2BALANCE: a cognitive-motor dual-task protocol for individuals with vestibular dysfunction

The effect of increased listening effort on the balance performance of patients with compensated vestibular lesion

OBJECTIVES

This study investigated the effects of listening effort (LE) on balance in patients with compensated vestibular deficits compared to healthy peers.

METHODS

The subjects included two main groups: a control group of 15 healthy subjects and a study group of 19 patients with compensated vestibular pathology. The computerized dynamic posturography test (CDP) was conducted without the speech-in-noise task as a baseline, then the participant was subjected to a dual task in which the auditory task (speech-in-noise sentences) was given as the primary task, and the balance function test was the secondary task.

RESULTS

WITHIN-GROUP ANALYSIS: The study group showed statistically significantly worse values of all body balance parameters under dual-task than the baseline in all conditions. These differences were much higher under the compliant platform conditions. However, these findings were not statistically significant in the control group.

BETWEEN-GROUP ANALYSIS

The study group showed a statistically significant decline in body balance reactions compared to the control group under dual-task with increased listening effort and the compliant platform. Study subgroup analysis revealed statistically significant differences between patients with unilateral vestibular loss (UVL) and those with bilateral vestibular loss (BVL) in the unstable platform condition.

CONCLUSION

Our study regarding implementing a dual-tasking paradigm as a measure of LE during the evaluation of chronic vestibular patients with CDP demonstrated how dual-tasking with increased LE affects postural stability. Because of this, patients will probably be more prone to tripping and falling in multitasking situations, as found in real-world settings. This fact should be taken into consideration while testing patients with chronic vertigo and compensated states at VNG. A dual-task paradigm helps uncover the unrevealed pathology.

A cross-sectional study on the neurocognitive outcomes in vestibular impaired school-aged children: are they at higher risk for cognitive deficits?

This study aimed to assess if children with a vestibular impairment (VI) are more prone to have neurocognitive deficits compared to typically developing (TD) peers, taking into account important confounding factors with hearing loss being the most important. The neurocognitive performance of fifteen VI children (6-13 years old) was compared to that of an age-, handedness- and sex-weighted group of TD peers (n = 60). Secondly, their performance was also compared to matched groups of TD and hearing impaired (HI) children to evaluate the involvement of HI. The protocol comprises cognitive tests assessing response inhibition, emotion recognition, visuospatial memory, selective and sustained attention, visual memory and visual-motor integration.Based on the results, the VI group had significantly reduced scores on 'social cognition' (p = 0.018), 'executive functions' (p < 0.01), and 'perceptual-motor functioning' (p = 0.020) compared to their TD and HI peers. For the categories 'complex attention' and 'learning and memory' no differences could be observed. Analogous to the findings of previous literature, the symptoms of a VI are often not limited to the primary functions of the system, but also comprise an impact on emotional and cognitive performance. Therefore, more holistic rehabilitation approaches should be encouraged, with a screening and attention for cognitive, emotional and behavioral dysfunctions in the vestibular population. Since this is one of the first studies to investigate the involvement of a VI in a child's cognitive development, these findings support the need for studies further characterizing the impact of a VI, the underlying pathophysiology and the effect of different rehabilitation procedures.

The impact of vestibular function on cognitive-motor interference: a case-control study on dual-tasking in persons with bilateral vestibulopathy and normal hearing

Bilateral vestibulopathy (BV) is a chronic vestibular disorder, characterized by bilaterally absent or significantly impaired vestibular function. Symptoms typically include, but are not limited to, unsteadiness and movement-induced blurred vision (oscillopsia). This prospective case-control study aimed to elucidate the impact of BV on cognitive and motor performance and on cognitive-motor interference. Cognitive and motor performance, as well as cognitive-motor interference were measured in persons with BV and normal hearing using the 2BALANCE dual-task protocol. The experimental group was matched to a healthy control group based on age, sex, and educational level. The 2BALANCE protocol comprises cognitive tests assessing visuospatial memory, mental rotation, visual and auditory response inhibition, visual and auditory working memory, and processing speed. The cognitive tests were performed in single-task condition (while seated), and in dual-task condition (during a static and a dynamic motor task). The static motor task consisted of balancing on a force platform with foam pad. The dynamic motor task consisted of walking at a self-selected speed. These motor tasks were also performed in single-task condition. A generalized estimating equations model was used to investigate group differences for all cognitive and motor outcome measures. The estimated marginal means, as well as the odds ratios (OR), and their 95% confidence intervals (CI) were calculated. For the backward digit recall test, a baseline measurement was performed and analyzed using a student-t test. A total of 22 patients with BV and normal hearing and 22 healthy control subjects were assessed [mean age (SD), BV = 53.66 (13.35) and HC = 53.21 (13.35), 68% male]. The BV group had poorer mental rotation skills in single-task condition, compared to the control group [odds ratio (OR) = 2.30, confidence interval (CI) = 1.12-4.73, P  =  0.024]. Similarly, auditory and visual working memory were also poorer in the BV group in single-task condition (P = 0.028 and P = 0.003, respectively). The BV group also performed poorer on the mental rotation task and the visual response inhibition task in dual-task condition (OR = 2.96, CI = 1.57-5.59, P  <  0.001 and OR = 1.08, CI = 1.01-1.16, P  =  0.032, respectively). Additionally, an interaction effect, indicating increased cognitive-motor interference in the BV group, was observed for mental rotation, response inhibition, and auditory working memory (P  =  0.003 to 0.028). All static motor outcome parameters indicated more postural sway in the BV group compared to the control group for all test conditions (P  <  0.001 to 0.026). No group differences were noted for the dynamic motor task. These findings suggest a link between vestibular function and cognitive performance, as well as a greater interference between cognitive and motor performance in BV, compared to healthy controls.

