The effect of virtual reality on visual vertigo symptoms in patients with peripheral vestibular dysfunction: a pilot study

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.

Computerized Dynamic Posturography-Guided Vestibular Rehabilitation Improves Vestibular Sensory Ratios

Background: Vestibular deficits are common and debilitating, and many patients struggle with dynamic balance, even after treatment with standard rehabilitation techniques. Objective: The objective of this study was to measure changes in computerized dynamic posturography sensory ratio information after computerized vestibular retraining therapy (CVRT). Methods: This prospective, single-group, interventional study enrolled adult participants with stable, unilateral vestibular deficits. Sensory ratios were obtained from sensory organization test scores before and after 12 twice-weekly sessions of CVRT. Results: Prior to CVRT, sensory organization test ratios indicated significant difficulty maintaining equilibrium on the moving, sway-referenced platform. After CVRT, the visual ratio (VIS) increased by 0.12 (-0.09 to 0.30; P = .0498), the vestibular ration (VEST) increased by 0.10 (-0.060 to 0.25; P = .0122), and the dynamic stability ration (DSR) increased by 0.15 (0.03 to 0.24; P = .0012). The somatosensory and visual preference ratios changed negligibly. Participants with mild disability [Dizziness Handicap Inventory (DHI) ≤30] showed no change while participants with moderate-to-severe disability (DHI >30) had significant improvements in VIS, VEST, and DSR. Conclusions: CVRT was associated with changes in VIS and VEST sensory ratios and improved postural control under conditions that favor use of vestibular information, consistent with increased weighting of vestibular information over vision (Clinicaltrials.gov registration NCT04875013; April 27, 2021).

Predictors of Chronic Dizziness in Acute Unilateral Vestibulopathy: A Longitudinal Prospective Cohort Study

OBJECTIVE

Chronic dizziness after acute unilateral vestibulopathy (AUVP) causes significant social and economic burdens. This study aims to identify predictors of chronic dizziness.

STUDY DESIGN

Prospective, longitudinal cohort study.

SETTING

ENT departments from secondary and tertiary hospitals.

METHODS

Participants meeting the Barany Society's diagnostic criteria for AUVP were included. Evaluations occurred within 0 to 21 days (T1), and at 4 (T2) and 10 weeks (T3) postonset. The primary outcome measure was the Dizziness Handicap Inventory (DHI) at 6 months, with a score >30 indicating chronic dizziness. Five clusters of predictors were assessed at T1-3: central vestibular compensation, visual dependence, movement exposure, psychological factors, and balance performance. Separate linear regression models for T1, T2, and T3 were constructed to explain the variability in the 6-month DHI score. Receiver operating characteristics analyses were conducted to predict chronic dizziness.

RESULTS

From June 2021 to January 2024, 103 participants (55.2 ± 16.6 years old, 49 women) were included. The regression models explained the variability in the 6-month DHI score by 33.0% at T1, 47.6% at T2, and 64.0% at T3 (P < .001), including psychological factors (T1, T2, T3), visual dependence (T2, T3), and static balance performance (T3). Cutoff values for the Vestibular Activities Avoidance Instrument (23/54), Visual Vertigo Analog Scale (33.5/100), and Hospital Anxiety and Depression Scale-Anxiety (7.5/21) at 10 weeks postonset predicted chronic dizziness.

CONCLUSION

Higher psychological burden, increased visual dependence, and poorer static balance performance were associated with chronic dizziness. Cutoff values were determined to identify individuals with AUVP at risk for chronic dizziness.

The comparison between intratympanic gentamicin prehabilitation and postoperative virtual reality exposure to standard vestibular training in patients with vestibular schwannoma

OBJECTIVE

Resection of the vestibular schwannoma causes acute peripheral vestibular loss. The process of central compensation starts immediately afterward. The rehabilitation goal is to support this process and restore the quality of life.

MATERIALS AND METHODS

In this prospective single-center study, 67 consecutive patients underwent vestibular schwannoma resection (40 females, mean age 52 ± 12 years). The patients were divided into three groups: the prehabilitation with intratympanic gentamicin group, the virtual reality group (optokinetic stimulation via virtual reality goggles in the first ten days after the surgery), and the control group. All patients were examined with objective methods and completed questionnaires before the prehabilitation, before the surgery, at the hospital discharge, and after three months.

RESULTS

Intratympanic gentamicin prehabilitation leads ipsilaterally to a significant aVOR reduction in all semicircular canals (p < 0.050), the increase of the unilateral weakness in air calorics (p = 0.026), and loss of cVEMPs responses (p = 0.017). Prehabilitation and postoperative exposure to virtual reality scenes improved the patient's perception of vertigo problems according to Dizziness Handicap Inventory (p = 0.039 and p = 0.076, respectively). These findings conform with the optokinetic testing results, which showed higher slow phase velocities at higher speeds (40 deg/s) in both targeted groups compared to the control group.

CONCLUSION

Preoperative intratympanic gentamicin positively affects peripheral vestibular function, influencing balance perception after VS resection. In long-term follow-up, prehabilitation and postoperative exposure to virtual reality improve patients' quality of life in the field of vertigo problems.

Training of spatial cognitive abilities reduces symptoms of visually induced motion sickness

Purpose

This study aims to explore the effectiveness of enhancing individual spatial cognitive abilities in alleviating the negative symptoms of visually induced motion sickness (VIMS). Additionally, it seeks to develop innovative intervention methods to improve spatial cognition and identify new treatment approaches for VIMS.

Methods

The study investigated the impact of innovative interventions on spatial cognitive abilities and their modulation of VIMS susceptibility. A total of 43 participants were recruited (23 in the experimental group and 20 in the control group). The experimental group underwent six sessions of spatial cognitive ability training, while the control group engaged in activities unrelated to spatial cognition.

Results

The analysis revealed that the spatial cognitive ability scores of the experimental group significantly improved after the intervention. Furthermore, the experimental group exhibited significant differences in nausea, oculomotor, disorientation, and total SSQ scores before and after the intervention, indicating that the intervention effectively mitigated VIMS symptoms.

Conclusion

This study developed a virtual reality training method that effectively enhances individual spatial cognitive abilities and significantly alleviates VIMS symptoms, providing a novel and effective approach for VIMS intervention and treatment.

Optokinetic stimulation for the treatment of vestibular and balance disorders: a systematic review with meta-analysis

OBJECTIVES

To analyse the effectiveness of optokinetic stimulation (OKS) for improving symptoms and function in patients with vestibular and balance disorders.

METHODS

PubMed (MEDLINE), SCOPUS, Web of Science (WOS), CINAHL Complete, and PEDro databases were searched to identify randomized controlled trials (RCTs) that included patients with vestibular and balance disorders and compared the effects of OKS versus other interventions or no intervention on subjective or objective functional outcomes. Data were analysed by the standardized mean difference (SMD) and its 95% confidence interval.

RESULTS

A total of 10 studies were selected including 468 patients, 177 of whom received OKS. There were no significant differences in scores on the Dizziness Handicap Inventory (DHI) (SMD = 0.02; 95% CI - 0.18 to 0.23; p = 0.83) or the visual analogue scale (VAS) for vertigo (SMD = 0.16; 95% CI - 1.25 to 1.58; p = 0.82). However, there were statistically significant differences in the timed up and go (TUG) test, with a large effect (SMD = - 1.13; 95% CI -2 to - 0.28; p = 0.009), and in the sensory organization test (SOT), with a medium effect (SMD = - 0.7; 95% CI - 1.21 to - 0.19; p = 0.007). Subgroup analysis showed significant effects of OKS on VAS (p = 0.017), TUG (p = 0.009) and SOT (p = 0.001) only in patients with balance disorders without vestibular disease (p > 0.05).

