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

BACKGROUND AND PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Digital biomarkers from gaze tests for classification of central and peripheral lesions in acute vestibular syndrome

Acute vestibular syndrome (AVS) is characterised by a sudden vertigo, gait instability, nausea and nystagmus. Accurate and rapid triage of patients with AVS to differentiate central (potentially sinister) from peripheral (usually benign) root causes is a challenge faced across emergency medicine settings. While there exist bedside exams which can reliably differentiate serious cases, they are underused due to clinicians' general unfamiliarity and low confidence interpreting results. Nystagmus is a fundamental part of AVS and can facilitate triaging, but identification of relevant characteristics requires expertise. This work presents two quantitative digital biomarkers from nystagmus analysis, which capture diagnostically-relevant information. The directionality biomarker evaluates changes in direction to differentiate spontaneous and gaze-evoked (direction-changing) nystagmus, while the intensity differential biomarker describes changes in intensity across eccentric gaze tests. In order to evaluate biomarkers, 24 sets of three gaze tests (left, right, and primary) are analysed. Both novel biomarkers were found to perform well, particularly directionality which was a perfect classifier. Generally, the biomarkers matched or eclipsed the performance of quantitative nystagmus features found in the literature. They also surpassed the performance of a support vector machine classifier trained on the same dataset, which achieved an accuracy of 75%. In conclusion, these biomarkers simplify the diagnostic process for non-specialist clinicians, bridging the gap between emergency care and specialist evaluation, ultimately benefiting patients with AVS.

Auditory processing disorder: an online survey of hearing healthcare professionals' knowledge and practices

OBJECTIVE

To investigate (1) the current level of awareness and knowledge on Auditory Processing Disorder (APD) among Audiologists and other hearing healthcare professionals; (2) current practices in screening, diagnosis, and management of APD in children and adults across the UK; (3) professional's acceptance of APD assessment and diagnosis.

DESIGN

An online survey was disseminated through the British Academy of Audiology and ENT UK.

STUDY SAMPLE

A total of 191 hearing healthcare professionals responded to the survey.

RESULTS

Overall, while 63% of the respondents considered themselves to be adequately informed about APD, only 4% viewed themselves as very informed on the topic. Fewer than half of the respondents report screening (31%), diagnosing (14%), or managing (36%) cases of APD. For screening APD, professionals most commonly use auditory processing tests in adults and take case histories in children, whereas routine audiological procedures are the primary method for diagnosing APD in both adults and children. Although modifying the listening environment is a widely recommended management strategy for APD, half of the respondents indicated that a diagnosis of APD has no implications for patient management.

CONCLUSIONS

There is a critical need to promote APD-related training to ensure they can provide appropriate referrals and management.

Acute positional vertigo in the emergency department-peripheral vs. central positional nystagmus

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.

Neuroinflammatory disorders of the brain and inner ear: a systematic review of auditory function in patients with migraine, multiple sclerosis, and neurodegeneration to support the idea of an innovative 'window of discovery'

Background

Hearing can be impaired in many neurological conditions and can even represent a forme fruste of specific disorders. Auditory function can be measured by either subjective or objective tests. Objective tests are more useful in identifying which auditory pathway (superior or inferior) is most affected by disease. The inner ear's perilymphatic fluid communicates with the cerebrospinal fluid (CSF) via the cochlear aqueduct representing a window from which pathological changes in the contents of the CSF due to brain inflammation could, therefore, spread to and cause inflammation in the inner ear, damaging inner hair cells and leading to hearing impairment identifiable on tests of auditory function.

Methods

A systematic review of the literature was performed, searching for papers with case-control studies that analyzed the hearing and migraine function in patients with neuro-inflammatory, neurodegenerative disorders. With data extracted from these papers, the risk of patients with neurological distortion product otoacoustic emission (DPOAE) was then calculated.

Results

Patients with neurological disorders (headache, Parkinson's disease, and multiple sclerosis) had a higher risk of having peripheral auditory deficits when compared to healthy individuals.

Conclusion

Existing data lend credence to the hypothesis that inflammatory mediators transmitted via fluid exchange across this communication window, thereby represents a key pathobiological mechanism capable of culminating in hearing disturbances associated with neuroimmunological and neuroinflammatory disorders of the nervous system.

