Framework for early detection and classification of balance pathologies using posturography and anthropometric variables

BACKGROUND

Early detection of balance-related pathologies in adults using Posturography, anthropometric and personal data is limited. Our goal is to address this issue. It will enable us to identify adults in early stages of balance disorders using easily accessible and measurable data.

METHODS

Open-source data of 163 subjects (47 males and 116 females) is used to train and test classification algorithms. Features include mean and standard deviation of the center of pressure displacement, obtained through posturography, the anthropometric and personal variables (age, sex, body mass index, foot length), and Trail Making Test scores. 75% of the data is employed for training and 25% of the data is used for testing. It is then validated using an indigenously collected dataset of healthy individuals.

FINDINGS

Accuracy and Sensitivity, both, increases when anthropometric and personal variables are included alongside center of pressure features for classification. Specificity decreases slightly with the addition of anthropometric and personal variables with center of pressure displacement feature, which also affects the classification algorithms' performance. Standard deviation of the center of pressure displacement is found to be more effective than the mean value. A similar trend of the increased performance is observed during validation, except when neural networks were used for the classification.

INTERPRETATION

Posturography data, Anthropometric measurements, personal data and self-assessment scales can identify balance issues in adults, making it suitable for community health centers with limited resources. Early detection prompts timely medical care, improving the management of disorders and thus enhancing the quality of life through rehabilitation.

Balance disorders and migraine

BACKGROUND

Migraine is associated with motion sensitivity symptoms such as kinetosis, vestibular symptoms and balance alterations. While focus is given to headache management, addressing these symptoms is often neglected, although they are related to additional migraine burden and increased disability.

PURPOSE

Our aim is to disseminate the current understanding of the motion sensitivity symptoms among patients with migraine, with focus on balance impairments. We discuss the susceptibility of migraine to motion sensitivity, its suggested mechanisms, the balance alterations during quiet standing, mobility tasks and reactions to external perturbations. The role of migraine subdiagnosis, implications for clinical practice and future perspectives are also acknowledged.

IMPLICATIONS

Balance disorders are one of the signs reflecting a broader and complex spectrum of motion sensitivity, which are present even between attacks. Migraineurs are especially inherent to these symptoms probably due to brain hyperexcitability and to shared pathophysiological mechanisms. Patients, especially with aura and chronic migraine, exhibit balance instability during quiet standing under different surface and visual input conditions. Migraineurs demonstrated reduced limits of stability and lower performance on walk, transposing obstacles and sit to stand tasks. Only patients with aura present impairment of motor control reactions following external perturbations. Balance alterations are associated with falls and are influenced by aura, migraine frequency and psychosocial aspects, but not by vestibular symptoms or vestibular migraine diagnosis. There is a high demand for high quality of evidence regarding the assessment and care of motion sensitivity symptoms in migraineurs, considering approaches to manage not just the pain, but its associated symptoms.

Upper limb contribution during tandem gait in multiple sclerosis: An early marker of balance impairments

Tandem gait is widely used during clinical exams to evaluate dynamic balance in chronic diseases, such as multiple sclerosis (MS). The early detection of balance impairments in MS is challenging to improve the understanding of patients' complaints. The objective was to propose two indexes to quantify the contributions and inefficiency of limb and trunk movements during tandem gait in early-stage MS patients. Fifteen patients with remitting-relapsed MS, with a median Expanded Disability Status Scale of 2.5 [0-4] were compared to 15 matched healthy participants. Three-dimensional motion analysis was performed during tandem gait to calculate spatiotemporal parameters, contribution and inefficiency indexes, based on the linear momentum of body segments. Compared to healthy participants, MS patients at the early stage of disease executed tandem gait with higher speed (p = 0.03) and increased step length (p = 0.03). The contribution indexes of upper limbs were significantly decreased during swing phase in MS patients. The inefficiency index for the upper limbs were around twice higher for MS patients compared to healthy participants. Since the additional movements concerned only light body segments and not contribute to the whole-body forward progression during tandem gait, they could reflected more both upper limb movements alterations and restoring movements to avoid loss of balance during tandem gait around swing phase in MS. These quantified indexes could be used as physical markers to quantify both the balance deterioration and the efficiency of rehabilitation program during the follow up of MS from the early stage of their disease.