CONCLUSIONS

OKS may improve dizziness intensity measured with VAS or dynamic balance measured whit TUG and SOT in patients with balance disorders not due to vestibular disease. The quality of the evidence was low or very low due to the small number of included studies.

PROSPERO REGISTRY NUMBER

CRD42023445024.

Optokinetic stimulation in the rehabilitation of visually induced dizziness in people with vestibular disorders: A systematic review

OBJECTIVE

This systematic review and meta-analysis investigates the effects optokinetic stimulation in people with vestibular disorders, with a specific focus on people with visually induced dizziness.

DATA SOURCES

A systematic review was conducted using three electronic databases, CINAHL, PubMed and Physiotherapy Evidence Database (PEDro), from 2000 up to February 2024.

REVIEW METHODS

Randomised controlled trials were included, which compared: (a) adults above 18 years old with vestibular disorders, (b) the study evaluated interventions using optokinetic stimulation, (c) the intervention was compared with usual care; placebo or to no intervention, (d) the study included at least one outcome measure evaluating vestibular symptoms and (e) published in English. The methodological quality of the included studies was assessed using the PEDro scale and PROSPERO's registration number ID: CRD42021273382).

RESULTS

Eleven randomised control trials, reported in 12 records, fulfilled the inclusion criteria. All of the studies were considered to have 'good' methodological quality according to the PEDro scale. All studies showed significant improvement in vestibular symptoms in both the intervention and control groups. A meta-analysis performed on six of the records found a preference towards the addition of OKS to conventional vestibular rehabilitation helped to further reduce dizziness symptoms for patients, but the results were not statistically significant.

CONCLUSION

No optimal duration or frequency for OKS has been determined. The addition of OKS to conventional vestibular rehabilitation may be beneficial in further improving vestibular symptoms in patients with dizziness. OKS could help to improve enjoyment and adherence to vestibular rehabilitation.

Three-dimensional exergaming conjunction with vestibular rehabilitation in individuals with Benign Paroxysmal Positional Vertigo: A feasibility randomized controlled study

BACKGROUND

To examine the effectiveness of 3D (dimensional)-vestibular rehabilitation therapy (VRT) on gait, balance problems, processing time speed and subjective complaints in patients with Benign Paroxysmal Positional Vertigo (BPPV) compared to a control group (CG). This study aimed to test the feasibility of virtual reality-based 3D exergaming conjunction with vestibular rehabilitation.

METHODS

Twenty-two patients with BPPV (negative DixHallpike/Roll test results, existing dizziness/balance complaints) were randomly allocated to the study group (SG, n:11 3D-VRT) or Control group (CG n:11, no exercise-rehabilitation) for 8 week. The SG performed 3D-VRT for 45 to 50 min/d, 3 times/wk, and the CG did receive only Canalith Repositioning Maneuver (CRM). CRM was applied in both groups before the study. Outcome measures included 10-Meter-Walk-Test (10-MWT) (with/without head turns), Dynamic Gait Index (DGI), Choice-Stepping-Reaction-Time-ped (CSRT-MAT), Fullerton Advanced Balance Scale (FAB), and Visual Analog Scale (VAS).

RESULTS

The SG showed significantly improvement in 10-MWT without (p5 = 0.00,η2 = 0.49), with horizontal (p5 = 0.00,η2 = 0.57),vertical (p5 = 0.01,η2 = 0.48) head turns, DGI (p5 = 0.00,η2 = 0.74), CSRT-MAT, FAB (p5 = 0.00,η2 = 0.78) and VAS-dizziness (p5 = 0.00,η2 = 0.65), VAS-balance problem (p5 = 0.00,η2 = 0.43), VAS-fear of falling (p5 = 0.00,η2 = 0.42) compared to the CG.

CONCLUSION

The 3D-VRT were effective in improving gait, balance, processing speed and resolving the subjective complaints in BPPV. The 3D-VRT method is feasible for patients who suffer from residual dizziness or balance complaints after CRM. Furthermore, the 3D-VRT is more accessible and less expensive than other virtual reality applications, which may facilitate further research or clinical use.

Leveraging Technology for Vestibular Assessment and Rehabilitation in the Operational Environment: A Scoping Review

INTRODUCTION

The vestibular system, essential for gaze and postural stability, can be damaged by threats on the battlefield. Technology can aid in vestibular assessment and rehabilitation; however, not all devices are conducive to the delivery of healthcare in an austere setting. This scoping review aimed to examine the literature for technologies that can be utilized for vestibular assessment and rehabilitation in operational environments.

MATERIALS AND METHODS

A comprehensive search of PubMed was performed. Articles were included if they related to central or peripheral vestibular disorders, addressed assessment or rehabilitation, leveraged technology, and were written in English. Articles were excluded if they discussed health conditions other than vestibular disorders, focused on devices or techniques not conducive to the operational environment, or were written in a language other than English.

RESULTS

Our search strategy yielded 32 articles: 8 articles met our inclusion and exclusion criteria whereas the other 24 articles were rejected.

DISCUSSION

There is untapped potential for leveraging technology for vestibular assessment and rehabilitation in the operational environment. Few studies were found in the peer-reviewed literature that described the application of technology to improve the identification of central and/or peripheral vestibular system impairments; triage of acutely injured patients; diagnosis; delivery and monitoring of rehabilitation; and determination of readiness for return to duty.

CONCLUSIONS

This scoping review highlighted technology for vestibular assessment and rehabilitation feasible for use in an austere setting. Such technology may be leveraged for prevention; monitoring exposure to mechanisms of injury; vestibular-ocular motor evaluation; assessment, treatment, and monitoring of rehabilitation progress; and return-to-duty determination after vestibular injury.

FUTURE DIRECTIONS

The future of vestibular assessment and rehabilitation may be shaped by austere manufacturing and 3D printing; artificial intelligence; drug delivery in combination with vestibular implantation; organ-on-chip and organoids; cell and gene therapy; and bioprinting.

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.

3D Virtual Reality Rehabilitation Therapy for Patients with Vertigo Due to Peripheral Vestibular Dysfunction

This study aimed to evaluate 3D virtual reality rehabilitation therapy in patients with vertigo due to peripheral vestibular dysfunction. The subjects were 20 patients with peripheral vestibular dysfunction confirmed by Videonystagmography, Divided into 2 groups: Group 1 (study group) underwent vestibular rehabilitation therapy using 3D virtual reality in a customised VR lab with specific headset (Oculus rift and htc vive) with software application, which allows vestibular rehabilitation treatment using high quality immersive virtual reality console in which environment appears real and in 3D. The exercises are designed for gaze stability, increase postural stability, improve vertigo and daily activities, through sensory stimuli and in addition to conventional Cawthorne-Choksey exercises. Group 2 (control group) are treated by conventional Cawthorne-Choksey exercises alone. A VSS-SF (Vertigo Symptom Scale-short form) questionnaire and VAS (Visual Analog Scale) were used to assess the levels of patient satisfaction compared before and after each treatment session in both groups. A significant higher level of subjective satisfaction was observed in patients who underwent 3D virtual reality rehabilitation therapy with conventional therapy (group 1) compared to patients who underwent conventional cawthorne-Choksey exercises alone (group 2). The study gave a substantial subjective satisfaction in patients using 3D virtual reality rehabilitation therapy with conventional therapy (group1) than conventional Cawthorne-Choksey exercises alone (group 2). Future of VR rehabilitation therapy brings a revolutionary novelty in field of rehabilitation therapy were it involves real time stimulation and interaction between sensory, motor and cognitive channels.

