Evidence of Vestibular and Balance Dysfunction in Patients With Mild Cognitive Impairment and Alzheimer's Disease.

OBJECTIVES: Given the expected rise in dementia prevalence, early diagnosis is vital. As a growing body of literature has identified a potential association between vestibular function and cognition, vestibular assessment may aid in early screening. The aim of the study was to better comprehend the proposed association between vestibular function and Alzheimer's disease (AD) by comparing vestibular parameters (vestibular function testing and clinical balance measures) between a group with mild cognitive impairment (MCI), AD, and healthy controls with age-normal cognition. DESIGN: Cross-sectional analysis of the GECkO study, an ongoing prospective single-center longitudinal cohort study. This study included 100 older adults (55 to 84 years). A total of 33 participants with MCI, 17 participants with AD, and 50 participants of age, sex, and hearing-matched healthy controls were included. RESULTS: Participants with AD demonstrated a delayed latency of the p13 component measured by cervical vestibular-evoked myogenic potentials (cVEMP) compared with healthy controls and participants with MCI. Other measures including n23 latency, presence of intact responses, rectified amplitude, mean rectified voltage (measured by cVEMP) and lateral vestibulo-ocular reflex gain (measured by video Head Impulse Test [vHIT]) did not differ between groups. The Timed Up and Go (TUG), Performance-Oriented Mobility Assessment-Balance subscale (POMA-B), and Functional Gait Assessment (FGA) differed significantly between the three groups. Here, more cognitively impaired groups were associated with worse clinical balance scores. CONCLUSIONS: Vestibular and balance deficits were more prevalent in groups with increasing cognitive decline. Regarding vestibular function testing, p13 latency as measured by cVEMP was delayed in participants with AD. Other cVEMP or vHIT measures did not differ between groups. All three clinical balance assessments (TUG, POMA-B, and FGA) resulted in worse scores along the AD continuum. Future research integrating vestibular parameters that add value (including otolith function testing, balance, and spatial navigation) is recommended to validate the association between vestibular function and cognition while avoiding redundant testing.

Compensatory strategies after an acute unilateral vestibulopathy: a prospective observational study.

PURPOSE: In case of an acute unilateral vestibulopathy (UVP), compensatory strategies such as restoration and adaptation will lead to a decrease in intensity of the symptoms. Although measurements of compensatory strategies are available, currently, an overview taking the different strategies into account is lacking. The objectives of this study are to explore compensatory strategies and to investigate the association between compensatory strategies and patient characteristics. METHODS: Restoration was objectified by the vestibulo-ocular reflex (VOR) gain on the video head impulse test, and adaptation-consisting of visual, multisensory, and behavioral substitution-was objectified by the Visual Vertigo Analog Scale (VVAS), Antwerp Vestibular Compensation Index (AVeCI), and Perez and Rey score (PR score), respectively. Adequate restoration and adaptation levels were interpreted as follows: VOR gain > 0.80, VVAS ≤ 40%, AVeCI > 0 and PR score ≤ 55. RESULTS: Sixty-two UVP patients, 34 men and 28 women, were included with an average age of 52.1 ± 17.3 years. At 10.5 ± 1.4 weeks after onset, 41.9% of the UVP patients reached adequate restoration levels and 58.1-86.9% reached adequate adaptation levels. Furthermore, significant associations were found between (1) restoration status and UVP etiology [Odds Ratio (OR) with 95% CI: 4.167 {1.353;12.828}] and balance performance (OR: 4.400 {1.258;15.386}), (2) visual sensory substitution status and perceived handicap (OR: 8.144 {1.644;40.395}), anxiety (OR: 10.000 {1.579;63.316}) and depression (OR: 16.667 {2.726;101.896}), and (3) behavioral substitution status and balance performance (OR: 4.143 {1.341;12.798}). CONCLUSION: UVP patients with adequate compensatory strategies presented with better balance performance, lower perceived handicap, and lower anxiety and depression scores.

A full-body motion capture gait dataset of 138 able-bodied adults across the life span and 50 stroke survivors.

This reference dataset contains biomechanical data of 138 able-bodied adults (21-86 years) and 50 stroke survivors walking bare-footed at their preferred speed. It is unique due to its size, and population, including adults across the life-span and over 70 years, as well as stroke survivors. Full-body kinematics (PiG-model), kinetics and muscle activity of 14 back and lower limbs muscles was collected with a Vicon motion capture system, ground-embedded force plates, and a synchronized surface EMG system. The data is reliable to compare within and between groups as the same methodology and infrastructure were used to gather all data. Both source files (C3D) and post-processed ready-to-use stride-normalized kinematics, kinetics and EMG data (MAT-file, Excel file) are available, allowing high flexibility and accessibility of analysis for both researchers and clinicians. These records are valuable to examine ageing, typical and hemiplegic gait, while also offering a wide range of reference data which can be utilized for age-matched controls during normal walking.