Audiological and vestibular symptoms following SARS-CoV-2 infection and COVID-19 vaccination in children aged 5-11 years

PURPOSE

The present study assessed the prevalence of audio-vestibular symptoms following SARS-COV-2 infection or COVID-19 vaccination among children, comparing the two groups. A further aim was to evaluate whether children with pre-existing unilateral hearing loss were more prone to adverse events.

MATERIALS AND METHODS

This retrospective study included children aged 5-11 years with normal hearing or a proven history of unilateral hearing loss who contracted SARS-CoV-2 or received two doses of COVID-19 vaccine. Tinnitus, hyperacusis, aural fullness, otalgia, otorrhea, new-onset hearing loss, vertigo and dizziness were investigated as possible complications of SARS-CoV-2 infection or the COVID-19 vaccine.

RESULTS

This study included 272 children (143 boys, 129 girls), with a mean age of 7.8 ± 2.3 years. Among these, 120 were affected by pre-existing unilateral hearing loss. The most common audio-vestibular symptoms reported by children following SARS-CoV-2 infection and COVID-19 vaccination were aural fullness (33/132, 25 %) and dizziness (5/140, 3.6 %), respectively. All symptoms following COVID-19 vaccination resolved within 24 h. Compared to children who received the COVID-19 vaccine, those infected with SARS-CoV-2 had a higher prevalence of tinnitus (p = 0.009), hyperacusis (p = 0.003), aural fullness (p < 0.001), otalgia (p < 0.001), otorrhea (p < 0.001), and vertigo (p = 0.006). Two girls also experienced new-onset unilateral sensorineural hearing loss following SARS-CoV-2 infection. Children with a known history of unilateral hearing loss did not have a higher prevalence of audio-vestibular symptoms than children with normal hearing.

CONCLUSIONS

Our results suggest that the COVID-19 vaccine is safe and can be recommended for children with unilateral hearing loss without fear of possible audio-vestibular sequelae.

Perception, knowledge, and attitude of medical doctors in Saudi Arabia about the role of physiotherapists in vestibular rehabilitation: a cross-sectional survey

Objectives

There is compelling scientific evidence about the role of physiotherapists in vestibular rehabilitation. However, patients with vestibular-associated dizziness and balance disturbances are seldom referred to physiotherapists in Saudi Arabia. Therefore, this study aims to achieve insight into perceptions, knowledge, attitudes, and referral practices among Saudi Arabian medical doctors relating to the role of physiotherapists in vestibular rehabilitation.

Methods

A sample of 381 medical doctors practicing in Saudi Arabia participated in this nationwide cross-sectional study. The sample was obtained from 226 hospitals across 13 provinces of Saudi Arabia by stratified sampling method. The 23-item questionnaire developed by a team of experts was emailed to medical doctors practicing in various hospitals across Saudi Arabia.

Results

Out of 1,231 medical doctors invited, 381 medical doctors responded, giving a response rate of 30.9%. One hundred ninety-three (50.6%) medical doctors reported managing patients with vestibular rehabilitation. The most preferred specialist for managing patients with vestibular disorders was an Ear Nose Throat (ENT) specialist (n = 173, 89.6%). Related Sample Cochran's Q test showed statistically significant difference between preferred specialist for managing patients with vestibular disorders (ENT specialists, physiotherapists, nurses, occupational therapists and audiologists) (χ2(4) = 482.476, p = 0.001). Out of 193 medical doctors, 153 (79.2%) reported no role of the physiotherapist in vestibular rehabilitation. One hundred forty-five (75.1%) of medical doctors reported that they were not aware of the role of physiotherapists in vestibular rehabilitation. Only 27 (15.5%) medical doctors reported referring patients with vestibular disorders to physiotherapists.

Conclusion

The study reports that physiotherapy services are underutilized in vestibular rehabilitation due to limited referral from Saudi Arabian medical doctors. Therefore, there is a need to increase the awareness among Saudi Arabian doctors about the physiotherapist's role in vestibular rehabilitation.