Vestibular rehabilitation potential of commercially available virtual reality video games

BACKGROUND

Peripheral vestibular disorders affect 2.8-6.5% of people. Standard treatment is vestibular rehabilitation therapy, and virtual reality (VR) could improve outcomes. The objective of this study was to identify the commercially available VR video game that is most congruent to vestibular rehabilitation therapy.

METHODS

A term search "virtual reality racing" was performed on the App Store in March 2022. Results were screened for free point-of-view racing games compatible with Android and iOS devices. An investigator was filmed playing each game and videos were distributed to 237 physiotherapists. Physiotherapists completed a survey of 5-point Likert scale questions that assessed the video games vestibular rehabilitation potential. Survey responses were analyzed using Friedman Two-Way ANOVA (alpha = 0.05) and paired samples sign test with Bonferroni correction.

RESULTS

The search yielded 58 games, 4 were included. Forty physiotherapists participated. VR Tunnel Race (VRTR) and VR Real World Bike Racing (VRWBR) had the greatest vestibular rehabilitation potential (median global scores = 18.00). VRTR replicated habituation exercises significantly (p < 0.001) better than Derby VR, and VRWBR replicated physiotherapist-prescribed exercises significantly (p < 0.001) better than VR X-Racer. There were no discernable significant differences between VRWBR and VRTR.

CONCLUSIONS

VRTR and VRWBR are the most congruent VR games to standard vestibular rehabilitation. VRWBR is preferable to VRTR with respect to ease of use and the ability to alter the amount of optokinetic stimulation. Prospective studies are needed to confirm the efficacy of these videos games and to determine if they could be used as solitary treatments.

TRIAL REGISTRATION

Not applicable.

Effectiveness of virtual reality-based programs as vestibular rehabilitative therapy in peripheral vestibular dysfunction: a meta-analysis

PURPOSE

To study the efficacy of virtual reality (VR) interventional programs as a vestibular rehabilitative method for patients with uncompensated peripheral vestibular disorders.

METHODS

The databases PubMed, Google scholar, Embase and Cochrane Library were used (up to July 2021). Studies selected in this study were controlled trials in which virtual reality was used as vestibular rehabilitative therapy in comparison to any other vestibular rehabilitative methods or medical or dietary recommendations. Comparison was made in at least one of these outcomes measures; Subjective measures such as Dizziness Handicap Inventory, Vertigo Symptom Scale-Short Form questionnaire, Activities-specific Balance Confidence questionnaire, Dizziness Analogue Scale or Visual Analogue Scale, besides objective measures as posturography. Six articles were included in the meta-analysis; tested for heterogeneity of the estimates using chi-squared and I2 tests, outcomes were expressed as mean difference and 95% CI. Estimates from included studies were pooled using the random-effect model.

RESULTS

virtual reality as a vestibular rehabilitative intervention was able to improve scores of Dizziness Handicap Inventory, Vertigo Symptom Scale-Short Form questionnaire, Visual Analogue sale and posturography as outcome measures of vestibular rehabilitation.

CONCLUSION

virtual reality has a potential clinical benefit for vestibular rehabilitation in peripheral vestibular dysfunction compared with conventional vestibular rehabilitation methods. However, further research is needed to document the exact parameters of an optimal protocol for virtual reality rehabilitation, the period needed for effective rehabilitation and its side effects.

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.

Systematic Review and Meta-Analysis of the Application of Virtual Reality in Hearing Disorders

Background and Objectives

Trendy technologies, such as artificial intelligence, virtual reality (VR), and augmented reality (AR) are being increasingly used for hearing loss, tinnitus, and vestibular disease. Thus, we conducted this systematic review and meta-analysis to identify the possible benefits of the use of VR and AR technologies in patients with hearing loss, tinnitus, and/or vestibular dysfunction, with the aim of suggesting potential applications of these technologies for both researchers and clinicians.

Materials and Methods

Published articles from 1968 to 2022 were gathered from six electronic journal databases. Applying our specified inclusion and/or exclusion criteria, 23 studies were analyzed. As only one article on hearing loss and two articles on tinnitus were found, 20 studies on vestibular dysfunction were only finally included for the meta-analysis. Standardized mean differences (SMDs) were chosen as estimates to compare the studies. A funnel plot and Egger’s regression analysis were used to identify any risk of bias.

Results

High heterogeneity (I²: 83%, τ²: 0.5431, p<0.01) was identified across the studies on vestibular dysfunction. VR-based rehabilitation was significantly effective for individuals with vestibular disease (SMDs: 0.03, 95% confidence interval [CI]: -0.08 to 0.15, p<0.05). A subgroup analysis revealed that only improvement in the subjective questionnaire was meaningful and statistically significant (SMDs: -0.66, 95% CI: -1.10 to -0.22).

Conclusions

VR-based vestibular rehabilitation showed potential for subjective rating measures like Dizziness Handicap Index. The negative effect of aging on vestibular disease was indirectly confirmed. More clinical trials and an evidence-based approach are needed to confirm the implementation of state-of-the-art technology for hearing loss and tinnitus, representative diseases in neurotology.

The potential use of virtual reality in vestibular rehabilitation of motion sickness

OBJECTIVE

Motion sickness (MS) can be triggered by direct or indirect stimuli due to mismatches in the visual-vestibular autonomic pathways. Various studies in the literature have shown that virtual reality technologies can generate provocative stimuli for MS. Therefore, our primary aim is to investigate the usability of virtual reality systems in MS rehabilitation METHODS: 20 normal and 19 MS patients were included. A total of six virtual reality rehabilitation sessions (VRrs) with a game called "Roller Coaster Dreams" playable via PlayStation VR Head Mounted Display were applied thrice a week for 2 weeks, or twice a week for 3 weeks. Participants were evaluated at the pre-rehabilitation phase twice and after third and sixth rehabilitation sessions with the sensory organization test (SOT). The effectiveness of the rehabilitation program was statistically analyzed by comparing the results of SOTs.

RESULTS

All SOT results of the patient group were compared each other to evaluate the effectiveness of rehabilitation. According to the post-hoc comparisons, a statistically significant difference was found between the 1st, 2nd, 3rd, and 4th SOT- Equilibrium Scores; Condition 2 (p = 0.043), Condition 3 (p = 0.006), Condition 4 (p = 0.031), Condition 5 (p = 0.002) and Condition 6 (p = 0.040). There is no difference obtained in Condition 1 (p > 0.05). The Equilibrium Scores of SOT 3rd and SOT 4th were similar and 4th SOT-Equilibrium Scores were the highest among all SOT measurements. The results show that while the first three sessions were accepted as an orientation and adaptation sessions, 4^th, 5^thand 6^th sessions are habilitation sessions.

CONCLUSIONS

VR proved to be significantly effective and useful for MS rehabilitation. Additionally, observations indicated that using VR makes rehabilitation fun, increases the efficiency of the process, and reduces the risk of inadaptability to exercise.

Persistent Postural-Perceptual Dizziness Interventions—An Embodied Insight on the Use Virtual Reality for Technologists

Persistent and inconsistent unsteadiness with nonvertiginous dizziness (persistent postural-perceptual dizziness (PPPD)) could negatively impact quality of life. This study highlights that the use of virtual reality (VR) systems offers bimodal benefits to PPPD, such as understanding symptoms and providing a basis for treatment. The aim is to develop an understanding of PPPD and its interventions, including current trends of VR involvement to extrapolate and re-evaluate VR design strategies. Therefore, recent virtual-reality-based research work that progressed in understanding PPPD is identified, collected, and analysed. This study proposes a novel approach to the understanding of PPPD, specifically for VR technologists, and examines the principles of effectively aligning VR development for PPPD interventions.

