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Male AJ, Holmes SL, Koohi N, Dudziec M, Hanna MG, Ramdharry GM, Pizzamiglio C, Pitceathly RDS, Kaski D. A diagnostic framework to identify vestibular involvement in multi-sensory neurological disease. Eur J Neurol 2024; 31:e16216. [PMID: 38247216 DOI: 10.1111/ene.16216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/13/2023] [Accepted: 01/04/2024] [Indexed: 01/23/2024]
Abstract
BACKGROUND AND PURPOSE Identifying vestibular causes of dizziness and unsteadiness in multi-sensory neurological disease can be challenging, with problems typically attributed to central or peripheral nerve involvement. Acknowledging vestibular dysfunction as part of the presentation provides an opportunity to access targeted vestibular rehabilitation, for which extensive evidence exists. A diagnostic framework was developed and validated to detect vestibular dysfunction, benign paroxysmal positional vertigo or vestibular migraine. The specificity and sensitivity of the diagnostic framework was tested in patients with primary mitochondrial disease. METHODS Adults with a confirmed diagnosis of primary mitochondrial disease were consented, between September 2020 and February 2022. Participants with and without dizziness or unsteadiness underwent remote physiotherapy assessment and had in-person detailed neuro-otological assessment. The six framework question responses were compared against objective neuro-otological assessment or medical notes. The output was binary, with sensitivity and specificity calculated. RESULTS Seventy-four adults completed the study: age range 20-81 years (mean 48 years, ±SD 15.05 years); ratio 2:1 female to male. The framework identified a vestibular diagnosis in 35 participants, with seven having two diagnoses. The framework was able to identify vestibular diagnoses in adults with primary mitochondrial disease, with a moderate (40-59) to very high (90-100) sensitivity and positive predictive value, and moderate to high (60-74) to very high (90-100) specificity and negative predictive value. CONCLUSIONS Overall, the clinical framework identified common vestibular diagnoses with a moderate to very high specificity and sensitivity. This presents an opportunity for patients to access effective treatment in a timely manner, to reduce falls and improve quality of life.
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Affiliation(s)
- Amanda J Male
- SENSE Research Unit, Department of Clinical and Movement Neurosciences, Institute of Neurology, University College London, London, UK
| | - Sarah L Holmes
- NHS Highly Specialised Service for Rare Mitochondrial Disorders, Queen Square Centre for Neuromuscular Diseases, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Nehzat Koohi
- SENSE Research Unit, Department of Clinical and Movement Neurosciences, Institute of Neurology, University College London, London, UK
| | - Magdalena Dudziec
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
- Queen Square Centre for Neuromuscular Diseases, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Michael G Hanna
- NHS Highly Specialised Service for Rare Mitochondrial Disorders, Queen Square Centre for Neuromuscular Diseases, The National Hospital for Neurology and Neurosurgery, London, UK
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Gita M Ramdharry
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
- Queen Square Centre for Neuromuscular Diseases, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Chiara Pizzamiglio
- NHS Highly Specialised Service for Rare Mitochondrial Disorders, Queen Square Centre for Neuromuscular Diseases, The National Hospital for Neurology and Neurosurgery, London, UK
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Robert D S Pitceathly
- NHS Highly Specialised Service for Rare Mitochondrial Disorders, Queen Square Centre for Neuromuscular Diseases, The National Hospital for Neurology and Neurosurgery, London, UK
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Diego Kaski
- SENSE Research Unit, Department of Clinical and Movement Neurosciences, Institute of Neurology, University College London, London, UK
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Koohi N, Male AJ, Kaski D. Acute positional vertigo in the emergency department-peripheral vs. central positional nystagmus. Front Neurol 2023; 14:1266778. [PMID: 37869150 PMCID: PMC10585259 DOI: 10.3389/fneur.2023.1266778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 09/21/2023] [Indexed: 10/24/2023] Open
Abstract
Introduction Benign paroxysmal positional vertigo (BPPV) is the most common cause of positional vertigo. However, positional vertigo can also be due to diseases affecting the central vestibular pathways, such as vestibular migraine. Accurate and timely diagnosis enables effective triage and management. Objectives To evaluate diagnoses made by emergency clinicians compared to acute vertigo specialists, in patients presenting to an emergency department (ED) with positional vertigo. Methods Following routine ED care, patients with a primary complaint of dizziness, vertigo, light-headedness or unsteadiness, underwent detailed neuro-otological assessment by acute vertigo specialists. Demographics and final diagnoses were recorded and analyzed. Results Of 71 consented patients (21-91 years; mean 56 years, ±16.7 years, 40 females), ED identified 13 with a peripheral cause of positional vertigo (mean 48.85 years, ±16.19, 8 females). Central positional nystagmus was not noted in any of the patients with positional vertigo seen by the ED clinicians. Acute vertigo specialists diagnosed nine patients with BPPV (age range 50-88 years, mean 66 years, ±12.22, 5 females), and six with central positional nystagmus (age range 23-59 years, mean 41.67 years, ±15.78, 6 females). Conclusion Positional vertigo should be assessed with positional maneuvers such as Dix-Hallpike and Roll tests in the ED to identify peripheral and central nystagmus features. Central causes are more common in younger females, with the presence of vomiting, and/or a background of motion sensitivity.