Postural stability disorders-early signs of aging-in physically non-active prisoners

BACKGROUND

There is a need for a study of possible relationship between serving a prison sentence and developing postural stability dysfunction. The aim of the study was to analyze postural stability of physically inactive prisoners. The study group consisted of 24 male prisoners aged 34.6 ± 7.02 years, imprisoned in closed prison and 30 healthy, non-active physically, aged 36.9 ± 7.5 years, who consisted control group. The subjects were imprisoned for a mean of 105.43 ± 58.48 months.

METHODS

The static balance test was conducted on bi-modular stabilometric platform CQStab2P.

RESULTS

We found statistically significant differences in several stability parameters. Prisoners results were significantly worse in parameters measured with eyes open: MA (mean amplitude p < 0.01), MAAP (mean amplitude in anterio-posterior plane p < 0.03), MAML (mean amplitude in medio-lateral plane p < 0.04), MaxAP (maximal sway in AP p < 0.01), MaxML (p < 0.01). With eyes closed the prisoner's results were significantly worse in SPML (sway path in medio-lateral plane p = 0.01), better in MAML (p < 0.01) and MaxML (p < 0.01), and faster in MVML (mean velocity in medio-lateral plane p < 0.01).

CONCLUSIONS

(1) Diagnostics aimed at early diagnoses of ageing symptoms should be performed in prisons. It would allow for better prisoner management in terms of assessment of ability to work, free time activity offer and falls prevention. (2) In prisons, in addition to counteracting the typical causes of balance disorders, action should be taken to counteract the causes for balance disorders typical for prison environment, inter alia: sensory deprivation-by implementing programmes comprehensively activating prisoners, and hypokinesis-by implementing physical activity programmes that cater for the needs of older prisoners.

Stress and the vestibular system

In this chapter we review the existing literature regarding the interactions between stress and the mechanisms that maintain balance. Evidence suggests that the interplay between neuro-endocrine and psychological factors may have a significant role in balance function. For example, in healthy individuals vestibular stimulation has been shown to trigger the stress response as indicated by increased blood cortisol levels, whereas in patients with vestibular pathology factors such as resilience and anxiety may be the key focus of interactions with stress. Critically, factors such as anxiety are known to influence clinical outcomes, despite our mechanistic understanding of these processes remaining in their infancy.

Usefulness of Ultrasound-Computer-Craniocorpography in Unilateral Ménière's Disease

Background

Ménière's disease (MD) is composed of a set of fluctuating symptoms, whereby vertigo is the most unpleasant among them and often accompanied by deterioration of the balance system.

Objectives

The purpose of this study is to objectively assess the Romberg and Unterberger-Fukuda tests by ultrasound-computer-craniocorpography (US-COMP-CCG) in patients suffering from MD and to characterize the balance disorders in different frames of MD.

Methods

This is a case-control study where 51 patients with normal vestibular system and 42 patients suffering from definite MD were examined by US-COMP-CCG. They were divided into three grades according to the attack rates and the complaints of the patient during the attack-free periods.

Results

Parameters of significance showing the worsening of the balance system with the aggravation of the disease are seen in both tests. In the standing test, the longitudinal and lateral sway and the forehead covering values are of importance, whereas in the stepping test, the parameter of relevance is the lateral sway.

Conclusions

The severity of worsening of the balance system, based on the objective results of the system parameters, are parallel to the worsening of MD based on our findings.

Mitochondrial mutations associated with hearing and balance disorders

Hearing and balance disorders are related to the inner ear and are among the major cause of falls in older adults. Hearing loss that commonly occurs with aging (aka presbyacusis) can result from noise exposure, smoking, ototoxic drugs and genetic factors such as mutations in nuclear and mitochondrial genes. Mutations in mitochondrial DNA (mtDNA) have been reported to play an important role in cell function by providing energy, as well as, cell death (apoptosis). This study aims to systematically review mitochondrial mutations associated with presbyacusis and suggests preventive measurements to improve the quality of life in older adults.