Association of Bilateral Vestibulopathy With and Without Hearing Loss With Cognitive-Motor Interference

Importance

The past years, evidence suggested that the primary symptoms traditionally associated with bilateral vestibulopathy (BV) do not represent the full picture of this patient population. Recent literature also demonstrated cognitive impairment. However, although multitasking and dual-tasking are widely present in everyday activities, most of these studies assessed cognitive function only in single-task conditions.

Objective

To uncover the association of BV with and without hearing loss with cognitive and motor performance and cognitive-motor interference.

Design, Setting, and Participants

This prospective case-control study assessed persons with an isolated BV and persons with BV and a concomitant hearing loss compared with a healthy control group. Data were analyzed in December 2022. The study was conducted at Ghent University (Ghent, Belgium). Data collection took place between March 26, 2021, and November 29, 2022.

Main Outcomes and Measures

All participants completed the 2BALANCE dual-task protocol, comprising a static and a dynamic motor task that was combined with 5 visual cognitive tasks. These cognitive tasks assessed mental rotation, visuospatial memory, working memory, response inhibition (executive function), and processing speed. All cognitive tasks were performed in a single-task condition (while seated) and in a dual-task condition (combined with a static and a dynamic motor task). The static task comprised balancing on a force platform with foam pad, and the dynamic task comprised walking at a self-selected speed on the GAITRite Walkway. Both motor tasks were performed in the single-task and dual-task condition.

Results

Nineteen persons with BV and hearing loss (mean [SD] age, 56.70 [10.12] years; 10 women [52.6%]), 22 persons with an isolated BV (mean [SD] age, 53.66 [13.35] years; 7 women [31.8%]), and 28 healthy control participants were included (mean [SD] age, 53.73 [12.77] years; 12 women [42.9%]). Both patient groups had mental rotation and working memory impairment in a single-task condition and slower processing speed when walking (ie, during the dynamic dual-task condition). Additionally, the patient group with hearing loss had impaired visuospatial memory and executive function deficits in single-task and dual-task conditions, while this could only be elicited when performing a motor task in persons with isolated BV (ie, when dual-tasking).

Conclusion and Relevance

The findings of this case-control study suggest an association between vestibular function and cognitive and motor performance, even greater in persons with a concomitant hearing loss than in persons with an isolated BV.

Hearing loss versus vestibular loss as contributors to cognitive dysfunction

In the last 5 years, there has been a surge in evidence that hearing loss (HL) may be a risk factor for cognitive dysfunction, including dementia. At the same time, there has been an increase in the number of studies implicating vestibular loss in cognitive dysfunction. Due to the fact that vestibular disorders often present with HL and other auditory disorders such as tinnitus, it has been suggested that, in many cases, what appears to be vestibular-related cognitive dysfunction may be due to HL (e.g., Dobbels et al. Front Neurol 11:710, 2020). This review analyses the studies of vestibular-related cognitive dysfunction which have controlled HL. It is suggested that despite the fact that many studies in the area have not controlled HL, many other studies have (~ 19/44 studies or 43%). Therefore, although there is certainly a need for further studies controlling HL, there is evidence to suggest that vestibular loss is associated with cognitive dysfunction, especially related to spatial memory. This is consistent with the overwhelming evidence from animal studies that the vestibular system transmits specific types of information about self-motion to structures such as the hippocampus.

An Auditory Stroop Test to Implement in Cognitive Hearing Sciences: Development and Normative Data

Objective:

This study developed and gained insight in an auditory Stroop test, implementable in cognitive hearing sciences.

Methods:

An auditory Stroop test was developed and performed in 178 participants, aged between 18 and 69 years. This Auditory Stroop test consisted of two tests: Stroop-tones and Stroop-words whereby the pitch of pure-tones and spoken words (i.e., the words high and low) had to be identified by high or low, respectively. An interference score was calculated as a measure of verbal executive functioning. Regression models were conducted to examine the effect of age, sex, education, awakeness, hearing, as well as visual and verbal working memory, and processing speed on the auditory Stroop scores. Normative data were obtained per age decade.