Acute truncal ataxia without nystagmus in patients with acute vertigo

BACKGROUND AND PURPOSE

Differentiating between peripheral and central aetiologies can be challenging in patients with acute vertigo, given substantial symptom overlap. A detailed clinical history and focused physical eye movement examination such as the HINTS eye examination appear to be the most reliable approach to identify acute cerebellar/brainstem stroke, outperforming even acute brain imaging. We have observed, however, that isolated vertigo of central cause may be accompanied by acute truncal ataxia, in the absence of nystagmus.

METHODS

We explored the frequency of ataxia without concurrent nystagmus in a cross section of patients with acute vertigo who presented to the emergency department at two centres in Argentina (Group A) and the UK (Group B). Patients underwent detailed clinical neuro-otological assessments (Groups A and B), which included instrumented head impulse testing and oculography (Group B).

RESULTS

A total of 71 patients in Group A and 24 patients in Group B were included in this study. We found acute truncal ataxia-without nystagmus-in 15% (n = 14) of our overall cohort. Lesions involved stroke syndromes affecting the posterior inferior cerebellar artery, anterior inferior cerebellar artery, and superior cerebellar artery, thalamic stroke, cerebral hemisphere stroke, multiple sclerosis, and a cerebellar tumour. Additional oculomotor deficits did not reliably identify a central cause in these individuals, even with oculography.

CONCLUSIONS

We have identified a significant subpopulation of patients with acute vertigo in whom the current standard approaches such as the HINTS examination that focus on oculomotor assessment may not be applicable, highlighting the need for a formal assessment of gait in this setting.

Reflexive and volitional saccadic eye movements and their changes in age and progressive supranuclear palsy

BACKGROUND AND OBJECTIVES

Saccades, rapid movements of the eyes towards a visual or remembered target, are useful in understanding the healthy brain and the pathology of neurological conditions such as progressive supranuclear palsy (PSP). We set out to investigate the parameters of horizontal reflexive and volitional saccades, both visually guided and memory-guided, over a 1 min epoch in healthy individuals and PSP patients.

METHODS

An experimental paradigm tested reflexive, volitional visually guided, and volitional memory-guided saccades in young healthy controls (n = 14; 20-31 years), PSP patients (n = 11; 46-75 years) and older age-matched healthy controls (n = 6; 56-71 years). The accuracy and velocity of saccades was recorded using an EyeBrain T2® video eye tracker and analyses performed using the MyEyeAnalysis® software. Two-way analysis of variance (ANOVA) was used to identify significant effects (p < 0.01) between young and older controls to investigate the effects of ageing upon saccades, and between PSP patients and age-matched controls to study the effects of PSP upon saccades.

RESULTS

In both healthy individuals and PSP patients, volitional saccades are slower and less accurate than reflexive saccades. In PSP patients, accuracy is lower across all saccade types compared to age-matched controls, but velocity is lower only for reflexive saccades. Crucially, there is no change in accuracy or velocity of consecutive saccades over short (one-minute) timescales in controls or PSP patients.

CONCLUSIONS

Velocity and accuracy of saccades in PSP does not decrease over one-minute timescales, contrary to that previously observed in Parkinson's Disease (PD), suggesting a potential clinical biomarker for the distinction of PSP from PD.

Video head impulse testing: Pitfalls in neurological patients

The video head impulse test (vHIT) assesses the vestibulo-ocular reflex (VOR) during a rapid high-velocity low amplitude (10°-20°) head rotation. Patients with peripheral vestibulopathy have a reduced VOR gain with corrective catch-up saccades during the head turn. There are several pitfalls, mainly technical, which may interfere with interpretation of vHIT data. In addition, intrusive eye movement disorders such as spontaneous nystagmus that affect normal eye position and tracking can affect the vHIT results. To date there has been little study of neurological saccadic eye movements that may interfere with the interpretation of vHIT data. Here, in ten patients with a range of central neurological disorders, we describe oculomotor abnormalities on vHIT in the presence of normal range VOR gain values, recorded at a tertiary vestibular neurology service.