Dizziness in Europe: from licensed fitness to drive to licence without fitness to drive

A common European Community driving licence was established in 1980. However, there are major differences among the countries as regards medical conditions that legally affect driving ability. This article discusses various assessment guidelines for dizzy patients. These range from a total absence of specified binding requirements in Finland or regulations open to clinical interpretation in Switzerland, to inappropriately strict regulations in Germany. We focus on requirements for patients with vestibular disorders in Germany which have been in force since 2014. These guidelines stipulate that for group 1 driving licence (private cars < 3.5 t, motorbikes): (1) patients with Menière's disease (attacks without prodromes) must have had no attacks for 2 years before it is possible to drive again. (2) Patients with vestibular migraine without prodromes must not have had any attacks for 3 years. For a group 1 and group 2 driving licence ("professional driver"): (3) patients with bilateral vestibulopathy as a rule are considered to have a driving disability. Similarly, strict restrictions have been formulated for ocular motor disorders such as downbeat and upbeat nystagmus and for patients with functional (psychosomatic) forms of dizziness such as phobic postural vertigo. The authors represent a working group of the European Dizzynet focusing on the topic "fitness to drive with vertigo and balance disorders". They agree that European guidelines must be revised and harmonized, for some are too strict and the required dizziness-free intervals are too long; others must be revised, for they are too lax. A common European standard is needed.

[Balance disorders]

Balance disorders may result from an impairment of one of the sensorial modalities involved in the perception of the self-location in space: vestibular, proprioception and vision, a deficit of the neuronal multisensorial integration, a less effective motor or loco-motor system, the medication side effects or psychological interferences. The basic examination of a dizzy patient implies the assessment of these different aspects. The balance is not restricted to à set of reflexes. It is a distinctive expression of the sixth sense : the sense of orientation. For every moving being, to go around in circles is ineffective to find new sources of food or avoid a predator. So, the ability of self-orientation in space is a primitive, unconscious function, critical to stay alive and closely related to the limbic system. The experience of the mobility, that required the spatial memory, which evolved towards the episodic memory, could be considered as the foundation of our thought.

DIZZYNET--a European network initiative for vertigo and balance research: visions and aims

Vertigo is one of the most common complaints in medicine. Despite its high prevalence, patients with vertigo often receive either inappropriate or inadequate treatment. The most important reasons for this deplorable situation are insufficient interdisciplinary cooperation, nonexistent standards in diagnostics and therapy, the relatively rare translations of basic science findings to clinical applications, and the scarcity of prospective controlled multicenter clinical trials. To overcome these problems, the German Center for Vertigo and Balance Disorders (DSGZ) started an initiative to establish a European Network for Vertigo and Balance Research called DIZZYNET. The central aim is to create a platform for collaboration and exchange among scientists, physicians, technicians, and physiotherapists in the fields of basic and translational research, clinical management, clinical trials, rehabilitation, and epidemiology. The network will also promote public awareness and help establish educational standards in the field. The DIZZYNET has the following objectives as regards structure and content:

to focus on multidisciplinary translational research in vertigo and balance disorders,

to develop interdisciplinary longitudinal and transversal networks for patient care by standardizing and personalizing the management of patients,

to increase methodological competence by implementing common standards of practice and quality management,

to internationalize the infrastructure for prospective multicenter clinical trials,

to increase recruitment capacity for clinical trials,

to create a common data base for patients with vertigo and balance disorders,

to offer and promote attractive educational and career paths in a network of cooperating institutions.

In the long term, the DIZZYNET should serve as an internationally visible network for interdisciplinary and multiprofessional research on vertigo and balance disorders. It ideally should equally attract the afflicted patients and those managing their disorders. DIZZYNET will not compete with the traditional national or international societies active in the field, but will function as an additional structure that addresses some of the above problems.

Muscle activation patterns related to diabetic neuropathy in elderly subjects: A Functional Reach Test study

BACKGROUND

This study was designed to assess, in healthy elderly, non-neuropathic and neuropathic diabetic subjects, the activation patterns of the main muscles involved in the Functional Reach Test, a well-recognized method to identify elderly subjects at risk of balance impairments.

METHODS

Surface electromyographic analysis of Sternocleidomastoideus, Rectus Abdominis, Erectores Spinae at L4 level, Rectus Femoris, Hamstrings, Tibialis Anterior and Soleus was performed in 10 healthy, 10 diabetic non-neuropathic and 10 diabetic neuropathic subjects.

FINDINGS

Results showed that in every group the first motor is Tibialis Anterior, that is recruited before the start of the test. An earlier activation of Tibialis Anterior (P<0.05) was detected in diabetic neuropathic (ON at -24% of the test period), compared with healthy (-11%) and diabetic non-neuropathic (-13%) groups. A significant earlier activation of Sternocleidomastoideus and Rectus Abdominis was found in diabetic neuropathic group, only with respect to healthy subjects. No significant difference was found in Rectus Femoris, Soleus, Hamstrings an Erectores Spinae onset among the three groups.

