Minimum detectable change and false positive rates of the vestibular/ocular motor screening (VOMS) tool: an NCAA-DoD care consortium analysis.

OBJECTIVE: To derive minimum detectable change (MDC) across individual Vestibular-Ocular Motor Screening (VOMS) items and VOMS overall score in 17-25 years old collegiate athletes and to examine false positive rates. METHOD: Participants (n = 378) completed VOMS pre-season for two consecutive years. MDC was identified for individual VOMS symptom items and NPC distance (cm). Both total and change methods of VOMS scoring were included in analysis. RESULTS: Regarding total scoring, MDC for ocular VOMS symptom items was 1 and MDC for vestibular VOMS symptoms items was 2. MDC for NPC was 4 cm and for VOMS overall score was 10. Regarding change scoring, MDC for each VOMS symptom item was 1, and for VOMS overall score was 8. False positives ranged from 5.3% to 15.9%. CONCLUSIONS: This study presents MDCs for each VOMS item and overall VOMS score, using total and change scoring. These values can be considered true change outside measurement error with 95% confidence in a 17-25 year old collegiate athlete population.

Risk Factors for Vestibular and Oculomotor Outcomes After Sport-Related Concussion.

OBJECTIVE: To investigate the association between risk factors and vestibular-oculomotor outcomes after sport-related concussion (SRC). STUDY DESIGN: Cross-sectional study of patients seen 5.7 ± 5.4 days (range 0-30 days) after injury. SETTING: Specialty clinic. PARTICIPANTS: Eighty-five athletes (50 male athletes and 35 female athletes) aged 14.1 ± 2.8 years (range 9-24 years) seeking clinical care for SRC. INTERVENTIONS: Participants completed a clinical interview, history questionnaire, symptom inventory, and vestibular/ocularmotor screening (VOMS). Chi-square tests with odds ratios and diagnostic accuracy were used to examine the association between risk factors and VOMS outcomes. MAIN OUTCOME MEASURES: The VOMS. RESULTS: Female sex (χ2 = 4.9, P = 0.03), on-field dizziness (χ2 = 7.1, P = 0.008), fogginess (χ2 = 10.3, P = 0.001), and post-traumatic migraine (PTM) symptoms including headache (χ2 = 16.7, P = 0.001), nausea (χ2 = 10.9, P = 0.001), light sensitivity (χ2 = 14.9, P = 0.001), and noise sensitivity (χ2 = 8.7, P = 0.003) were associated with presence of one or more postconcussion VOMS score above clinical cutoff. On-field dizziness (χ2 = 3.8, P = 0.05), fogginess (χ2 = 7.9, P = 0.005), and PTM-like symptoms including nausea (χ2 = 9.0, P = 0.003) and noise sensitivity (χ2 = 7.2, P = 0.007) were associated with obtaining a postconcussion near-point convergence (NPC) distance cutoff >5 cm. The likelihood ratios were 5.93 and 5.14 for VOMS symptoms and NPC distance, respectively. CONCLUSIONS: Female sex, on-field dizziness, fogginess, and PTM symptoms were predictive of experiencing vestibular-oculomotor symptoms/impairment after SRC.

Fixational eye movements following concussion.

The purpose of this study was to evaluate fixational eye movements (FEMs) with high spatial and temporal resolution following concussion, where oculomotor symptoms and impairments are common. Concussion diagnosis was determined using current consensus guidelines. A retinal eye-tracking device, the tracking scanning laser ophthalmoscope (TSLO), was used to measure FEMs in adolescents and young adults following a concussion and in an unaffected control population. FEMs were quantified in two fixational paradigms: (1) when fixating on the center, or (2) when fixating on the corner of the TSLO imaging raster. Fixational saccade amplitude in recent concussion patients (≤ 21 days) was significantly greater, on average, in the concussion group (mean = 1.03°; SD = 0.36°) compared with the controls (mean = 0.82°; SD = 0.31°), when fixating on the center of the imaging raster (t = 2.87, df = 82, p = 0.005). These fixational saccades followed the main sequence and therefore also had greater peak velocity (t = 2.86, df = 82, p = 0.006) and peak acceleration (t = 2.80, df = 82, p = 0.006). These metrics significantly differentiated concussed from controls (AUC = 0.67-0.68, minimum p = 0.005). No group differences were seen for the drift metrics in either task or for any of the FEMs metrics in the corner-of-raster fixation task. Fixational saccade amplitudes were significantly different in the concussion group, but only when fixating on the center of the raster. This task specificity suggests that task optimization may improve differentiation and warrants further study. FEMs measured in the acute-to-subacute period of concussion recovery may provide a quick (<3 minutes), objective, sensitive, and accurate ocular dysfunction assessment. Future work should assess the impact of age, mechanism of injury, and post-concussion recovery on FEM alterations following concussion.