Fear avoidance beliefs, anxiety, and depression in healthy individuals and persons with vestibular disorders across cultures.

Background/introduction: In persons with vestibular disorders, disturbed vestibular input and accompanying dizziness can be associated with anxiety or depression. To avoid dizziness, persons with vestibular disorders can develop mal-adaptive fear avoidance behaviors which can negatively influence daily life functioning. The aims of this study were to (1) document different psychological factors in patients with vestibular disorders and healthy adults across cultures and (2) to assess the convergent validity of the 9-item Vestibular Activities Avoidance Instrument (VAAI), which quantifies fear avoidance beliefs. Methods: Psychological factors and disability were measured in Dutch-speaking healthy adults and English- and Dutch-speaking persons with vestibular disorders using the VAAI, the Dizziness Handicap Inventory (DHI), the Hospital Anxiety and Depression Scale (HADS) and the Activities-Specific Balance Confidence Scale (ABC). The convergent validity of the VAAI was investigated by performing correlation analyses between the VAAI, the DHI, the HADS, and the ABC. Results: A total of 151 Dutch-speaking healthy adults, 404 English-speaking participants with vestibular disorders, and 126 Dutch-speaking participants with vestibular disorders were included. Participants with vestibular disorders presented with higher levels of fear avoidance beliefs (VAAI), perceived disability (DHI), anxiety and depression (HADS), and lower confidence during balance activities (ABC) compared to healthy adults. Regarding the convergent validity of the VAAI, there were moderate to strong correlation coefficients (r = 0.39-0.74) between fear avoidance and the DHI, HADS, and ABC in participants with vestibular disorders. Conclusions: Participants with vestibular disorders report a higher psychological burden compared to healthy adults. These results emphasize the importance of assessing psychological factors in persons with vestibular disorders. In addition, evidence was provided for convergent validity, supporting the VAAI as a valid outcome measure across cultures.

Chronic symptoms in patients with unilateral vestibular hypofunction: systematic review and meta-analysis.

Objective: To systematically evaluate the full spectrum of self-reported chronic symptoms in patients with unilateral vestibular hypofunction (UVH) and to investigate the effect of interventions on these symptoms. Methods: A systematic review was conducted following the guidelines of the Preferred Reporting Items for Systematic Review and Meta-Analysis Statement (PRISMA). A literature search was performed in Pubmed, Web of Science, Embase, and Scopus to investigate self-reported symptoms and self-report questionnaires in patients with UVH. All original studies ranging from full-text clinical trials to case reports, written in English, German, and French, were included. The frequency of self-reported symptoms was presented. For self-report questionnaires, a meta-analysis was carried out to synthesize scale means by the pre- and post-intervention means and mean changes for studies that investigated interventions. Results: A total of 2,110 studies were retrieved. Forty-seven studies were included after title-abstract selection and full-text selection by two independent reviewers. The symptoms of UVH patients included chronic dizziness (98%), imbalance (81%), symptoms worsened by head movements (75%), visually induced dizziness (61%), symptoms worsened in darkness (51%), and oscillopsia (22%). Additionally, UVH could be accompanied by recurrent vertigo (77%), tiredness (68%), cognitive symptoms (58%), and autonomic symptoms (46%). Regarding self-report questionnaires, UVH resulted on average in a moderate handicap, with an estimated mean total score on the Dizziness Handicap Inventory (DHI) and the Vertigo Symptom Scale (VSS) of 46.31 (95% CI: 41.17-51.44) and 15.50 (95% CI: 12.59-18.41), respectively. In studies that investigated the effect of vestibular intervention, a significant decrease in the estimated mean total DHI scores from 51.79 (95% CI: 46.61-56.97) (pre-intervention) to 27.39 (95% CI: 23.16-31.62) (post intervention) was found (p < 0.0001). In three studies, the estimated mean total Visual Analog Scale (VAS) scores were 7.05 (95% CI, 5.64-8.46) (pre-intervention) and 2.56 (95% CI, 1.15-3.97) (post-intervention). Finally, a subgroup of patients (≥32%) persists with at least a moderate handicap, despite vestibular rehabilitation. Conclusion: A spectrum of symptoms is associated with UVH, of which chronic dizziness and imbalance are most frequently reported. However, semi-structured interviews should be conducted to define the whole spectrum of UVH symptoms more precisely, in order to establish a validated patient-reported outcome measure (PROM) for UVH patients. Furthermore, vestibular interventions can significantly decrease self-reported handicap, although this is insufficient for a subgroup of patients. It could therefore be considered for this subgroup of patients to explore new intervention strategies like vibrotactile feedback or the vestibular implant. Systematic review registration: [https://www.crd.york.ac.uk/prospero/], identifier [CRD42023389185].