Head shaking does not alter vestibulo ocular reflex gain in vestibular migraine

Vestibular Migraine (VM) is the most common cause of non-positional episodic vestibular symptoms. Patients with VM commonly report increased motion sensitivity, suggesting that vestibular responses to head movement may identify changes specific to VM patients. Here we explore whether the vestibulo-ocular reflex (VOR) gain alters in response to a clinical “headshake” maneuver in patients with VM. Thirty patients with VM in the inter-ictal phase, 16 patients with Benign Positional Paroxysmal Vertigo (BPPV) and 15 healthy controls were recruited. Patients responded to the question “Do you feel sick reading in the passenger seat of a car?” and completed a validated motion sickness questionnaire as a measure of motion sensitivity. Lateral canal vHIT testing was performed before and after headshaking; the change in VOR gain was calculated as the primary outcome. Baseline VOR gain was within normal limits across all participants. There was no significant change in VOR gain after headshaking in any group (p = 0.264). Patients were 4.3 times more likely to be in the VM group than in the BPPV group if they reported nausea when reading in the passenger seat of a car. We postulate that a headshake stimulus may be insufficient to disrupt cortical interactions and induce a change in VOR gain. Alternatively, changes in VOR gain may only be apparent in the acute phase of VM. Reading in the passenger seat of a car was considered uncomfortable in all VM patients suggesting that this specific question may be useful for the diagnosis of VM.

Clinician's perspectives in using head impulse-nystagmus-test of skew (HINTS) for acute vestibular syndrome: UK experience

BACKGROUND

Acute vestibular syndrome (AVS) features continuous dizziness and may result from a benign inner ear disorder or stroke. The head impulse-nystagmus-test of skew (HINTS) bedside assessment is more sensitive than brain MRI in identifying stroke as the cause of AVS within the first 24 hours. Clinicians' perspectives of the test in UK secondary care remains unknown. Here, we explore front-line clinicians' perspectives of use of the HINTS for the diagnosis of AVS.

METHODS

Clinicians from two large UK hospitals who assess AVS patients completed a short online survey, newly designed with closed and open questions.

RESULTS

Almost half of 73 total responders reported limited (n=33), or no experience (n=19), reflected in low rates of use of HINTS (n=31). While recognising the potential utility of HINTS, many reported concerns about subjectivity, need for specialist skills and poor patient compliance. No clinicians reported high levels of confidence in performing HINTS, with 98% identifying training needs. A lack of formalised training was associated with onward specialist referrals and neuroimaging (p=0.044).

CONCLUSIONS

Although the low sample size in this study limits the generalisability of findings to wider sites, our preliminary data identified barriers to the application of the HINTS in AVS patients and training needs to improve rapid, cost-effective and accurate clinical diagnosis of stroke presenting with vertigo.

Patient Experience of Flunarizine for Vestibular Migraine: Single Centre Observational Study

Vestibular migraine (VM) is a leading cause of episodic vertigo, affecting up to 1% of the general population. Despite established diagnostic criteria, there is currently no evidence-based approach for acute treatment of VM, with treatment recommendations generally extrapolated from studies on classical migraine headache. Several small-scale studies have identified flunarizine as a potentially effective prophylactic medication in VM. We conducted a single-centre observational service evaluation study exploring patient experiences of preventative medications over a 28-month period, including flunarizine, for control of VM symptoms. To compare patient experience of flunarizine with other medications, data from patients taking flunarizine were separately analysed. A total of 90% of VM patients taking flunarizine reported symptomatic improvement, compared to only 32% of patients on other medications. Whilst 50% of patients on flunarizine reported side effects. these were not deemed to outweigh the clinical benefits, with most patients deciding to continue treatment. Our data supports the use of flunarizine in VM.

Prevalence of acute dizziness and vertigo in cortical stroke

BACKGROUND AND PURPOSE

In posterior circulation stroke, vertigo can be a presenting feature. However, whether isolated hemispheric strokes present with vertigo is less clear, despite a few single case reports in the literature. Here, (a) the prevalence of vertigo/dizziness in acute stroke is explored and (b) the cortical distribution of the lesions in relation to both the known vestibular cortex and the evolution of the symptoms, are considered.

METHODS

Structured interviews were conducted in 173 consecutive unselected patients admitted to the hyperacute stroke unit at the University College London Hospitals. The interview was used to evaluate whether the patient was suffering from dizziness and/or vertigo before the onset of the stroke and at the time of the stroke (acute dizziness/vertigo), and the nature of these symptoms.

RESULTS

In all, 53 patients had cortical infarcts, of which 21 patients reported acute dizziness. Out of these 21, five patients reported rotational vertigo. Seventeen of the total 53 patients had lesions in known vestibular cortical areas distributed within the insular and parietal opercular cortices.