Association of acute vestibular/ocular motor screening scores to prolonged recovery in collegiate athletes following sport-related concussion.

INTRODUCTION: Researchers have yet to explore the association of acute (i.e., within 3 days) post-injury VOMS scores and length of time until clearance to return to play in collegiate athletes. OBJECTIVE: The purpose was to determine if individual Vestibular/Ocular Motor Screening (VOMS) component symptom scores (e.g., smooth pursuits, convergence, vestibular-ocular reflex) can predict clearance to return to activity from a sport-related concussion. METHODS: Pre-season demographic and medical history and post-injury VOMS testing were collected (n = 79) on collegiate student-athletes following concussion. Impaired vestibulo-ocular function post-injury scores (≥2) were compared to normal scores using survival analysis, with days to clearance to return to sport as the outcome. RESULTS: Abnormal scores on smooth pursuits (p =.026), horizontal saccades (p =.025), vertical saccades (p =.028), and convergence (p =.031) were associated with lower probability of clearance in comparison with normal scores. Any score ≥2 predicted significantly greater days to clearance for return to play (13.1 days; 95% CI: 11.9-14.3; p = .025) compared with athletes with no abnormal test scores (9.6 days; 95% CI: 7.2-12.1, P =.014). DISCUSSION: Post-injury symptoms with VOMS smooth pursuit, saccades, and convergence is associated with increased time-to-clearance for return to sport in collegiate athletes.

Measurement Properties of the Dizziness Handicap Inventory-Children and Adolescents for Children and Adolescents Postconcussion.

PURPOSE: The purpose of this study was to examine and report the construct validity, internal consistency, and item structure of the Dizziness Handicap Inventory-Children and Adolescents (DHI-CA) in postconcussion children and adolescents. METHODS: A retrospective chart review was conducted for 132 participants. Data were extracted on the DHI-CA, Sports Concussion Assessment Tool-III symptom inventory, and Vestibulo-ocular Motor Screening. The DHI-CA was examined for validity, internal consistency, and factor structure. RESULTS: The DHI-CA had fair convergent validity (rs = 0.30-0.40), but discriminant validity findings were inconclusive. The functional subscale demonstrated least consistent loadings and 4 items had cross-loading. Reliability analysis indicated possible item redundancy given that the overall Cronbach α was higher than the subscales. CONCLUSION: Despite demonstrating convergent validity, structural inconsistencies and possible item redundancy warrant further exploration and restructuring of the DHI-CA. Caution is recommended while making clinical decisions based on the DHI-CA results alone. VIDEO ABSTRACT: For more insights from the authors, see Supplemental Digital Content 1, available at: http://links.lww.com/PPT/A303.

Changes in Vestibular/Ocular-Motor Screen Scores in Adolescents Treated With Vestibular Therapy After Concussion.

PURPOSE: To examine interrelationships among Vestibular/Ocular-Motor Screen (VOMS) items and to characterize the recovery of VOMS performance in a sample of adolescents treated with vestibular physical therapy (VPT) after concussion. METHODS: Seventy-seven patients with concussion and 77 participants without concussion completed the study. Adolescents with concussion received an individualized VPT intervention consisting of targeted exercises for gaze stability, postural stability, ocular-motor control, habituation, and aerobic activities. The exercises were performed during a weekly clinic visit and via a home exercise program. RESULTS: Except for near-point convergence distance, all VOMS items were significantly interrelated. Over the course of VPT, significant improvements in VOMS performance were observed, and discharge scores were similar to scores observed in adolescents without concussion. CONCLUSIONS: The VOMS measured moderately related functions and captured changes over the course of VPT. Clinicians should consider the contextual risk of "false positive" in their interpretation of VOMS.

Recovery Following Sport-Related Concussion: Integrating Pre- and Postinjury Factors Into Multidisciplinary Care.