Results:

Compared to the visual counterparts, the auditory Stroop outcomes were better predicted by verbal working memory and processing speed. A trend was observed showing a decrease in performances with increasing age. No other participant-related variables had a significant relationship with the auditory Stroop test.

Conclusion:

This auditory Stroop test was considered a good test for measuring executive functioning using auditory stimuli. Implementing this auditory Stroop test within cognitive hearing sciences will contribute to unravel the auditory-cognitive perspective of speech understanding.

Balanced Growth project: a protocol of a single-centre observational study on the involvement of the vestibular system in a child's motor and cognitive development

INTRODUCTION

The involvement of the vestibular system in the motor and higher (cognitive) performances of typically developing or vestibular-impaired children is currently unknown or has only scarcely been explored. Interestingly, arguments for an interaction between vestibular, motor and cognitive functions in children can also be supported by research on children known for their difficulties in motor and/or cognitive processing (eg, children with neurodevelopmental disorders (NDD)), as they often present with vestibular-like characteristics. Therefore, in order to elucidate this interaction, and to increase the understanding of the pathophysiology and symptomatology of vestibular disorders and NDD in children, the Balanced Growth project was developed. It includes the following objectives: (1) to understand the association between motor skills, cognitive performances and the vestibular function in typically developing school-aged children, with special focus on the added value of the vestibular system in higher cognitive skills and motor competence; (2) to investigate whether a vestibular dysfunction (with/without an additional auditory disease) has an impact on motor skills, cognitive performances and motor-cognitive interactions in children and (3) to assess if an underlying vestibular dysfunction can be identified in school-aged children with NDD, with documentation of the occurrence and characteristics of vestibular dysfunctions in this group of children using an extensive vestibular test battery.

METHODS AND ANALYSIS

In order to achieve the objectives of the observational cross-sectional Balanced Growth study, a single-task and dual-task test protocol was created, which will be performed in three groups of school-aged children (6-12 years old): (1) a typically developing group (n=140), (2) (audio) vestibular-impaired children (n=30) and (3) children with an NDD diagnosis (n=55) (ie, autism spectrum disorder, attention deficit/hyperactivity disorder and/or developmental coordination disorder). The test protocol consists of several custom-made tests and already existing validated test batteries and includes a vestibular assessment, an extensive motor assessment, eight neurocognitive tests, a cognitive-motor interaction assessment and includes also additional screenings to control for potential confounding factors (eg, hearing status, intelligence, physical activity, etc).

ETHICS AND DISSEMINATION

The current study was approved by the ethics committee of Ghent University Hospital on 4 June 2019 with registration number B670201940165 and is registered at Clinical Trials (clinicaltrials.gov) with identifier NCT04685746. All research findings will be disseminated in peer-reviewed journals and presented at vestibular as well as multidisciplinary international conferences and meetings.

TRIAL REGISTRATION NUMBER

NCT04685746.

Paving the Way Toward Distinguishing Fallers From Non-fallers in Bilateral Vestibulopathy: A Wide Pilot Observation

Patients with bilateral vestibulopathy (BVP) present with unsteadiness during standing and walking, limiting their activities of daily life and, more importantly, resulting in an increased risk of falling. In BVP patients, falls are considered as one of the major complications, with patients having a 31-fold increased risk of falling compared to healthy subjects. Thus, highlighting objective measures that can easily and accurately assess the risk of falling in BVP patients is an important step in reducing the incidence of falls and the accompanying burdens. Therefore, this study investigated the interrelations between demographic characteristics, vestibular function, questionnaires on self-perceived handicap and balance confidence, clinical balance measures, gait variables, and fall status in 27 BVP patients. Based on the history of falls in the preceding 12 months, the patients were subdivided in a "faller" or "non-faller" group. Results on the different outcome measures were compared between the "faller" and "non-faller" subgroups using Pearson's chi-square test in the case of categorical data; for continuous data, Mann-Whitney U test was used. Performances on the clinical balance measures were comparable between fallers and non-fallers, indicating that, independent from fall status, the BVP patients present with an increased risk of falling. However, fallers tended to report a worse self-perceived handicap and confidence during performing activities of daily life. Spatiotemporal parameters of gait did not differ between fallers and non-fallers during walking at slow, preferred, or fast walking speed. These results may thus imply that, when aiming to distinguish fallers from non-fallers, the BVP patients' beliefs concerning their capabilities may be more important than the moderately or severely affected physical performance within a clinical setting. Outcome measures addressing the self-efficacy and fear of falling in BVP patients should therefore be incorporated in future research to investigate whether these are indeed able to distinguish fallers form non-fallers. Additionally, information regarding physical activity could provide valuable insights on the contextual information influencing behavior and falls in BVP.