How do patients with chronic dizziness experience a web-based home rehabilitation programme for customised vestibular therapy ('WeBaVeR')? A qualitative study.

BACKGROUND: Vestibular rehabilitation therapy (VRT) is the first choice approach for chronic dizziness. However, current home treatment programmes often lack attention to the individual needs of the patient and the integration of visual desensitisation therapy. We therefore developed a customised web-based VRT programme containing visual desensitisation exercises. OBJECTIVE: To assess the user experience (usability, satisfaction, acceptability, and quality) of patients with chronic dizziness with the customised WEb-BAsed VEstibular Rehabilitation, further called 'WeBaVeR'. METHODS: Patients with chronic dizziness, attending the Department of Otorhinolaryngology of the Antwerp University Hospital (period September 2021 to May 2022), received a customised programme, i.e. exercises supported by our web application and booklet. The programme lasted 6 weeks, with weekly supervision by phone. Patients' user experience was examined with the System Usability Scale (SUS), Client Satisfaction Questionnaire (CSQ), Service User Technology Acceptability Questionnaire (SUTAQ), and the User version of the Mobile Application Rating Scale (uMARS). RESULTS: Twelve patients with chronic dizziness (mean age: 45.33 ± 13.26 years) participated. The overall rated level of perceived usability (mean SUS score: 78.75 ± 8.95 points), satisfaction (mean CSQ score: 33.08 ± 3.37 points), acceptability (mean SUTAQ score: 105.67 ± 13.40 points) and quality (mean uMARS score: 94.58 ± 10.69 points) was good. The main remarks concerned the user interface and the interactive capabilities of the web application, and that WeBaVeR does not increase health awareness, or accessibility to health care providers. CONCLUSION: Patients with chronic dizziness consider WeBaVeR as useful, acceptable, satisfactory and of good quality. To facilitate implementation in practice, further optimisation of WeBaVeR based on the feedback received, is useful.

Subjective perception of activity level: A prognostic factor for developing chronic dizziness after vestibular schwannoma resection?

Introduction: A vestibular schwannoma (VS) resection causes an acute unilateral vestibular deafferentation resulting in acute postoperative symptoms. Despite the expected resolution of most of the symptoms, due to central vestibular compensation, more than one out of four patients develop chronic dizziness. Several predictive factors, such as age and tumor size, have been suggested. Despite its potential effect on the process of central vestibular compensation, the level of physical activity after VS resection was not yet considered. Therefore, the association between the level of physical activity and chronic dizziness after VS resection will be investigated. Methods: This retrospective cohort study included 66 patients who underwent a retro-sigmoid VS resection between October 2001 and February 2007. Patients were assessed before surgery and at 9 weeks and 6 months postoperatively. At 9 weeks, patients were asked to report their level of physical activity (PA) during the past week by using a visual analogue scale and their balance performance was assessed by four standing balance conditions with eyes closed and the Timed Up and Go test (TUG). Based on the Dizziness Handicap Inventory (DHI) score at 6 months, patients were divided in a chronic dizziness group (DHI > 30) and non-chronic dizziness group (DHI-score ≤ 30). Age, sex, Koos classification, preoperative vestibular function, treatment group, balance performance, and level of PA were compared between both groups and used as independent variables in linear regression analyses with the DHI score at 6 months as dependent variable. Results: The chronic dizzy patients revealed to have significantly lower levels of PA (p < 0.001) and worse static and dynamic balance performance (p = 0.023 and p = 0.041, respectively) 9 weeks after surgery. After elimination, the multiple regression analysis resulted in a model with two variables (PA level, TUG) which significantly predicted the DHI score (F 2,42 = 6.581; R 2 = 0.239; p = 0.003). Conclusion: This study revealed associations between (1) the level of PA and balance performance in the subacute phase and (2) chronic dizziness after VS resection. Assessment of the level of PA and balance performance during the subacute phase, which can be performed in a non-invasive and non-time-consuming way, might therefore provide prognostic information after VS resection.