Visually Evoked Postural Responses (VEPRs) in Children with Vestibular Migraine

Vestibular migraine (VM) is the most common cause of episodic vertigo in children. Vertigo, nausea, dizziness and unsteadiness are often complained of by children with migraine, which can precede, follow or be present simultaneously with headache. The aim of this study was to use posturography to investigate the visually evoked postural responses (VEPRs) of children with VM and compare them to data obtained from children with primary headache (M) and controls (C). Twenty children diagnosed as affected by VM, nineteen children with M without aura and twenty healthy subjects were recruited in this cross-sectional study. Posturography was performed by a standardized stabilometric force-platform (Svep-Politecnica) in the following conditions: open eyes (OE), closed eyes (CE) and during full-field horizontal optokinetic stimulation (OKN-S). Electronystagmography was performed simultaneously to analyze optokinetic reflex parameters. In the OE condition, no difference was found between groups with respect to body sway area. In contrast, this parameter increased in the two pathological groups with respect to controls in the CE condition. The optokinetic stimulations also induced a similar increase of body sway area in the M group relative to controls, but a further increase was elicited in the VM group. Electronystagmographic recording also revealed different optokinetic reflex parameters in the latter groups. This study disclosed an abnormal sensitivity of children with M and VM to full-field moving scenes and a consequent destabilization of posture, as documented by the abnormal VEPRs. Children with VM were particularly exposed to this risk. Possible clinical implications of these findings are discussed.

Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Updated Clinical Practice Guideline From the Academy of Neurologic Physical Therapy of the American Physical Therapy Association

Background:

Uncompensated vestibular hypofunction can result in symptoms of dizziness, imbalance, and/or oscillopsia, gaze and gait instability, and impaired navigation and spatial orientation; thus, may negatively impact an individual's quality of life, ability to perform activities of daily living, drive, and work. It is estimated that one-third of adults in the United States have vestibular dysfunction and the incidence increases with age. There is strong evidence supporting vestibular physical therapy for reducing symptoms, improving gaze and postural stability, and improving function in individuals with vestibular hypofunction. The purpose of this revised clinical practice guideline is to improve quality of care and outcomes for individuals with acute, subacute, and chronic unilateral and bilateral vestibular hypofunction by providing evidence-based recommendations regarding appropriate exercises.

Methods:

These guidelines are a revision of the 2016 guidelines and involved a systematic review of the literature published since 2015 through June 2020 across 6 databases. Article types included meta-analyses, systematic reviews, randomized controlled trials, cohort studies, case-control series, and case series for human subjects, published in English. Sixty-seven articles were identified as relevant to this clinical practice guideline and critically appraised for level of evidence.

Results:

Based on strong evidence, clinicians should offer vestibular rehabilitation to adults with unilateral and bilateral vestibular hypofunction who present with impairments, activity limitations, and participation restrictions related to the vestibular deficit. Based on strong evidence and a preponderance of harm over benefit, clinicians should not include voluntary saccadic or smooth-pursuit eye movements in isolation (ie, without head movement) to promote gaze stability. Based on moderate to strong evidence, clinicians may offer specific exercise techniques to target identified activity limitations and participation restrictions, including virtual reality or augmented sensory feedback. Based on strong evidence and in consideration of patient preference, clinicians should offer supervised vestibular rehabilitation. Based on moderate to weak evidence, clinicians may prescribe weekly clinic visits plus a home exercise program of gaze stabilization exercises consisting of a minimum of: (1) 3 times per day for a total of at least 12 minutes daily for individuals with acute/subacute unilateral vestibular hypofunction; (2) 3 to 5 times per day for a total of at least 20 minutes daily for 4 to 6 weeks for individuals with chronic unilateral vestibular hypofunction; (3) 3 to 5 times per day for a total of 20 to 40 minutes daily for approximately 5 to 7 weeks for individuals with bilateral vestibular hypofunction. Based on moderate evidence, clinicians may prescribe static and dynamic balance exercises for a minimum of 20 minutes daily for at least 4 to 6 weeks for individuals with chronic unilateral vestibular hypofunction and, based on expert opinion, for a minimum of 6 to 9 weeks for individuals with bilateral vestibular hypofunction. Based on moderate evidence, clinicians may use achievement of primary goals, resolution of symptoms, normalized balance and vestibular function, or plateau in progress as reasons for stopping therapy. Based on moderate to strong evidence, clinicians may evaluate factors, including time from onset of symptoms, comorbidities, cognitive function, and use of medication that could modify rehabilitation outcomes.

Discussion:

Recent evidence supports the original recommendations from the 2016 guidelines. There is strong evidence that vestibular physical therapy provides a clear and substantial benefit to individuals with unilateral and bilateral vestibular hypofunction.

Limitations:

The focus of the guideline was on peripheral vestibular hypofunction; thus, the recommendations of the guideline may not apply to individuals with central vestibular disorders. One criterion for study inclusion was that vestibular hypofunction was determined based on objective vestibular function tests. This guideline may not apply to individuals who report symptoms of dizziness, imbalance, and/or oscillopsia without a diagnosis of vestibular hypofunction.

Disclaimer:

These recommendations are intended as a guide to optimize rehabilitation outcomes for individuals undergoing vestibular physical therapy. The contents of this guideline were developed with support from the American Physical Therapy Association and the Academy of Neurologic Physical Therapy using a rigorous review process. The authors declared no conflict of interest and maintained editorial independence.

Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A369).

Brain Correlates of Persistent Postural-Perceptual Dizziness: A Review of Neuroimaging Studies

Persistent postural-perceptual dizziness (PPPD), defined in 2017, is a vestibular disorder characterized by chronic dizziness that is exacerbated by upright posture and exposure to complex visual stimuli. This review focused on recent neuroimaging studies that explored the pathophysiological mechanisms underlying PPPD and three conditions that predated it. The emerging picture is that local activity and functional connectivity in multimodal vestibular cortical areas are decreased in PPPD, which is potentially related to structural abnormalities (e.g., reductions in cortical folding and grey-matter volume). Additionally, connectivity between the prefrontal cortex, which regulates attentional and emotional responses, and primary visual and motor regions appears to be increased in PPPD. These results complement physiological and psychological data identifying hypervigilant postural control and visual dependence in patients with PPPD, supporting the hypothesis that PPPD arises from shifts in interactions among visuo-vestibular, sensorimotor, and emotional networks that overweigh visual over vestibular inputs and increase the effects of anxiety-related mechanisms on locomotor control and spatial orientation.

Virtual and augmented reality in the vestibular rehabilitation of peripheral vestibular disorders: systematic review and meta-analysis

Vestibular rehabilitation therapy is an established treatment for patients with vestibular dysfunction. Virtual reality (VR) and augmented reality (AR) can be utilised in vestibular rehabilitation. Evidence of the efficacy of VR and AR delivered rehabilitation in patients with peripheral vestibular disorders is reviewed. MEDLINE, EMBASE, CENTRAL, CINAHL, PsychInfo, PsychBITE, OTSeeker, Ei Compendex, IEE, Clinical trials.gov and WebofScience databases were searched. Reduction in vestibular dysfunction symptoms 0-3 months post-intervention was the primary outcome. Secondary outcomes included long-term symptom improvement and side effects. Risk of bias assessment and meta analyses were planned. Five studies meeting eligibility criteria were included. Dizziness Handicap Inventory (DHI) scores 0-3 months post-intervention were reported by four studies. Meta-analysis identified a 1.13 (95% CI, - 1.74, - 0.52) standardized mean difference reduction in DHI in VR and AR treated patients compared to controls. Side effects reported by two studies were reduced by week four of VR intervention. Bias assessment identified DHI scores and side effects to be at high risk or of some concern. Adjunct VR interventions reduced patient DHI significantly more than vestibular rehabilitation alone 0-3 months post-intervention in adult patients diagnosed with unilateral vestibular disease. High quality studies are needed.