OBJECTIVE: Update concussion recovery curves by considering pre- and postinjury modifying factors. Determine whether there is a dose-response for modifying factors on recovery. SETTING: Sports medicine concussion clinic. PARTICIPANTS: A total of 314 athletes aged 12-23 years within 7 days of a concussion enrolled between 2015 and 2018. DESIGN: Prospective cohort study. MAIN MEASURES: Categorical recovery time defined as days from injury to full medical clearance for return to play per established criteria. Preinjury factors included age, gender, concussion history, and migraine history. Postinjury factors included loss of consciousness, posttraumatic amnesia, posttraumatic migraine symptoms, and high symptom burden. RESULTS: Average recovery was 27.5 ± 25 days. Five factors were prognostic of recovery: (1) younger than 18 years, (2) female, (3) history of migraine, (4) posttraumatic migraine symptoms, and (5) high symptom burden (P < .05). Recovery percentage at 21 days after injury was 96.7% for participants with 0 factor, 65.3% for those with 1 to 2, and 31.8% for those with 3 to 5-with prognostic separation in low- to high-risk groups of 62%. CONCLUSIONS: Findings support a dose-response for combined pre- and postinjury factors on recovery. Both the type and quantity of modifying factors influence recovery and should be considered in prognosis and approaches to multidisciplinary care.

Reliability of Postural Sway Measures of Standing Balance Tasks.

The reliability of balance exercises performance in experimental and clinical studies has typically been confined to a small set of exercises. In order to advance the field of assessing balance exercise intensity, establishing the reliability of performance during a more diverse array of exercises should be undertaken. The purpose of this study was to investigate the test-retest reliability of postural sway produced during performance of 24 different balance tasks, and to evaluate the reliability of different measures of postural sway. Sixty-two healthy subjects between the ages of 18 and 85 years of age (50% female, mean age 55 ± 20 years) participated. Subjects were tested during two visits one week apart and performed two sets of the 24 randomized standing tasks per visit. The tasks consisted of combinations of the following factors: surface (firm and foam), vision (eyes open and eyes closed), stance (feet apart and semi-tandem), and head movement (no movement, yaw, and pitch). Angular position displacement, angular velocity, and linear acceleration postural sway in the pitch and roll planes was recorded via an inertial measurement unit. The postural sway measures demonstrated at fair to good test-retest reliability with few exceptions, and angular velocity measures demonstrated the greatest reliability. The between-visit reliability of two averaged trials was excellent for most tasks. The study indicates that performance of most balance tasks used as part of balance rehabilitation is reliable, and quantitative assessment could be used to document change.

A Quality Improvement Project in Balance and Vestibular Rehabilitation and Its Effect on Clinical Outcomes.

BACKGROUND AND PURPOSE: Unwarranted variation in practice is among the principal contributors of suboptimal outcomes in health care. This variation can be minimized via quality improvement initiatives. However, quality improvement projects focus mostly on assessing processes, and less attention is given to the effect of the variation on clinical outcomes. An effective implementation of a clinical treatment algorithm (CTA) could improve care for individuals with balance and vestibular disorders. The first aim of this quality improvement project was to examine adherence to a CTA developed by physical therapists who treat persons with balance and vestibular disorders. The second aim was to examine the effect of adherence on patient outcomes. METHODS: Twenty-three physical therapists who provided rehabilitation for individuals with balance and vestibular disorders participated in the quality improvement project. All physical therapists worked for the same health care provider, and developed the minimum data set and CTA. The physical therapists were cluster randomized into 2 groups; both groups received educational training and reminders regarding adherence to the CTA. The first group received the training and reminders after an 8-week baseline period (initial group), and the second group (delayed group) after a 12-week baseline period. The prescribed interventions were classified as being adherent or nonadherent to the CTA. Clinical outcomes, including the Activities-Specific Balance Confidence (ABC) scale, Dizziness Handicap Inventory (DHI), and the Global Rating of Change (GRC), were recorded at the initial evaluation and discharge for 454 individual with balance or vestibular disorders. RESULTS: Across the 16-week project, adherence rates improved significantly by 9% and 12% for the initial and delayed groups, respectively (P = 0.008), but there was no difference between groups related to the timing of the educational training and adherence reminders. Clinical outcomes improved for individuals, with balance or vestibular disorders but there was no differences in the change in ABC, DHI, and GRC scores based on whether the interventions were or were not adherent to the CTA. DISCUSSION AND CONCLUSIONS: This quality improvement project was effective in increasing the adherence to the CTA in both groups. Although on average individuals with balance and vestibular disorders showed improvement on the clinical outcomes, there was no additional benefit in the clinical outcome for adherent interventions.Video abstract is available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A125).

Relationship Between Cognitive Assessment and Balance Measures in Adolescents Referred for Vestibular Physical Therapy After Concussion.