Outcome for dizzy patients in a physiotherapy practice: an observational study.

BACKGROUND: Dizziness is a common reason for referral to physiotherapy. Additional information on clinical characteristics, treatment effect and prognostic indicators in physiotherapy practice are needed. METHODS: A retrospective observational study. Based on a standardised clinical evaluation patients were labelled as having Benign Paroxysmal Positioning Vertigo (BPPV) or not (no-BPPV). BPPV was treated with repositioning manoeuvres and exercises. In no-BPPV, treatment was based on additional clinical tests. Treatment was provided once per week and considered successful when the patient was free of symptoms confirmed by negative positional tests. RESULTS: From 148 referred patients, 88 were labelled as having BPPV, 60 as no-BPPV. The symptom of a short-lasting spinning sensation provoked by head movements was highly suggestive of BPPV. On average, in BPPV treatment was completed after 2.27 ± 1.68 treatments, in no-BPPV this was after 4.91 ± 3.46 treatments. The delayed outcome was related to higher 'age' and 'concomitant neck pain' in BPPV and with higher 'age' only in no-BPPV. Favourable outcome was related to the feature 'dizziness provoked by movements in the horizontal plane' in BPPV. CONCLUSIONS: Clinical evaluation and treatment in physiotherapy practice can be an effective and safe option for patients with dizziness. Several clinical variables with prognostic values were identified.Key messagesClinical evaluation and treatment in physiotherapy practice can be part of low threshold care for dizzy patients.Despite prior medical screening, one-third of patients without signs of BPPV were sent back for further evaluation, illustrating the need for interdisciplinary collaboration.Based on the description of the dizziness symptom (vertigo rather than light-headedness), provocation of the dizziness by movements, and a short duration of the dizziness attack, and positive clinical vestibular tests, BPPV treatment could be initiated.

Associations of Bilateral Vestibulopathy With Cognition in Older Adults Matched With Healthy Controls for Hearing Status.

Importance: Recent literature suggests there may be a significant effect of the vestibular system on cognition and visuospatial processing. Given the increasing prevalence of dementia and individuals at risk for it, exploring possible modifiable risk factors, including vestibular dysfunction, is vital. Objectives: To explore the association of bilateral vestibulopathy (BV) with cognitive function in older adults, taking hearing status into account, and to explore multiple vestibular characteristics and their potential associations with cognition in patients with BV. Design, Setting, and Participants: This cross-sectional study assessed older adults (age 55-84 years) with diagnosed BV from a single center using baseline measurements from the Gehoor, Evenwicht en Cognitie (GECKO) study, an ongoing prospective longitudinal cohort study. Each participant was individually matched with a healthy control based on age, sex, and hearing performance. Data were analyzed in January 2022. Main Outcomes and Measures: The primary outcome measure was cognition, measured by the Repeatable Battery for the Assessment of Neuropsychological Status for Hearing-Impaired Individuals (RBANS-H). Results: A total of 68 patients were assessed, including 34 patients with BV (mean [SD] age, 63.3 [6.0] years; 18 [53%] men) matched with 34 control individuals without BV. Overall, participants with BV had a clinically meaningful lower score on the RBANS-H total scale compared with those without BV (mean [SD] score, 98.62 [12.70] vs 105.91 [11.03]). This decline was most pronounced in the subdomains of immediate memory (mean [SD] score, 107.74 [10.66] vs 112.26 [10.66]), visuospatial cognition (mean [SD] score, 90.06 [13.34] vs 100.47 [13.91]), and attention (mean [SD] score, 94.79 [16.39] vs 102.06 [12.97]). There were no differences in language or delayed memory subdomains. Within the BV population, 1 vestibular parameter (the Performance-Oriented Mobility Assessment, in particular the balance subscale) was associated with lower cognitive scores (r32 = 0.51; 95% CI, 0.20 to 0.72; η2 = 0.26). Other vestibular parameters, including measurements of the peripheral vestibular end organ and questionnaires, showed no association. Conclusions and Relevance: These findings suggest there was an association between vestibular loss and cognitive impairment. Further research on the causal mechanisms underlying this association and the possible impact of vestibular rehabilitation on cognition is needed.

Comparison of Clinical Balance and Visual Dependence Tests in Patients With Chronic Dizziness With and Without Persistent Postural-Perceptual Dizziness: A Cross-Sectional Study.