Customised vestibular rehabilitation with the addition of virtual reality based therapy in the management of persistent postural-perceptual dizziness

OBJECTIVE

Visual-vestibular mismatch patients experience persistent postural and perceptual dizziness. Previous studies have shown the benefit of vestibular rehabilitation for visual desensitisation using gaze stabilisation exercises and optokinetic stimulation. This study assessed the benefit of customised vestibular rehabilitation with visual desensitisation and virtual reality based therapy rehabilitation in the management of patients with persistent postural-perceptual dizziness.

METHODS

This retrospective study included 100 patients with Situational Characteristic Questionnaire scores of more than 0.9. All patients received virtual reality based therapy along with usual vestibular rehabilitation using gaze stabilisation exercises with a plain background followed by graded visual stimulation and optokinetic digital video disc stimulation. Patients' symptoms were assessed before and after vestibular rehabilitation using the Situational Characteristic Questionnaire, Generalised Anxiety Disorder Assessment-7, Nijmegen Questionnaire and Dizziness Handicap Inventory.

RESULTS

There were statistically significant improvements in Situational Characteristic Questionnaire scores, Nijmegen Questionnaire scores and Dizziness Handicap Inventory total score. However, there was a statistically insignificant difference in Generalised Anxiety Disorder Assessment-7 scores. There was a significant positive correlation between post-rehabilitation Situational Characteristic Questionnaire scores and other questionnaire results.

CONCLUSION

Incorporating virtual reality based therapy with customised vestibular rehabilitation exercises results in significant improvement in persistent postural-perceptual dizziness related symptoms.

Virtual Reality for Vestibular Rehabilitation: A Systematic Review

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effect of vestibular exercise and optokinetic stimulation using virtual reality in persistent postural-perceptual dizziness

To determine the effect of customized vestibular exercise (VE) and optokinetic stimulation (OS) using a virtual reality system in patients with persistent postural-perceptual dizziness (PPPD). Patients diagnosed with PPPD were randomly assigned to the VE group or VE with OS group. All participants received VE for 20 min using a virtual reality system with a head mount display once a week for 4 weeks. The patients in the VE with OS group additionally received OS for 9 min. We analysed the questionnaires, timed up-to-go (TUG) test, and posturography scores at baseline and after 4 weeks. A total of 28 patients (median age = 74.5, IQR 66-78, men = 12) completed the intervention. From baseline to 4 weeks, the dizziness handicap inventory, activities of daily living (ADL), visual vertigo analogue scale, and TUG improved in the VE group, but only ADL and TUG improved in the VE with OS group. Patients with severe visual vertigo improved more on their symptoms than patients with lesser visual vertigo (Pearson's p = 0.716, p < 0.001). Our VE program can improve dizziness, quality of life, and gait function in PPPD; however, additional optokinetic stimuli should be applied for individuals with visual vertigo symptoms.

Visual-vestibular mismatch correlates with headache

BACKGROUND

Dizziness affects 20-30%of the general population. A subgroup of dizzy patients with chronic migraine suffers vertigo implying that the migraine has a vestibular component. Vestibular migraine remains a diagnosis of exclusion based on history.

OBJECTIVE

A link between headaches and dizziness suggests that these individuals would demonstrate dizziness and instability in complex, dynamic visual environments as a result of an inability to correctly process conflicting visual and vestibular signals.

METHODS

A convenience sample of 74 patients (22 men and 52 women; average age 56.2 years) who presented with complaints of dizziness participated. Effects of Visual-Vestibular Mismatch (VVM) were measured using a modified VVM questionnaire. Visual dependence was measured as the error to subjective visual vertical using a computerized Rod and Frame test.

RESULTS

Forty-two participants (56.8%) tested positive for VVM. Of these, 68.9%were patients with concomitant complaints of headaches. Visual dependence was present in 41.5%of all patients but showed no significant correlation with headache. 22.2%of patients had visual dependence and complained of headaches.

CONCLUSIONS

These results demonstrate that sensory reweighting occurs in patients experiencing dizziness and headache, supports the role of vestibular involvement in this disorder, and provides future direction for novel interventions.

The Untapped Potential of Virtual Reality in Rehabilitation of Balance and Gait in Neurological Disorders

Dynamic systems theory transformed our understanding of motor control by recognizing the continual interaction between the organism and the environment. Movement could no longer be visualized simply as a response to a pattern of stimuli or as a demonstration of prior intent; movement is context dependent and is continuously reshaped by the ongoing dynamics of the world around us. Virtual reality is one methodological variable that allows us to control and manipulate that environmental context. A large body of literature exists to support the impact of visual flow, visual conditions, and visual perception on the planning and execution of movement. In rehabilitative practice, however, this technology has been employed mostly as a tool for motivation and enjoyment of physical exercise. The opportunity to modulate motor behavior through the parameters of the virtual world is often ignored in practice. In this article we present the results of experiments from our laboratories and from others demonstrating that presenting particular characteristics of the virtual world through different sensory modalities will modify balance and locomotor behavior. We will discuss how movement in the virtual world opens a window into the motor planning processes and informs us about the relative weighting of visual and somatosensory signals. Finally, we discuss how these findings should influence future treatment design.

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

OBJECTIVE

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

DATA SOURCES

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

REVIEW METHODS

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

RESULTS

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

CONCLUSIONS

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

Virtual Reality Vestibular Rehabilitation in 20 Patients with Vertigo Due to Peripheral Vestibular Dysfunction

Background

Vestibular compensation is disrupted in patients with chronic vestibular syndrome. Vestibular rehabilitation is an exercise therapy that optimizes the process of vestibular compensation. This study aimed to evaluate virtual reality (VR) vestibular rehabilitation in 20 patients with vertigo due to peripheral vestibular dysfunction at a single center.

Our study aim was to initially assess the impact of using virtual reality technology in vestibular rehabilitation.

Material/Methods

The subjects were 20 patients with unilateral vestibular hypofunction (UVH), as confirmed by videonystagmography. These were divided into 2 groups: Group 1 underwent vestibular rehabilitation using virtual reality and Group 2 was treated by conventional therapy. A VSS-SF questionnaire and the VAS scale were used to assess the effects and levels of patient satisfaction with therapy.

Results

Both groups demonstrated significantly (P<0.001) lower values on the VSS-SF scales and VAS scales when assessed after treatment as compared to before treatment. Those undergoing conventional therapy reported significantly more severe symptoms on the VAS scale than did Group 1 at their second and third therapy visits. Indeed, Group 1 patients that underwent rehabilitation with the virtual reality component awarded significantly higher (P=0.015) levels of subjective satisfaction when compared to Group 2.

Conclusions

We found that virtual reality vestibular rehabilitation in patients with vertigo due to peripheral vestibular dysfunction was as effective as conventional rehabilitation, with significantly increased levels of patient satisfaction.

Vestibular and Balance Dysfunction Following Sport-Related Concussion

Purpose

Sport-related concussion is a significant public health concern that requires a multidisciplinary team to appropriately manage. Athletes often report dizziness and imbalance following concussion, and these symptoms can predict increased time to recover. Vestibular diagnostic evaluations provide important information regarding the athlete's oculomotor, gaze stability, and balance function in order to identify deficits for rehabilitation. These measures also describe objective function helpful for determining when an athlete is ready to return to play. The purpose of this clinical focus article is to provide background on the current understanding of the effects of concussion on the peripheral and central vestibular system, as well as information on a protocol that can be used for acute concussion assessment. Case studies describing 3 common postconcussion presentations will highlight the usefulness of this protocol.