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Affiliation(s)
| | | | - Diego Kaski
- Department of Clinical and Movement Neurosciences, The UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
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Male AJ, Holmes SL, Hanna MG, Pitceathly RDS, Ramdharry GM, Kaski D. Correction to: Development of a diagnostic framework for vestibular causes of dizziness and unsteadiness in patients with multisensory neurological disease: a Delphi consensus. J Neurol 2023; 270:4156. [PMID: 37022482 DOI: 10.1007/s00415-023-11683-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Affiliation(s)
- Amanda J Male
- Department of Clinical and Movement Neurosciences, University College London, Queen Square, London, WC1N 3BG, UK.
| | - Sarah L Holmes
- NHS Highly Specialised Service for Rare Mitochondrial Disorders, Queen Square Centre for Neuromuscular Diseases, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Michael G Hanna
- NHS Highly Specialised Service for Rare Mitochondrial Disorders, Queen Square Centre for Neuromuscular Diseases, The National Hospital for Neurology and Neurosurgery, London, UK
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Robert D S Pitceathly
- NHS Highly Specialised Service for Rare Mitochondrial Disorders, Queen Square Centre for Neuromuscular Diseases, The National Hospital for Neurology and Neurosurgery, London, UK
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Gita M Ramdharry
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
- Queen Square Centre for Neuromuscular Diseases, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Diego Kaski
- Department of Clinical and Movement Neurosciences, University College London, Queen Square, London, WC1N 3BG, UK
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Male AJ, Holmes SL, Hanna MG, Pitceathly RDS, Ramdharry GM, Kaski D. Development of a diagnostic framework for vestibular causes of dizziness and unsteadiness in patients with multisensory neurological disease: a Delphi consensus. J Neurol 2023; 270:3252-3257. [PMID: 36842099 DOI: 10.1007/s00415-023-11640-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 02/18/2023] [Accepted: 02/20/2023] [Indexed: 02/27/2023]
Affiliation(s)
- Amanda J Male
- Department of Clinical and Movement Neurosciences, University College London, Queen Square, London, WC1N 3BG, UK.
