DHI-A (rho: 0.537 and 0.387, respectively).

CONCLUSION

VVAS-A is a valid, reliable tool to evaluate VV in patients with vestibular disorders.

Comprehensive Clinical Assessment of Vestibular Function in Multiple Sclerosis

BACKGROUND AND PURPOSE

Balance disorders and dizziness are common in people with multiple sclerosis (MS), suggesting dysfunction of the vestibular system. Evaluating how people with MS perform on objective clinical vestibular tools will help broaden understanding of vestibular function in MS. This cross-sectional study's goal was to complete a robust battery of vestibular-ocular reflex (VOR), dynamic visual acuity (DVA), subjective visual vertical (SVV), and cervical and ocular vestibular-evoked myogenic potential (c/oVEMP) tests in people with and without MS.

METHODS

Forty people with relapsing-remitting MS (Expanded Disability Status Scale [EDSS] ≤6.5) and 20 controls completed the vestibular testing battery. Results were compared between groups and correlations with EDSS scores were calculated.

RESULTS

People with MS were less able to visually cancel their VOR and showed a larger variance in response on SVV. EDSS significantly correlated with VOR cancellation, SVV variance, and DVA lines lost; linear regression showed that VOR cancellation and SVV variance significantly predicted EDSS.

DISCUSSION AND CONCLUSION

Vestibular functions requiring central integration of vestibular information, but not reflexive vestibular functions like VEMP, were impaired in people with MS and correlated with EDSS, suggesting that clinical evaluation of functions requiring central integration best evaluates MS-related vestibular dysfunction. Measures assessing central vestibular integration and not vestibular reflexes may be more sensitive to detecting vestibular deficits in people with mild to moderate MS.Video Abstract available for more insight from the authors (see Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A344).

Objective Vestibular Test Battery and Patient Reported Outcomes in Cochlear Implant Recipients

OBJECTIVE

Cochlear implantation (CI) may have undesired effects on the vestibular apparatus. However, the literature holds no consensus on vestibular affection and the testing tools applied to test for vestibular dysfunction after cochlear implantation are inconsistent. We aimed to investigate the impact of CI on vestibular function by an extensive test battery including patient-reported outcomes.

STUDY DESIGN

Prospective observational study.

SETTING

University hospital.

PATIENTS

Forty adult unilateral first-time CI recipients.

INTERVENTION

Vestibular function was evaluated pre- and post-implantation with the video head impulse test (VHIT), the caloric test and cervical vestibular evoked myogenic potentials (cVEMPs), and the patient-reported dizziness handicap inventory (DHI).

RESULTS

Mean VHIT gain decreased from preoperative 0.92 to 0.84 postoperative (p = 0.018); mean caloric unilateral weakness increased from 20.5% preoperative to 42.9% postoperative (p < 0.0001); cVEMP responses were present on 10 operated ears preoperative and five ears postoperative, and compared with non-implanted ears, cVEMP responses on implanted ears were impaired (p = 0.023). 50% of patients reported early postoperative dizziness, but the mean DHI score remained unchanged (p = 0.94). The DHI scores correlated poorly with the objective outcomes (rs = 0.19 and rs = -0.22).

CONCLUSION

Vestibular function is significantly affected after cochlear implantation, but vestibular hypofunction varies with the test used. Although early dizziness after implantation is common, later DHI scores are not significantly higher than before the implantation, indicating that central compensation plays a major role for these patients.

Epley manoeuvre for posterior semicircular canal benign paroxysmal positional vertigo in people with multiple sclerosis: protocol of a randomised controlled trial

INTRODUCTION

Vestibular disorders in multiple sclerosis (MS) could have central or peripheral origin. Although the central aetiology is the most expected in MS, peripheral damage is also significant in this disease. The most prevalent effect of vestibular peripheral damage is benign paroxysmal positional vertigo (BPPV). Impairments of the posterior semicircular canals represent 60%-90% of cases of BPPV. The standard gold treatment for this syndrome is the Epley manoeuvre (EM), the effectiveness of which has been poorly studied in patients with MS. Only one retrospective research study and a case study have reported encouraging results for EM with regard to resolution of posterior semicircular canal BPPV. The aim of this future randomised controlled trial (RCT) is to assess the effectiveness of EM for BPPV in participants with MS compared with a sham manoeuvre.

METHODS AND ANALYSIS

The current protocol describes an RCT with two-arm, parallel-group design. Randomisation, concealed allocation and double-blinding will be conducted to reduce possible bias. Participants and evaluators will be blinded to group allocation. At least 80 participants who meet all eligibility criteria will be recruited. Participants will have the EM or sham manoeuvre performed within the experimental or control group, respectively. The primary outcome of the study is changes in the Dix Hallpike test. The secondary outcome will be changes in self-perceived scales: Dizziness Handicap Inventory and Vestibular Disorders Activities of Daily Living Scale. The sample will be evaluated at baseline, immediately after the intervention and 48 hours postintervention.

ETHICS AND DISSEMINATION

The study was approved by the Andalusian Review Board and Ethics Committee of Virgen Macarena-Virgen del Rocio Hospitals (ID 0107-N-20, 23 July 2020). The results of the research will be disseminated by the investigators to peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04578262.