Conclusion

Sport-related concussion is a highly visible disorder with many symptoms that may be evaluated in the vestibular clinic. A thoughtful protocol evaluating the typical presentation of these patients may help guide the multidisciplinary team in determining appropriate management and clearance for return to sport.

Dizziness in a Child With Irlen Syndrome: Differentiating Visual and Vestibular Complaints

PURPOSE

A case study of a 12-year-old boy with Irlen syndrome illustrates the overlapping symptoms of Irlen syndrome and vestibular-related dizziness.

SUMMARY OF KEY POINTS

Individuals with Irlen syndrome have eyestrain and headache, and often report visual perceptual distortions of blurring, doubling, and movement of print on the page. These symptoms can be relieved with the use of individually prescribed tinted lenses or overlays. Visually induced dizziness, also known as visual vertigo, is characterized by dizziness and/or unsteadiness that is triggered by complex, distorted, large field/moving visual stimuli. Visually induced dizziness can be effectively treated with progressive, controlled exposure to optokinetic visual stimuli. The child with Irlen syndrome had impaired balance, impaired gaze stability, and symptoms of visual vertigo. His complaint of visually induced dizziness resolved following vestibular rehabilitation.

CONCLUSIONS AND RECOMMENDATIONS FOR CLINICAL PRACTICE

When an individual with Irlen syndrome complains of dizziness, ruling out a concomitant diagnosis of a central and/or peripheral vestibular disorder is warranted.

WHAT THIS ADDS TO THE EVIDENCE

The visual symptoms associated with Irlen syndrome can overlap with those of visually induced dizziness. This case report is the first to describe overlapping visual and vestibular complaints of dizziness in an individual with Irlen syndrome.

Feasibility of Eye Tracking Assisted Vestibular Rehabilitation Strategy Using Immersive Virtual Reality

OBJECTIVES

Even though vestibular rehabilitation therapy (VRT) using head-mounted display (HMD) has been highlighted recently as a popular virtual reality platform, we should consider that HMD itself do not provide interactive environment for VRT. This study aimed to test the feasibility of interactive components using eye tracking assisted strategy through neurophysiologic evidence.

METHODS

HMD implemented with an infrared-based eye tracker was used to generate a virtual environment for VRT. Eighteen healthy subjects participated in our experiment, wherein they performed a saccadic eye exercise (SEE) under two conditions of feedback-on (F-on, visualization of eye position) and feedback-off (F-off, non-visualization of eye position). Eye position was continuously monitored in real time on those two conditions, but this information was not provided to the participants. Electroencephalogram recordings were used to estimate neural dynamics and attention during SEE, in which only valid trials (correct responses) were included in electroencephalogram analysis.

RESULTS

SEE accuracy was higher in the F-on than F-off condition (P=0.039). The power spectral density of beta band was higher in the F-on condition on the frontal (P=0.047), central (P=0.042), and occipital areas (P=0.045). Beta-event-related desynchronization was significantly more pronounced in the F-on (-0.19 on frontal and -0.22 on central clusters) than in the F-off condition (0.23 on frontal and 0.05 on central) on preparatory phase (P=0.005 for frontal and P=0.024 for central). In addition, more abundant functional connectivity was revealed under the F-on condition.

CONCLUSION

Considering substantial gain may come from goal directed attention and activation of brain-network while performing VRT, our preclinical study from SEE suggests that eye tracking algorithms may work efficiently in vestibular rehabilitation using HMD.

Effect of vestibular rehabilitation on recovery rate and functioning improvement in patients with chronic unilateral vestibular hypofunction and bilateral vestibular hypofunction

BACKGROUND

The minimal number of studies have documented the impact of Vestibular rehabilitation (VR) on the recovery rate of patients with Chronic Unilateral Vestibular Hypofunction (CUVH) and Bilateral Vestibular Hypofunction (BVH).

OBJECTIVES

The goal of the study was to show and compare the impact of vestibular rehabilitation (VR) in patients with CUVH and BVH.

METHODS

We analysed the data of 30 patients with CUVH and 20 with BVH treated with VR. The patients with CUVH during their eight-week treatment were controlled every two weeks, while the patients with BVH were controlled every three months during their one-year treatment; they filled in the DHI and ABC questionnaires every time.

RESULTS

In both groups of patients, there was significantly less disablement between the initial and final DHI scores (from 59-20 in CUVH and 74-41 in BVH group). There was a significant increase in the balance confidence between the initial and final ABC Scale in both groups of patients (from 49.5-90% in CUVH and 42-73% in BVH group).

CONCLUSIONS

Well-planned and individually adjusted system of vestibular exercises leads to a significant decrease in clinical symptoms and improvement of functioning and confidence in activities in both the CUVH and the BVH patients.

Perceptual Postural Imbalance and Visual Vertigo

PURPOSE OF REVIEW

Disorders of posture and balance cause significant patient morbidity, with reduction of quality of life as patients refrain from critical activities of daily living such as walking outside the home and driving. This review describes recent efforts to characterize visual disorders that interact with the neural integrators of positional maintenance and emerging therapies for these disorders.

RECENT FINDINGS

Abnormalities of gait and body position sense may be unrecognized by patients but are correlated with focal neurological injury (stroke). Patients with traumatic brain injury can exhibit visual vertigo despite otherwise normal visual functioning. The effect of visual neglect on posture and balance, even in the absence of a demonstrable visual field defect, has been characterized quantitatively through gait analysis and validates the potential therapeutic value of prism treatment in some patients. In addition, the underlying neural dysfunction in visual vertigo has been explored further using functional imaging, and these observations may allow discrimination of patients with structural causes from those whose co-morbid psychosocial disorders may be primarily contributory.

An fMRI study of visuo-vestibular interactions following vestibular neuritis

Vestibular neuritis (VN) is characterised by acute vertigo due to a sudden loss of unilateral vestibular function. A considerable proportion of VN patients proceed to develop chronic symptoms of dizziness, including visually induced dizziness, specifically during head turns. Here we investigated whether the development of such poor clinical outcomes following VN, is associated with abnormal visuo-vestibular cortical processing. Accordingly, we applied functional magnetic resonance imaging to assess brain responses of chronic VN patients and compared these to controls during both congruent (co-directional) and incongruent (opposite directions) visuo-vestibular stimulation (i.e. emulating situations that provoke symptoms in patients). We observed a focal significant difference in BOLD signal in the primary visual cortex V1 between patients and controls in the congruent condition (small volume corrected level of p < .05 FWE). Importantly, this reduced BOLD signal in V1 was negatively correlated with functional status measured with validated clinical questionnaires. Our findings suggest that central compensation and in turn clinical outcomes in VN are partly mediated by adaptive mechanisms associated with the early visual cortex.

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VN clinical status related to V1 response to congruent visuo-vestibular stimuli

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Reduced V1 BOLD signal during congruent stimulation correlates with subjective dizziness scores

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No association between V1 BOLD signal and incongruent visuo-vestibular stimulation

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Changes in V1 activity may reflect cortical adaptive mechanisms following VN

Virtual Reality, Visual Cliffs, and Movement Disorders

We outline an experimental setup designed to dynamically understand neural responses to visual cliffs while walking. The goal of our work is understanding and mitigating fear of falling, particularly among the elderly. In our setup, an EEG cap monitors a subject's neural activity while the subject is immersed in a virtual world and walking on an instrumented treadmill. The subject's response to visual stimuli is measured by both the EEG cap and by speed and pressure data from the treadmill. Based on this data, we can dynamically alter the landscape in the virtual world. We hope that our setup may be useful in helping subjects develop mechanisms to compensate for significant fear of falling while walking.