Background: The diagnosis of persistent postural-perceptual dizziness (PPPD) is primarily based on medical history taking. Research on the value of clinical balance and visual dependence tests in identifying PPPD is scarce. Objectives: (1) to contrast clinical balance and visual dependence tests between PPPD patients, dizzy non-PPPD patients, and healthy persons; and (2) to evaluate whether these clinical tests can help to identify PPPD in patients with chronic dizziness. Methods: Consecutive patients with chronic dizziness (38 PPPD and 21 non-PPPD) and 69 healthy persons underwent Static Balance tests, the Timed Up and Go test, the Tandem Gait test, and the Functional Gait Assessment (FGA). Visual dependence tests included the Visual Vertigo Analog Scale (VVAS), the Rod-and-Disc test (RDT), and postural sway while facing rotating dots. Groups were compared using ANOVA with post-hoc Tukey, or independent samples t-tests. The value of the clinical tests for PPPD identification was evaluated through logistic regression and Partial Least Squares Discriminant (PLS-DA) analyses. Results: PPPD patients had significantly higher VVAS scores than dizzy non-PPPD patients (p = 0.006). Facing rotating dots, PPPD and dizzy non-PPPD patients had increased postural sway compared to healthy persons (PPPD vs. healthy: center of pressure (COP) velocity p < 0.001, and COP area p < 0.001; but non-PPPD vs. healthy: COP velocity p = 0.116 and COP area p = 0.207). PPPD patients had no significantly increased postural sway compared to dizzy non-PPPD patients. PPPD and dizzy non-PPPD patients also scored significantly worse on balance tests compared to healthy persons (PPPD vs. healthy: for all balance tests p < 0.001; non-PPPD vs. healthy: FGA p < 0.001, for all other tests p < 0.05). Differences were insignificant in balance scores between PPPD and dizzy non-PPPD patients, or in RDT scores between the three study groups. In patients with chronic dizziness, a higher VVAS score was most associated with PPPD [odds ratio 1.04; 95% CI (1.01; 1.07); p = 0.010]. The cross-validated (CV) PLS-DA model with all clinical tests included, had fair discriminative ability (CVerror = 47%). Conclusion: PPPD patients were more visually dependent, but did not have worse postural balance compared to dizzy non-PPPD patients. Elevated VVAS scores characterized PPPD most in patients with chronic dizziness.

Systematic review and meta-analysis of the therapeutic management of patients with cervicogenic dizziness.

BACKGROUND: Patients with cervicogenic dizziness (CGD) present with dizziness, cervical spine dysfunctions, and postural imbalance, symptoms that can significantly impact their daily functioning. OBJECTIVES: To provide evidence-based recommendations for the management of patients with CGD. METHODS: Three databases were searched for randomized controlled trials (RCTs) (last search 15 May 2021). Outcome measures included dizziness, cervical spine, and balance parameters. Cochrane standard methodological procedures were used and included the RoB 2.0 and GRADE. Where possible, RCTs were pooled for meta-analysis. RESULTS: Thirteen RCTs (n = 898 patients) of high (two RCTs), moderate (five RCTs), and low (six RCTs) methodological quality were analyzed. Six RCTs were included in the meta-analysis. Only three RCTs specified the cause of CGD. They showed inconsistent findings for the effectiveness of exercise therapy in patients with traumatic CGD. Manual therapy and manual therapy combined with exercise therapy may reduce CGD, cervical spine, and balance dysfunctions. CONCLUSION: There is moderate quality of evidence that manual therapy reduces CGD, cervical spine, and balance symptoms. When manual therapy is combined with exercise therapy, the positive effect on CGD, cervical spine, and balance symptoms is even stronger. However, the quality of the evidence here is very low.

Clinical characteristics and diagnostic aspects of cervicogenic dizziness in patients with chronic dizziness: A cross-sectional study.