INTERPRETATION

Results suggest a trend of diabetic neuropathic patients in earlier anticipation of the activation of the anterior body-muscles. In particular, the earlier onset of Tibialis Anterior is likely to be performed to adjust the movement timing and to compensate for the delay in the recruitment of the motor units. This anticipation might be involved in the altered postural control with increased balance impairment detected in diabetic neuropathic patients, and thereby it might also be proposed as an index of neuropathy, evidenced in a simple and non-invasive manner.

Otorhinolaryngological, audiovestibular and swallowing manifestations of patients with Niemann-Pick disease Type C

OBJECTIVES

The aim of this study is to evaluate audiovestibular and swallowing impairment of patients with NPC.

METHODS

Audiovestibular and swallowing evaluation were performed on patients with Niemann-Pick disease type C (NPC) at Hacettepe University between 20013 and 2015 prospectively. Pure-tone audiometry (PTA), Auditory Brain stem response (ABR), Flexible endoscopic evaluation of swallowing (FEES) test and posturography were done. Hearing, swallowing and balance states were measured.

RESULTS

There were 16 patients (5 male and 11 female, with a median age of 6.5 years old). The most common ABR abnormalities observed were absent waves I and III (%70 absent I waves, %43.75 absent III waves). Twelve of sixteen patients (%75) had an ABR abnormality in at least one ear, of these, four patients had normal hearing and three of them had periferal hearing loss. 12 (75%) patients had complaint of postural imbalance. 11(69%) of patients had peripheral and one (6%) patient had central impairment. Nine of sixteen patients (56.25%) show some degree of dysphagia (either penetration or aspiration). Two patients (12.5%) showed aspiration both liquid and viscous nutrition. Three patients (18.75%) showed aspiration primarily in liquids and two of them had penetration with viscous nutrition. Three patients (18.75%) had penetration with no aspiration neither liquid nor viscous nutrition (PEN-ASP score was 3, 3, 5, respectively).

CONCLUSION

There is no curative treatment for this devastating and fatal disorder and hearing impairment, balance and swallowing disorders can be seen especially late onset form of disease.

Tailored balance exercises on people with multiple sclerosis: A pilot randomized, controlled study

BACKGROUND

Altered integration of signals from visual (VIS), somatosensory (PROP) and vestibular system (VEST) lead to balance control impairments affecting the daily living activities of patients with multiple sclerosis (PwMS). As a consequence, tailored interventions could be crucial in improving efficacy of balance rehabilitation treatments.

OBJECTIVE

The objective of this paper is to assess the efficacy of tailored rehabilitation treatments for balance disorders based on visual, somatosensory and vestibular deficits versus traditional rehabilitation exercises.

METHODS

Thirty-two PwMS were assessed with the Berg Balance Scale (BBS), the composite score (CS) obtained by computerized dynamic posturography (CDP) test and the Modified Fatigue Impact Scale (MFIS). Based on CDP analysis, prevalent VIS, PROP or VEST deficits were identified and patients randomly allocated to a personalized (PRG) or traditional (TRG) rehabilitation group.

RESULTS

BBS score showed a significant difference between pre- and post-treatment scores of 6.3 and 2.0 points respectively for PRG and TRG. CS showed a significant difference between pre- and post-treatment scores of 16.6 and 7.6 points respectively for PRG and TRG. No interaction effect was found for MFIS score.

CONCLUSIONS

BBS and CS showed changes in the PRG group that met clinical relevant difference, underlining that tailored rehabilitation interventions based on patient-specific sensory system impairment could improve balance and postural control in PwMS.

Episodisch auftretendes Schwindelgefühl

While an acute loss of unilateral vestibular function (for example in case of neuritis vestibularis or temporal bone fracture) leads to long-term vertigo, this paper deals with the phenomenon of episodic vertigo (duration: seconds up to hours).Both peripheral-vestibular and central disturbances can be responsible for this symptom. The aim of this paper is to present otological and neurological diseases which can lead to episodic attacks of vertigo.