Three-dimensional head-mounted gaming task procedure maximizes effects of vestibular rehabilitation in unilateral vestibular hypofunction: a randomized controlled pilot trial

Considering the emerging advantages related to virtual reality implementation in clinical rehabilitation, the aim of the present study was to discover possible (i) improvements achievable in unilateral vestibular hypofunction patients using a self-assessed head-mounted device (HMD)-based gaming procedure when combined with a classical vestibular rehabilitation protocol (HMD group) as compared with a group undergoing only vestibular rehabilitation and (ii) HMD procedure-related side effects. Therefore, 24 vestibular rehabilitation and 23-matched HMD unilateral vestibular hypofunction individuals simultaneously underwent a 4-week rehabilitation protocol. Both otoneurological measures (vestibulo-ocular reflex gain and postural arrangement by studying both posturography parameters and spectral values of body oscillation) and performance and self-report measures (Italian Dizziness Handicap Inventory; Activities-specific Balance Confidence scale; Zung Instrument for Anxiety Disorders, Dynamic Gait Index; and Simulator Sickness Questionnaire) were analyzed by means of a between-group/within-subject analysis of variance model. A significant post-treatment between-effect was found, and the HMD group demonstrated an overall improvement in vestibulo-ocular reflex gain on the lesional side, in posturography parameters, in low-frequency spectral domain, as well as in Italian Dizziness Handicap Inventory and Activities-specific Balance Confidence scale scores. Meanwhile, Simulator Sickness Questionnaire scores demonstrated a significant reduction in symptoms related to experimental home-based gaming tasks during the HMD procedure. Our findings revealed the possible advantages of HMD implementation in vestibular rehabilitation, suggesting it as an innovative, self-assessed, low-cost, and compliant tool useful in maximizing vestibular rehabilitation outcomes.

Acetazolamide: A New Treatment for Visual Vertigo

Visual vertigo is a disorder characterised by symptoms of dizziness, vertigo, unsteadiness, disorientation, and general discomfort induced by visual triggers. It is currently treated with vestibular rehabilitation therapy, with no effective pharmacotherapy available for treatment-resistant cases. The objective of this study was to evaluate the efficacy of oral acetazolamide in improving symptoms of visual vertigo. A comparative case series of adult patients clinically diagnosed with visual vertigo was conducted from January 1992 to May 2015. Patients without a full neurologic or otorhinolaryngologic work-up, negative magnetic resonance imaging (MRI), and an organic cause for their symptoms were excluded. The identified patients were then contacted by phone to complete a voluntary symptom survey. Main outcome was the subjective reported percentage in symptom improvement. Secondary outcomes were subjective improvement by symptom triggers. The participants were retrospectively divided into three groups based on their treatment with acetazolamide: currently on acetazolamide, terminated acetazolamide, or never initiated acetazolamide. Fifty-seven patients met the inclusion criteria and were willing to complete the phone survey (19 currently on acetazolamide, 27 terminated acetazolamide, and 11 never initiated therapy). Overall symptomatic improvement was reported by 18 (94.7%) patients currently on acetazolamide, 18 (66.7 %) who terminated acetazolamide, and 5 (45.5%) who never initiated therapy, varying significantly by group (p = 0.0061). Greatest improvement was reported in symptoms triggered by being a passenger in a car. These results show that acetazolamide has a positive association with improvement of symptoms of visual vertigo.

Visually Induced Dizziness in Children and Validation of the Pediatric Visually Induced Dizziness Questionnaire

Aims

To develop and validate the Pediatric Visually Induced Dizziness Questionnaire (PVID) and quantify the presence and severity of visually induced dizziness (ViD), i.e., symptoms induced by visual motion stimuli including crowds and scrolling computer screens in children.

Methods

169 healthy (female n = 89; recruited from mainstream schools, London, UK) and 114 children with a primary migraine, concussion, or vestibular disorder diagnosis (female n = 62), aged 6–17 years, were included. Children with primary migraine were recruited from mainstream schools while children with concussion or vestibular disorder were recruited from tertiary balance centers in London, UK, and Pittsburgh, PA, USA. Children completed the PVID, which assesses the frequency of dizziness and unsteadiness experienced in specific environmental situations, and Strength and Difficulties Questionnaire (SDQ), a brief behavioral screening instrument.

Results

The PVID showed high internal consistency (11 items; α = 0.90). A significant between-group difference was noted with higher (i.e., worse) PVID scores for patients vs. healthy participants (U = 2,436.5, z = −10.719, p < 0.001); a significant difference was noted between individual patient groups [χ²(2) = 11.014, p = 0.004] but post hoc analysis showed no significant pairwise comparisons. The optimal cut-off score for discriminating between individuals with and without abnormal ViD levels was 0.45 out of 3 (sensitivity 83%, specificity 75%). Self-rated emotional (U = 2,730.0, z = −6.169) and hyperactivity (U = 3,445.0, z = −4.506) SDQ subscale as well as informant (U = 188.5, z = −3.916) and self-rated (U = 3,178.5, z = −5.083) total scores were significantly worse for patients compared to healthy participants (p < 0.001).

Conclusion

ViD is common in children with a primary concussion, migraine, or vestibular diagnosis. The PVID is a valid measure for identifying the presence of ViD in children and should be used to identify and quantify these symptoms, which require specific management incorporating exposure to optokinetic stimuli.

Framing visual roll-motion affects postural sway and the subjective visual vertical

Effects of visual roll-motion on postural sway and the subjective visual vertical (SVV) often is studied using mechanical devices, whereas electronic displays offer cheaper and more flexible alternatives. These devices typically emit and reflect light scattered by the edges of the screen, providing Earth-fixed cues of verticality. These cues may decrease the effects of rotating stimuli, a possibility that has not been studied explicitly before in one experimental design. We exposed 16 participants to a visual dot pattern, either stationary, or rotating in roll, that was or was not surrounded by a visible Earth-fixed reference frame. To eliminate unintended visual cues, the experiment was performed in complete darkness and participants wore neutral density goggles passing only 1% of light. Postural sway was measured using a force platform. SVV measurements were obtained from a visible rod. To monitor the participants, motion sickness severity was obtained with an 11-point rating scale. Results showed that the presence of an Earth-fixed frame significantly decreased the effect of the rotating pattern on postural sway and SVV deviations. Therefore, when studying subjective verticality related effects of visual stimuli, it is imperative that all visual Earth-fixed cues are not just minimized but completely eliminated. The observation that an Earth-fixed frame significantly decreased the effect of the rotating pattern on both postural sway and the SVV points towards a common neural origin, possibly involving a neural representation of verticality. Finally, we showed that an electronic screen can yield similar effect sizes as those taken from the literature using mechanical devices.

Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Evidence-Based Clinical Practice Guideline: FROM THE AMERICAN PHYSICAL THERAPY ASSOCIATION NEUROLOGY SECTION

BACKGROUND

Uncompensated vestibular hypofunction results in postural instability, visual blurring with head movement, and subjective complaints of dizziness and/or imbalance. We sought to answer the question, "Is vestibular exercise effective at enhancing recovery of function in people with peripheral (unilateral or bilateral) vestibular hypofunction?"

METHODS

A systematic review of the literature was performed in 5 databases published after 1985 and 5 additional sources for relevant publications were searched. Article types included meta-analyses, systematic reviews, randomized controlled trials, cohort studies, case control series, and case series for human subjects, published in English. One hundred thirty-five articles were identified as relevant to this clinical practice guideline.