BACKGROUND AND OBJECTIVES: Chronic dizziness can significantly affect quality of life, but identifying the underlying cause remains challenging. This study focuses on proprioceptive cervicogenic dizziness (CGD) and aims: (1) to compare clinical test results between patients with CGD, dizzy patients without CGD, and healthy controls; and (2) to evaluate the diagnostic value of the clinical tests for CGD in patients with chronic dizziness. METHODS: Sixty patients with chronic dizziness (18 with CGD and 42 without CGD), and 43 healthy controls underwent clinical tests evaluating neck function (mobility, proprioception, muscle function and disability), balance control, and the presence of visually induced dizziness. Data were analysed through one-way ANOVA, chi-square, independent samples t-test, and logistic regression analyses. RESULTS: Patients with CGD had significantly more neck pain-related disability (Neck Bournemouth questionnaire (NBQ), p = 0.006), but better static (Static Balance, p = 0.001) and dynamic balance (Tandem Gait, p = 0.049), compared to dizzy patients without CGD. Univariable analyses revealed that increased NBQ (OR 1.05 [1.01; 1.09], p = 0.017), Joint Position Error (JPE) after extension (OR 1.52 [1.00; 2.32], p = 0.050), and Tandem Gait scores (OR 1.09 [1.01; 1.18], p = 0.046) were individually associated with higher odds of having CGD. Their optimal cut-off level (based on the maximum Youden index) had high sensitivity but low specificity for CGD. The multivariable model, including NBQ and Tandem Gait, had fair discriminative ability (AUC = 0.74, 95% CI [0.61; 0.87]). CONCLUSION: The combined use of the NBQ and Tandem Gait tests had the highest discriminative ability to detect CGD in patients with chronic dizziness.

The reliability of the Dutch version of the vestibular activities avoidance instrument in persons with and without dizziness.

BACKGROUND: Avoidance of activities that trigger dizziness in persons with vestibular disorders may inhibit dynamic vestibular compensation mechanisms. OBJECTIVE: To determine the reliability of the Vestibular Activities Avoidance Instrument (VAAI) 81 and 9 item tool and to compare the VAAI scores in Dutch-speaking healthy adults and in patients with vestibular disorders. METHODS: A prospective cohort study was conducted including 151 healthy participants and 106 participants with dizziness. All participants completed the 81-item VAAI. Within 7 days, the VAAI was completed a second time by 102 healthy adults and 43 persons with dizziness. RESULTS: The average 81-item VAAI scores [54.8(47.1) vs. 228.1(78.3)] and 9-item VAAI scores [2.4(5.9) vs. 28.1(12)] were significantly different between healthy adults and participants with dizziness (p < 0.001). In participants with dizziness the ICC for the 81-item VAAI was 0.95 (95% CI: 0.91, 0.97) and for the 9-item VAAI was 0.92 (95% CI: 0.85, 0.95). Cronbach's alpha for the 81-item VAAI was 0.97 and 0.85 for the 9-item VAAI. The minimal detectable change was 47.8 for the 81-item VAAI and 8.9 for the 9-item VAAI. CONCLUSIONS: Persons with dizziness have a greater tendency to avoid movements. Both test-retest reliability and internal consistency of the Dutch version of the VAAI were excellent.

Effect of age on treatment outcomes in benign paroxysmal positional vertigo: A systematic review.

BACKGROUND: Benign paroxysmal positional vertigo (BPPV) can lead to an increased fall risk in older adults. Therefore, we examined the influence of age on the effectiveness of canalith-repositioning procedures (CRPs) for the treatment of BPPV. METHODS: Pubmed, Web of Science, and the bibliographies of selected articles were searched for studies conducted before September 2020 that examined the effectiveness of treatments for BPPV in various age groups. Meta-analyses were performed to compare treatment effectiveness and recurrence rates for younger and older adults. Odds ratios were calculated in a random-effects model. Mean differences were calculated using a fixed-effects model. A significance level of p < 0.05 (95% confidence interval) was set. The risk of bias and the methodological quality of all included articles were examined. RESULTS: Forty-five studies were retrieved after full-text screening, of which 29 studies were included for a qualitative review. The remaining 16 studies were eligible for inclusion in the meta-analysis (3267 participants with BPPV). The success rate of a single CRP was higher in the younger group (72.5% vs. 67%, p < 0.001). An average of 1.4 and 1.5 CRPs was needed for complete recovery in the younger and older groups, respectively (p = 0.02). However, global treatment success did not differ between these groups (97.5% vs. 94.6%, p = 0.41). The recurrence rate was higher in the older population (23.2% vs. 18.6%, p = 0.007). CONCLUSIONS: Although more CRPs are needed, the rate of complete recovery in older adults is similar to that observed in younger adults.

The Relationship Between the Activities-Specific Balance Confidence Scale and Balance Performance, Self-perceived Handicap, and Fall Status in Patients With Peripheral Dizziness or Imbalance.