OBJECTIVE: To examine the relationship between cognitive and balance performance in adolescents with concussion. DESIGN: Retrospective case series. SETTING: Tertiary. PATIENTS: Sixty patients. INTERVENTIONS: Correlation analyses were performed to describe the relationship between symptoms, cognitive measure, and balance measure at the time of initiation of vestibular physical therapy. MAIN OUTCOME MEASURES: Cognitive performance was assessed using the Immediate Post-concussion Assessment and Cognitive Testing (ImPACT). The dizziness and balance function measures included dizziness severity rating, Activities-specific Balance Confidence scale (ABC), Dizziness Handicap Inventory (DHI), Functional Gait Assessment, gait speed, Timed "UP and GO," Five Times Sit to Stand, and Sensory Organization Test (SOT). To account for multiple comparisons, the False Discovery Rate method was used. RESULTS: Performance measures of balance were significantly correlated with cognitive measures. Greater total symptom scores were related to greater impairment in the ABC and DHI (r = 0.35-0.39, P ≤ 0.008) and worse performance in condition 2 of the SOT (r = -0.48, P = 0.004). Among the ImPACT composite scores, lower memory scores were correlated with impaired balance performance measures (r = 0.37-0.59, P ≤ 0.012). Lower visual memory was also correlated with worse ABC scores. CONCLUSIONS: The significant relationships reported between the cognitive performance scores and balance measures may reflect that similar levels of functioning exist across domains in individuals with protracted recovery who receive vestibular physical therapy. CLINICAL RELEVANCE: The weak-to-moderate relationships warrant the continuous use of multiple domains of assessment. A better understanding to the relationships between the domains of functioning after concussion may improve the overall management approach for adolescents with concussion.

Cross-cultural adaptation and measurement properties of the Arabic version of the Fall Efficacy Scale International.

OBJECTIVE: To translate the Falls Efficacy Scale International (FES-I) into Arabic according to the World Health Organization`s (WHO) criteria and to evaluate the concurrent validity of the FES-I in persons living with balance and vestibular disorders. METHODS: This cross-sectional descriptive study included 43 persons with balance and vestibular disorders presenting to an outpatient dizziness center at King Abdulaziz University Hospital, Riyadh, Kingdom of Saudi Arabia between June 2012 and May 2013. All participants completed the Arabic version of the FES-I and the Dizziness Handicap Inventory (DHI) during their assessment with the clinical audiologist. In addition, subjects completed the Dynamic Gait Index 4-item (DGI-4) gait test. An additional 55 control participants also completed the Arabic FES-I, the DGI-4, and the Arabic DHI. RESULTS: Forty-three participants with vestibular disorders (36 females, 7 males) with a mean age of 32 years (standard deviation (SD) 10 years, range 18-56 years) and 55 control participants (27 females, 28 males) with a mean age of 33, (SD-12), and age range of 18-78 participated. The correlation between the Arabic FES-I and the Arabic DHI was 0.75 in patients and 0.77 in control participants. The correlation between the Arabic FES-I and the DGI-4 was r=-0.30 (p=0.003). CONCLUSION: The Arabic FES-I has established concurrent validity and may be helpful for measuring an individual`s concern of falling in people with vestibular and balance disorders.

Responsiveness and minimal detectable change of the dynamic gait index and functional gait index in persons with balance and vestibular disorders.

BACKGROUND AND PURPOSE: We performed a retrospective chart review to determine the responsiveness and minimal detectable change (MDC95) in persons with balance and vestibular disorders with the dynamic gait index (DGI) and the functional gait assessment (FGA). METHODS: The study cohort consisted of 326 patients with a mean age of 60 ± 18.3 years (range, 18-95 years; 69% female). The DGI, FGA, Activities-Specific Balance Confidence (ABC) scale, and the dizziness handicap inventory (DHI) were collected at intake and discharge. RESULTS: The standardized response mean as an index of responsiveness was greater for the FGA (1.25) than for the DGI (0.72). Both measures demonstrated good internal consistency with baseline measures. The amount of pre- to posttreatment change that exceeds chance variation was estimated at 4 points for the DGI and 6 points for the FGA. In both the DGI and the FGA, a magnitude of change equivalent to the respective MDC95 was significantly associated with improvements in self-reported disability as measured by the ABC and DHI. DISCUSSION AND CONCLUSIONS: The DGI and the FGA are responsive to change over time in persons with balance and vestibular disorders. More complex gait measures need to be developed, as close to 50% of the subjects received optimal scores at discharge from a physical therapy exercise program, indicating that these measures have a ceiling effect.

Estimating postural control with the balance rehabilitation unit: measurement consistency, accuracy, validity, and comparison with dynamic posturography.