RESULTS/DISCUSSION

Based on strong evidence and a preponderance of benefit over harm, clinicians should offer vestibular rehabilitation to persons with unilateral and bilateral vestibular hypofunction with impairments and functional limitations related to the vestibular deficit. Based on strong evidence and a preponderance of harm over benefit, clinicians should not include voluntary saccadic or smooth-pursuit eye movements in isolation (ie, without head movement) as specific exercises for gaze stability. Based on moderate evidence, clinicians may offer specific exercise techniques to target identified impairments or functional limitations. Based on moderate evidence and in consideration of patient preference, clinicians may provide supervised vestibular rehabilitation. Based on expert opinion extrapolated from the evidence, clinicians may prescribe a minimum of 3 times per day for the performance of gaze stability exercises as 1 component of a home exercise program. Based on expert opinion extrapolated from the evidence (range of supervised visits: 2-38 weeks, mean = 10 weeks), clinicians may consider providing adequate supervised vestibular rehabilitation sessions for the patient to understand the goals of the program and how to manage and progress themselves independently. As a general guide, persons without significant comorbidities that affect mobility and with acute or subacute unilateral vestibular hypofunction may need once a week supervised sessions for 2 to 3 weeks; persons with chronic unilateral vestibular hypofunction may need once a week sessions for 4 to 6 weeks; and persons with bilateral vestibular hypofunction may need once a week sessions for 8 to 12 weeks. In addition to supervised sessions, patients are provided a daily home exercise program.

DISCLAIMER

These recommendations are intended as a guide for physical therapists and clinicians to optimize rehabilitation outcomes for persons with peripheral vestibular hypofunction undergoing vestibular rehabilitation.Video Abstract available for more insights from the author (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A124).

Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): Consensus document of the committee for the Classification of Vestibular Disorders of the Bárány Society

This paper presents diagnostic criteria for persistent postural-perceptual dizziness (PPPD) to be included in the International Classification of Vestibular Disorders (ICVD). The term PPPD is new, but the disorder is not. Its diagnostic criteria were derived by expert consensus from an exhaustive review of 30 years of research on phobic postural vertigo, space-motion discomfort, visual vertigo, and chronic subjective dizziness. PPPD manifests with one or more symptoms of dizziness, unsteadiness, or non-spinning vertigo that are present on most days for three months or more and are exacerbated by upright posture, active or passive movement, and exposure to moving or complex visual stimuli. PPPD may be precipitated by conditions that disrupt balance or cause vertigo, unsteadiness, or dizziness, including peripheral or central vestibular disorders, other medical illnesses, or psychological distress. PPPD may be present alone or co-exist with other conditions. Possible subtypes await future identification and validation. The pathophysiologic processes underlying PPPD are not fully known. Emerging research suggests that it may arise from functional changes in postural control mechanisms, multi-sensory information processing, or cortical integration of spatial orientation and threat assessment. Thus, PPPD is classified as a chronic functional vestibular disorder. It is not a structural or psychiatric condition.

Virtual reality applications in assessing the effect of anxiety on sensorimotor integration in human postural control

Falls are a leading cause of injury and mortality among adults over the age of 65 years. Given the strong relation between fear of falling and fall risk, identification of the mechanisms that underlie anxiety-related changes in postural control may pave the way to the development of novel therapeutic strategies aimed at reducing fall risk in older adults. First, we review potential mechanisms underlying anxiety-mediated changes in postural control in older adults with and without neurological conditions. We then present a system that allows for the simultaneous recording of neural, physiological, and behavioral data in an immersive virtual reality (VR) environment while implementing sensory and mechanical perturbations to evaluate alterations in sensorimotor integration under conditions with high postural threat. We also discuss applications of VR in minimizing falls in older adults and potential future studies.

Vestibular rehabilitation for unilateral peripheral vestibular dysfunction

BACKGROUND

This is an update of a Cochrane review first published in The Cochrane Library in Issue 4, 2007 and previously updated in 2011.Unilateral peripheral vestibular dysfunction (UPVD) can occur as a result of disease, trauma or postoperatively. The dysfunction is characterised by complaints of dizziness, visual or gaze disturbances and balance impairment. Current management includes medication, physical manoeuvres and exercise regimes, the latter known collectively as vestibular rehabilitation.

OBJECTIVES

To assess the effectiveness of vestibular rehabilitation in the adult, community-dwelling population of people with symptomatic unilateral peripheral vestibular dysfunction.

SEARCH METHODS

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The most recent search was 18 January 2014.

SELECTION CRITERIA

Randomised controlled trials of adults living in the community, diagnosed with symptomatic unilateral peripheral vestibular dysfunction. We sought comparisons of vestibular rehabilitation versus control (e.g. placebo), other treatment (non-vestibular rehabilitation, e.g. pharmacological) or another form of vestibular rehabilitation. Our primary outcome measure was change in the specified symptomatology (for example, proportion with dizziness resolved, frequency or severity of dizziness). Secondary outcomes were measures of function, quality of life and/or measure(s) of physiological status, where reproducibility has been confirmed and shown to be relevant or related to health status (for example, posturography), and adverse effects

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We included 39 studies involving 2441 participants with unilateral peripheral vestibular disorders in the review. Trials addressed the effectiveness of vestibular rehabilitation against control/sham interventions, medical interventions or other forms of vestibular rehabilitation. Non-blinding of outcome assessors and selective reporting were threats that may have biased the results in 25% of studies, but otherwise there was a low risk of selection or attrition bias.Individual and pooled analyses of the primary outcome, frequency of dizziness, showed a statistically significant effect in favour of vestibular rehabilitation over control or no intervention (odds ratio (OR) 2.67, 95% confidence interval (CI) 1.85 to 3.86; four studies, 565 participants). Secondary outcomes measures related to levels of activity or participation measured, for example, with the Dizziness Handicap Inventory, which also showed a strong trend towards significant differences between the groups (standardised mean difference (SMD) -0.83, 95% CI -1.02 to -0.64). The exception to this was when movement-based vestibular rehabilitation was compared to physical manoeuvres for benign paroxysmal positional vertigo (BPPV), where the latter was shown to be superior in cure rate in the short term (OR 0.19, 95% CI 0.07 to 0.49). There were no reported adverse effects.

AUTHORS' CONCLUSIONS

There is moderate to strong evidence that vestibular rehabilitation is a safe, effective management for unilateral peripheral vestibular dysfunction, based on a number of high-quality randomised controlled trials. There is moderate evidence that vestibular rehabilitation resolves symptoms and improves functioning in the medium term. However, there is evidence that for the specific diagnostic group of BPPV, physical (repositioning) manoeuvres are more effective in the short term than exercise-based vestibular rehabilitation; although a combination of the two is effective for longer-term functional recovery. There is insufficient evidence to discriminate between differing forms of vestibular rehabilitation.

Interaction between Vestibular Compensation Mechanisms and Vestibular Rehabilitation Therapy: 10 Recommendations for Optimal Functional Recovery

This review questions the relationships between the plastic events responsible for the recovery of vestibular function after a unilateral vestibular loss (vestibular compensation), which has been well described in animal models in the last decades, and the vestibular rehabilitation (VR) therapy elaborated on a more empirical basis for vestibular loss patients. The main objective is not to propose a catalog of results but to provide clinicians with an understandable view on when and how to perform VR therapy, and why VR may benefit from basic knowledge and may influence the recovery process. With this perspective, 10 major recommendations are proposed as ways to identify an optimal functional recovery. Among them are the crucial role of active and early VR therapy, coincidental with a post-lesion sensitive period for neuronal network remodeling, the instructive role that VR therapy may play in this functional reorganization, the need for progression in the VR therapy protocol, which is based mainly on adaptation processes, the necessity to take into account the sensorimotor, cognitive, and emotional profile of the patient to propose individual or "à la carte" VR therapies, and the importance of motivational and ecologic contexts. More than 10 general principles are very likely, but these principles seem crucial for the fast recovery of vestibular loss patients to ensure good quality of life.