CONCLUSIONS

The prevalence of vertigo in acute cortical strokes was 9%, with no single locus of lesion overlap. There is growing evidence supporting a lateralized vestibular cortex, with speculation that cortical strokes affecting the right hemisphere are more likely to cause vestibular symptoms than left hemispheric strokes. A trend was observed for this association, with the right hemisphere affected in four of five patients who reported spinning vertigo at the onset of the stroke.

Effectiveness of the Auditory Temporal Ordering and Resolution Tests to Detect Central Auditory Processing Disorder in Adults With Evidence of Brain Pathology: A Systematic Review and Meta-Analysis

Background: Auditory temporal processing tests are key clinical measures in order to diagnose central auditory processing disorder (CAPD). Although these tests have been used for decades, there is no up-to-date evidence to determine the effectiveness of detecting the abnormalities in central auditory processing in adults while the available national CAPD guidelines predominantly address CAPD in the pediatric population.

Purpose: To determine the efficacy of the auditory temporal ordering tests [duration pattern test (DPT) and frequency pattern test (FPT)], and a temporal resolution test [gaps-in-noise (GIN) test] for detecting the central auditory processing abnormalities in adults with documented brain pathology.

Research Design: Systematic reviews and meta-analyses.

Study samples: Four databases, including PubMed, Web of Science, Embase, and Scopus, were systematically searched. The publications in the English language that recruited adults (above 16 years old) with pathologic brain conditions and described the diagnostic tests for auditory temporal processing were selected for review.

Data Collections and Analysis: All data were systematically evaluated, extracted, categorized, and summarized in tables. The meta-analysis was done in order to determine the effectiveness of the DPT, FPT, and GIN tests.

Results: The results showed significantly poorer performance of DPT and FPT, compared between participants with confirmed brain disease and normal controls, at the mean differences of percent correct −21.93 (95% CI, −26.58 to −17.29) and −31.37 (95% CI, −40.55 to −22.19), respectively. Subjects with brain pathology also performed poorer in GIN test at the mean difference of 3.19 milliseconds (95% CI, 2.51 to 3.87).

Conclusion: The results from the meta-analysis provide evidence that DPT, FPT, and GIN clinical measures are effective in the diagnosis of CAPD in adults with neurological disorders. Poor performance on these tests is significantly related to the confirmed brain pathology. However, different units in results presentation and variety of testing strategies are limitations for this meta-analysis. The standard pattern of result reporting and international protocols test strategies should be developed in order to conduct better meta-analyses with a larger collection of suitable studies and less heterogeneity.

Auditory Phenotypic Variability in Friedreich's Ataxia Patients

Auditory neural impairment is a key clinical feature of Friedreich’s Ataxia (FRDA). We aimed to characterize the phenotypical spectrum of the auditory impairment in FRDA in order to facilitate early identification and timely management of auditory impairment in FRDA patients and to explore the relationship between the severity of auditory impairment with genetic variables (the expansion size of GAA trinucleotide repeats, GAA1 and GAA2), when controlled for variables such as disease duration, severity of the disease and cognitive status. Twenty-seven patients with genetically confirmed FRDA underwent baseline audiological assessment (pure-tone audiometry, otoacoustic emissions, auditory brainstem response). Twenty of these patients had additional psychophysical auditory processing evaluation including an auditory temporal processing test (gaps in noise test) and a binaural speech perception test that assesses spatial processing (Listening in Spatialized Noise-Sentences Test). Auditory spatial and auditory temporal processing ability were significantly associated with the repeat length of GAA1. Patients with GAA1 greater than 500 repeats had more severe auditory temporal and spatial processing deficits, leading to poorer speech perception. Furthermore, the spatial processing ability was strongly correlated with the Montreal Cognitive Assessment (MoCA) score. To our knowledge, this is the first study to demonstrate an association between genotype and auditory spatial processing phenotype in patients with FRDA. Auditory temporal processing, neural sound conduction, spatial processing and speech perception were more severely affected in patients with GAA1 greater than 500 repeats. The results of our study may indicate that auditory deprivation plays a role in the development of mild cognitive impairment in FRDA patients.