| | - Sarah L Holmes
- NHS Highly Specialised Service for Rare Mitochondrial Disorders, Queen Square Centre for Neuromuscular Diseases, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Michael G Hanna
- NHS Highly Specialised Service for Rare Mitochondrial Disorders, Queen Square Centre for Neuromuscular Diseases, The National Hospital for Neurology and Neurosurgery, London, UK
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Robert D S Pitceathly
- NHS Highly Specialised Service for Rare Mitochondrial Disorders, Queen Square Centre for Neuromuscular Diseases, The National Hospital for Neurology and Neurosurgery, London, UK
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Gita M Ramdharry
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
- Queen Square Centre for Neuromuscular Diseases, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Diego Kaski
- Department of Clinical and Movement Neurosciences, University College London, Queen Square, London, WC1N 3BG, UK
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Holmes S, Male AJ, Ramdharry G, Woodward C, James N, Skorupinska I, Skorupinska M, Germain L, Kozyra D, Bugiardini E, Poole OV, Quinlivan R, Hanna MG, Kaski D, Pitceathly RDS. Vestibular dysfunction: a frequent problem for adults with mitochondrial disease. J Neurol Neurosurg Psychiatry 2019; 90:838-841. [PMID: 30478136 PMCID: PMC6585572 DOI: 10.1136/jnnp-2018-319267] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/05/2018] [Accepted: 10/11/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Sarah Holmes
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | - Amanda J Male
- Therapy Services, National Hospital for Neurology and Neurosurgery, London, UK
| | - Gita Ramdharry
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | - Cathy Woodward
- Neurogenetics Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - Natalie James
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | - Iwona Skorupinska
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | - Mariola Skorupinska
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | - Louise Germain
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | - Damian Kozyra
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK.,Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Enrico Bugiardini
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK.,Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Olivia V Poole
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK.,Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Ros Quinlivan
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK.,Dubowitz Neuromuscular Centre, Great Ormond Street Hospital, London, UK
| | - Michael G Hanna
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK.,Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Diego Kaski
- Department of Neuro-Otology, University College London Hospitals, London, UK
| | - Robert D S Pitceathly
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK .,Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
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Male AJ, Ramdharry GM, Grant R, Davies RA, Beith ID. A survey of current management of Benign Paroxysmal Positional Vertigo (BPPV) by physiotherapists' interested in vestibular rehabilitation in the UK. Physiotherapy 2018; 105:307-314. [PMID: 30389100 DOI: 10.1016/j.physio.2018.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Benign Paroxysmal Positional Vertigo (BPPV) is the most common cause of dizziness. Extensive research has identified the best assessment and treatment manoeuvres for each subtype of BPPV. Education in vestibular rehabilitation (VR) is inconsistent. It is unclear if the evidence has been adopted by UK physiotherapists in clinical practice and no research has investigated this specifically. DESIGN An online survey with closed- and open-text answers. PARTICIPANTS A purposive sample of physiotherapists interested in VR. A response rate of 67% (100/150) was obtained, from which 20 responses were excluded. RESULTS Participants had good evidence-based awareness in assessment (79/80, 99%) and treatment (72/80, 90%) of posterior BPPV. Horizontal BPPV assessment awareness was lower than treatment (37/80, 46% vs 60/80, 75%). Differential diagnosis was poor in subjective (20/80, 25%) and objective stages of assessment (34/80, 43%). Thirty six percent (29/80) were able to list ≥3 test precautions with all three nystagmus characteristics described by 29% (23/80). Eighty one percent (65/80) encourage activity restrictions post-treatment. Only 28% (22/80) were aware of practice guidelines or Cochrane reviews in BPPV. External courses were rated the top method for learning how to manage BPPV. Lack of peer support (26/77, 34%) was the main challenge faced whilst learning. Recommendations for improving BPPV education included more external courses (23/87, 26%) and competency guidelines (13/87, 15%). CONCLUSIONS Good awareness of research evidence was observed in some aspects of BPPV management but many areas require development. Translation and implementation of evidence remains poor and suggests changes in education and knowledge dissemination are warranted.
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Affiliation(s)
- A J Male
- Faculty of Health Social Care and Education, Kingston University and St. George's University of London, Cranmer Terrace, London SW17 0RE, United Kingdom; Therapy Services, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, United Kingdom.
| | - G M Ramdharry
- Faculty of Health Social Care and Education, Kingston University and St. George's University of London, Cranmer Terrace, London SW17 0RE, United Kingdom
| | - R Grant
- Faculty of Health Social Care and Education, Kingston University and St. George's University of London, Cranmer Terrace, London SW17 0RE, United Kingdom
| | - R A Davies
- Department of Neuro-Otology, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, United Kingdom
| | - I D Beith
- Faculty of Health Social Care and Education, Kingston University and St. George's University of London, Cranmer Terrace, London SW17 0RE, United Kingdom
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