OBJECTIVE: Describe the relationship between the Activities-Specific Balance Confidence (ABC) scale and Dizziness Handicap Inventory (DHI) with balance performance, as well as fall status in patients with peripheral vestibular disorders. STUDY DESIGN: Retrospective. SETTING: Outpatient balance clinic, tertiary referral center. PATIENTS: Data from 97 patients (age: 54.8 ±â€Š12.3 yrs; 48 women) with dizziness or imbalance symptoms of peripheral vestibular origin were used for analysis. INTERVENTIONS: /. MAIN OUTCOME MEASURES: ABC-scores, DHI-scores, static and dynamic balance tests, and fall status of the past 4 weeks, 2 months, and 6 months before the time of measurement were collected. Spearman's rho correlations, χ2 with post-hoc testing, and Kruskal-Wallis with post-hoc Mann-Whitney U test results were interpreted. RESULTS: The ABC- and DHI-scores show moderate correlations with static balance (ABC: r = 0.44; DHI: r = -0.34) and dynamic balance tests (ABC: r = [-0.47;0.56]; DHI: r = [-0.48;0.39]) and a strong inverse correlation with each other (ABC: 70 ±â€Š25; DHI: 33 ±â€Š26; r = -0.84). Related to fall status, weak correlations were found (ABC: r = [-0.29;-0.21]; DHI: r = [0.29;0.33]). Additional results show that subjects in the low-level functioning (ABC) or severe self-perceived disability (DHI) categories have a poorer balance assessed by standing balance, Timed-Up-and-Go and Functional Gait Assessment and are more likely to have experienced multiple falls. CONCLUSIONS: The ABC-scale and DHI showed a strong convergent validity, additionally the ABC-scale showed a better concurrent validity with balance performances and the DHI with fall history. In general, patients with peripheral vestibular impairments reporting a lower self-confidence or a more severe self-perceived disability show worse balance performances and a higher fall incidence.

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

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

An exploratory investigation on spatiotemporal parameters, margins of stability, and their interaction in bilateral vestibulopathy.

Integration of accurate vestibular, visual, and proprioceptive information is crucial in managing the centre of mass in relation to the base of support during gait. Therefore, bilateral loss of peripheral vestibular function can be highly debilitating when performing activities of daily life. To further investigate the influence of an impaired peripheral vestibular system on gait stability, spatiotemporal parameters, step-to-step variability, and mechanical stability parameters were examined in 20 patients with bilateral vestibulopathy and 20 matched healthy controls during preferred overground walking. Additionally, using a partial least squares analysis the relationship between spatiotemporal parameters of gait and the margins of stability was explored in both groups. Patients with bilateral vestibulopathy showed an increased cadence compared to healthy controls (121 ± 9 vs 115 ± 8 steps/min; p = 0.02; d = 0.77). In addition, although not significant (p = 0.07), a moderate effect size (d = 0.60) was found for step width variability (Coefficient of Variation (%); Bilateral vestibulopathy: 19 ± 11%; Healthy controls: 13 ± 5%). Results of the partial least squares analysis suggest that patients with peripheral vestibular failure implement a different balance control strategy. Instead of altering the step parameters, as is the case in healthy controls, they use the single and double support phases to control the state of the centre of mass to improve the mechanical stability.

The Antwerp Vestibular Compensation Index (AVeCI): an index for vestibular compensation estimation, based on functional balance performance.

PURPOSE: To create an index that is a measure of the amount of vestibular compensation and for which only functional balance performance is needed. METHODS: The medical charts of 62 eligible peripheral vestibular dysfunction (PVD) patients were analyzed retrospectively. To be included, the following vestibulo-ocular reflex (VOR) and balance performance data had to be available: (1) caloric and sinusoidal harmonic acceleration test (SHA) and (2) standing balance sum-eyes closed (SBS-EC), Timed Up and Go Test and Dynamic Gait Index. Patients were divided into three groups: normal caloric- and SHA test (group 1), abnormal caloric- and normal SHA test (group 2, PVD compensated) and abnormal caloric- and SHA test (group 3, PVD uncompensated). Next to the use of non-parametric tests to study the VOR and balance variables, logistic regression was used to identify the balance measures that predict whether PVD patients were compensated or uncompensated. This resulted also in the construction of a continuous measure representing the degree of compensation. RESULTS: Logistic regression identified SBS-EC and age to classify uncompensated from compensated patients with sensitivity of 83.9% and specificity of 72.4%. Then an index was created, called the Antwerp Vestibular Compensation Index, AVeCI = - 50 + age × 0.486 + SBS-EC × 0.421. A patient belongs to the uncompensated group when AVeCI < 0 and to the compensated group when AVeCI > 0, with respective group means of - 5 and 5. CONCLUSION: AVeCI stages the degree of compensation of PVD patients and can serve to evaluate rehabilitation effects.