A Hearing Screening Protocol for Stroke Patients: An Exploratory Study

Background: Auditory impairment post stroke is common and may be due to both peripheral hearing loss and or central auditory processing disorder (CAPD). When auditory impairment remains untreated, it may impact on patient communication and rehabilitation after stroke. Offering a comprehensive audiological assessment to all stroke patients would be both costly and time-consuming. A brief hearing screening is thus required. Objective: The aim of this study was to determine whether a two-tiered hearing screening approach, with use of a handheld hearing screener and two validated hearing questionnaires could be used as a hearing screening for peripheral hearing loss and CAPD in stroke survivors. The sensitivity and specificity of the screening method was analyzed. Methods: This was a prospective study conducted in a tertiary neurology hospital. Forty-two consecutive stroke patients were recruited and tested within 3-12 months post-onset of their stroke. Three screening tools for the identification of hearing impairment were evaluated in this study: A handheld hearing screener for determination of peripheral audiometric hearing loss and two validated questionnaires (The Amsterdam Inventory Auditory for Disability (AIAD) and the Hearing Handicap Inventory for Elderly (HHIE) questionnaires) for determination of peripheral hearing loss and/or CAPD. Results: The hearing screener had a sensitivity of 92. 59% detecting a hearing loss and specificity of 100%. The greatest test accuracy in identifying a central auditory processing type hearing impairment in stroke patients was found when the handheld hearing screener and the AIAD questionnaire were combined. Conclusion: This study is a first step toward addressing the complex auditory needs of stroke survivors in a systematic manner, with the ultimate aim to support their communication needs and long-term recovery and wellbeing. Registration: Project Identification number 11/0469 and REC ref 11/LO/1675.

Hearing Characteristics of Stroke Patients: Prevalence and Characteristics of Hearing Impairment and Auditory Processing Disorders in Stroke Patients

BACKGROUND

Stroke survivors may suffer from a range of hearing impairments that may restrict their participation in postacute rehabilitation programs. Hearing impairment may have a significant impact on listening, linguistic skills, and overall communication of the affected stroke patient. However, no studies sought to systematically characterize auditory function of stroke patients in detail, to establish the different types of hearing impairments in this cohort of patients. Such information would be clinically useful in understanding and addressing the hearing needs of stroke survivors.

PURPOSE

The present study aimed to characterize and classify the hearing impairments, using a detailed audiological assessment test battery, in order to determine the level of clinical need and inform appropriate rehabilitation for this patient population.

RESEARCH DESIGN

A case-control study.

STUDY SAMPLE

Forty-two recruited stroke patients who were discharged from a stroke unit and 40 control participants matched for age.

DATA COLLECTION AND ANALYSIS

All participants underwent pure-tone audiometry and immittance measurements including acoustic reflex threshold, transient-evoked otoacoustic emissions, auditory-evoked brainstem response, and a central auditory processing assessment battery, performed in a single session. Hearing impairments were classified as peripheral hearing loss (cochlear and neural type), central auditory processing disorder (CAPD), and as a combination of CAPD and peripheral hearing loss.

RESULTS

Overall mean hearing thresholds were not significantly different between the control and stroke groups. The most common type of hearing impairment in stroke patients was the combination type, "peripheral and CAPD," in the 61- to 80-yr-old subgroup (in 55%), and auditory processing deficits in 18- to 60-yr-olds (in 40%), which were both significantly higher than in controls.

CONCLUSIONS

This is the first study to examine hearing function in detail in stroke patients. Given the importance of hearing for the efficiency of communication, it is essential to identify hearing impairments and differentiate peripheral and central deficits to define an appropriate intervention plan.

Long-term use benefits of personal frequency-modulated systems for speech in noise perception in patients with stroke with auditory processing deficits: a non-randomised controlled trial study

OBJECTIVES

Approximately one in five stroke survivors suffer from difficulties with speech reception in noise, despite normal audiometry. These deficits are treatable with personal frequency-modulated systems (FMs). This study aimed to evaluate long-term benefits in speech reception in noise, after daily 10-week use of personal FMs, in non-aphasic patients with stroke with auditory processing deficits.

DESIGN

This was a prospective non-randomised controlled trial study. Patients were allocated to an intervention care group or standard care subjects group according to their willingness to use the intervention or not.

SETTING

Tertiary care setting.

PARTICIPANTS

Nine non-aphasic subjects with ischaemic stroke, normal/near-normal audiometry and auditory processing deficits and with reported difficulties understanding speech in background noise were recruited in the subacute stroke stage (3-12 months after stroke).

INTERVENTIONS

Four patients (intervention care subjects) used the FMs in their daily life over 10 weeks. Five patients (standard care subjects) received standard care.

PRIMARY OUTCOME MEASURES

All subjects were tested at baseline (visit 1) and 10 weeks later (visit 2) on a sentences in noise test with the FMs (aided) and without the FMs (unaided).

RESULTS

Speech reception thresholds showed clinically and statistically significant improvements in intervention but not in standard care subjects at 10 weeks in aided and unaided conditions.

CONCLUSIONS

10-week use of FMs by adult patients with stroke may lead to benefits in unaided speech in noise perception. Our findings may indicate auditory plasticity type changes and require further investigation.

TRIAL REGISTRATION NUMBER

Pre-results; NCT02889107.

Auditory rehabilitation after stroke: treatment of auditory processing disorders in stroke patients with personal frequency-modulated (FM) systems

PURPOSE

Auditory disability due to impaired auditory processing (AP) despite normal pure-tone thresholds is common after stroke, and it leads to isolation, reduced quality of life and physical decline. There are currently no proven remedial interventions for AP deficits in stroke patients. This is the first study to investigate the benefits of personal frequency-modulated (FM) systems in stroke patients with disordered AP.

METHODS

Fifty stroke patients had baseline audiological assessments, AP tests and completed the (modified) Amsterdam Inventory for Auditory Disability and Hearing Handicap Inventory for Elderly questionnaires. Nine out of these 50 patients were diagnosed with disordered AP based on severe deficits in understanding speech in background noise but with normal pure-tone thresholds. These nine patients underwent spatial speech-in-noise testing in a sound-attenuating chamber (the "crescent of sound") with and without FM systems.

RESULTS

The signal-to-noise ratio (SNR) for 50% correct speech recognition performance was measured with speech presented from 0° azimuth and competing babble from ±90° azimuth. Spatial release from masking (SRM) was defined as the difference between SNRs measured with co-located speech and babble and SNRs measured with spatially separated speech and babble. The SRM significantly improved when babble was spatially separated from target speech, while the patients had the FM systems in their ears compared to without the FM systems.

CONCLUSIONS

Personal FM systems may substantially improve speech-in-noise deficits in stroke patients who are not eligible for conventional hearing aids. FMs are feasible in stroke patients and show promise to address impaired AP after stroke. Implications for Rehabilitation This is the first study to investigate the benefits of personal frequency-modulated (FM) systems in stroke patients with disordered AP. All cases significantly improved speech perception in noise with the FM systems, when noise was spatially separated from the speech signal by 90° compared with unaided listening. Personal FM systems are feasible in stroke patients, and may be of benefit in just under 20% of this population, who are not eligible for conventional hearing aids.

Peripheral vestibular dysfunction is prevalent in older adults experiencing multiple non-syncopal falls versus age-matched non-fallers: a pilot study

BACKGROUND

vestibular disorders are common in the general population, increasing with age. However, it is unknown whether older adults who fall have a higher proportion of vestibular impairment compared with age-matched older adult non-fallers.

OBJECTIVE

to identify whether a greater proportion of older adult fallers have a peripheral vestibular impairment compared with age-matched healthy controls.

DESIGN

case-controlled study.

SETTING

tertiary falls and neuro-otology clinics and local community centres, London, UK.

PARTICIPANTS AND METHODS

community-dwelling older adults experiencing: (i) ≥2 unexplained falls within the previous 12-months (Group F, n = 25), (ii) a confirmed peripheral vestibular disorder (Group PV, n = 15) and (iii) healthy non-fallers (Group H, n = 16). All the participants completed quantitative vestibular function tests, the functional gait assessment (FGA), physiological profile assessment (PPA) and subjective measures for common vestibular symptoms (i.e. giddiness), balance confidence during daily activities and psychological state.

RESULTS

a clinically significant vestibular impairment was noted for 80% (20/25) of Group F compared with 18.75% (3/16) for Group H (P < 0.01). Group F performed less well in complex gait tasks (FGA), and reported a greater number of falls than both Groups H and PV (P < 0.05). Vestibular symptom scores showed no significant difference between Groups F and PV.

CONCLUSION

vestibular dysfunction is significantly more prevalent in older adult fallers versus non-fallers. Individuals referred to a falls clinic are older, more impaired and report more falls than those referred to a neuro-otology department. A greater awareness of vestibular impairments may lead to more effective management and treatment for older adult fallers.