Aging and the Relationship between Balance Performance, Vestibular Function and Somatosensory Thresholds.

OBJECTIVES: The objective of this study was two-fold: (1) To evaluate the impact of the physiological aging process on somatosensory, vestibular, and balance functions, and (2) To examine the extent to which age and somatosensory and vestibular functions can predict balance performance. MATERIALS AND METHODS: In this cross-sectional study, 141 asymptomatic subjects were assessed for touch pressure thresholds (TPT) with Semmes-Weinstein monofilaments (SWF), vibration thresholds (VT) with a neurothesiometer (NT) and a Rydel-Seiffer tuning fork 128Hz (RSTF). Horizontal vestibulo-ocular reflexes (HVOR gain and asymmetry) were assessed using the video Head Impulse Test (vHIT). A modified version of the Romberg test was used to assess standing balance and the Timed Up and Go test (TUG) and tandem gait (TG) to evaluate dynamic balance. RESULTS: Significant age effects were found for TPT, VT, and balance but not for HVOR gain or asymmetry. Standing balance was explained for 47.2% by age, metatarsal 1 (MT1) (NT), and heel (SWF). The variance in TUG performance was explained for 47.0% by age, metatarsal 5 (MT5) (SWF), and medial malleolus (MM) (NT). Finally, the variance in TG performance was predicted for 43.1% by age, MT1 (NT), HVOR gain, and heel (SWF). CONCLUSION: Among asymptomatic adult population, both somatosensation and balance performance deteriorate with aging. In contrast, HVOR remains rather constant with age, which is possibly explained by the process of vestibular adaptation. Furthermore, this study provides evidence that the VT, TPT, HVOR gain, and age partly predict balance performance. Still, further research is needed, especially with bigger samples in decades 8 and 9.

Vestibular rehabilitation in Europe: a survey of clinical and research practice.

Vestibular rehabilitation (VR) is practiced across Europe but little in this area has been quantified. The aim of this study was to investigate current VR assessment, treatment, education, and research practices. This was an online, cross-sectional survey with 39 VR specific questions and four sections: demographics, current practice, education, and research. The survey was disseminated through the Dizzynet network to individual therapists through country-specific VR special interest groups. Results were analysed descriptively. A thematic approach was taken to analyse open questions. A total of 471 individuals (median age 41, range 23 - 68 years, 73.4% women), predominately physiotherapists (89.4%) from 20 European countries responded to the survey. They had worked for a median of 4 years (range < 1 - 35) in VR. The majority (58.7%) worked in hospital in-patient or out-patient settings and 21.4% in dedicated VR services. Most respondents specialized in neurology, care of the elderly (geriatrics), or otorhinolaryngology. VR was reported as hard/very hard to access by 48%, with the main barriers to access identified as lack of knowledge of health care professionals (particularly family physicians), lack of trained therapists, and lack of local services. Most respondents reported to know and treat benign paroxysmal positional vertigo (BPPV 87.5%), unilateral vestibular hypofunction (75.6%), and cervicogenic dizziness (63%). The use of vestibular assessment equipment varied widely. Over 70% used high-density foam and objective gait speed testing. Over 50% used dynamic visual acuity equipment. Infrared systems, Frenzel lenses, and dynamic posturography were not commonly employed (< 20%). The most frequently used physical outcome measures were the Clinical Test of the Sensory Interaction of Balance, Functional Gait Assessment/Dynamic Gait Index, and Romberg/Tandem Romberg. The Dizziness Handicap Inventory, Visual Analogue Scale, Falls Efficacy Scale, and the Vertigo Symptom Scale were the most commonly used patient reported outcome measures. Adaptation, balance, and habituation exercises were most frequently used (> 80%), with virtual reality used by 15.6%. Over 70% reported knowledge/use of Semont, Epley and Barbeque-Roll manoeuvres for the treatment of BPPV. Most education regarding VR was obtained at post-registration level (89.5%) with only 19% reporting pre-registration education. There was strong (78%) agreement that therapists should have professionally accredited postgraduate certification in VR, with blended learning the most popular mode. Three major research questions were identified for priority: management of specific conditions, effectiveness of VR, and mechanisms/factors influencing vestibular compensation and VR. In summary, the survey quantified current clinical practice in VR across Europe. Knowledge and treatment of common vestibular diseases was high, but use of published subjective and objective outcome measures as well as vestibular assessment varied widely. The results stress the need of improving both training of therapists and standards of care. A European approach, taking advantage of best practices in some countries, seems a reasonable approach.