OBJECTIVE: To examine the psychometric properties (test-retest reliability, concurrent validity, construct validity) of the Balance Rehabilitation Unit (BRU) during testing of sensory integration processes in healthy adults and individuals with vestibular disorders. DESIGN: Experimental cross-sectional design. SETTING: Clinic. PARTICIPANTS: Participants (N=90) included 30 subjects with vestibular disorders (age range, 18-85y), 30 young healthy adults (age range, 18-50y), and 30 older healthy adults (age range, 60-85y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participants were tested twice with the BRU and once with the SMART EquiTest Sensory Organization Test (SOT). The center of pressure (COP) in the anteroposterior direction (COPap) and the COP in the mediolateral direction (COPml) were recorded. The COPap and COPml time series were used to estimate the area and velocity of the COP. RESULTS: The intraclass correlation coefficient of the COP area and velocity measures for the BRU for all subjects was at least .76 in all sensory organization conditions (P<.001). Significant correlations were found between the BRU and the SOT, ranging from .64 to .81 for COP area and from .44 to .76 for COP velocity. The older control group had significantly greater COP area and velocity compared with younger controls for the BRU and the SOT. The COP (area, velocity) was significantly higher for the younger individuals in the vestibular group than the younger controls. CONCLUSIONS: The reliability and validity of COP measurements obtained during testing of the sensory integration processes were demonstrated using the BRU. Future work should examine the responsiveness of these measures when individuals with balance disorders participate in rehabilitation.

Predictors of functional and gait outcomes for persons poststroke undergoing home-based rehabilitation.

BACKGROUND: The literature on the impact of home-based rehabilitation on functional outcomes for patients after stroke is limited. The purpose of this study was to describe the outcomes of home-based rehabilitation (HBR) on functional and gait performance for patients after stroke and associated factors that contribute to better outcomes after an episode of care. METHODS: The nature of the study design was retrospective and the settings used were home care services. The total number of subjects receiving home care services after stroke was 213 (mean age 76.5 ± 9 years, 51% female). Treatment records for patients receiving HBR in 2010 were reviewed at the start of care and discharge. The primary outcome measure was a change in a gait speed and activities of daily living (ADL) performance between admission and discharge from home health care services. The composite score to calculate overall functional status (Outcome Information and Assessment Set-version C [OASIS-C]) was used. Mean change in ADL and gait scores and factors predictive of improvement were identified using an analysis of covariance and multivariate linear models. The main outcome measures were change in the OASIS-C composite scores and gait speed. RESULTS: After adjustment for age and ADL score at the start of care, discharge from skilled nursing or long-term facilities, presence of confusion most of the times, cognitive impairment, and memory deficits were negatively associated with an improvement in functional scores (ADL). Living in congregate facilities was also negatively associated with an improvement in gait speed. The best multivariate model included age, baseline ADL composite scores, confusion status, and gait speed at the start of care, which predicted 41% of the variance in ADL score changes over the course of intervention. CONCLUSIONS: Gait speed and ADL scores at the start of care had largest influence on functional and gait improvement. Type of discharge facility, confusion status, and living arrangement had effects on HBR outcomes for stroke survivors.

Performance of high school adolescents on functional gait and balance measures.

PURPOSE: To describe the performance of high school adolescents during common functional gait and balance measures used in vestibular physical therapy. METHODS: A cross-sectional study of 91 participants determined their performance on the Activities-specific Balance Confidence (ABC) scale, Dynamic Gait Index, Functional Gait Assessment, Timed "Up and Go" (TUG), Five Times Sit to Stand (FTSTS) test, tests of gait speed (GS), and the Balance Error Scoring System. In a subset of this sample, GS, TUG, and the FTSTS were repeated twice to examine test-retest reliability. RESULTS: The measures of GS, TUG, and FTSTS were normally distributed. The Activities-specific Balance Confidence, Dynamic Gait Index, and Functional Gait Assessment exhibited a ceiling effect. The timed measures exhibited moderate to good reliability. CONCLUSIONS: These performance scores may provide end points for discharge from vestibular physical therapy. However, clinicians should be aware of the ceiling effect exhibited by some measures.

Associations between performance-based and patient-reported physical functioning and real-world mobile sensor metrics in older cancer survivors: A pilot study.

INTRODUCTION: Older cancer survivors are at increased risk for impaired physical functioning, but current assessments of function are difficult to implement in busy oncology clinics. Mobile devices measuring continuous activity and mobility in daily life may be useful for estimating physical functioning. The goal of this pilot study was to examine the associations between consumer wearable device (a wrist-worn activity tracker) and smartphone sensor data and commonly used clinical measures of physical function in cancer survivors aged 65 and older. MATERIALS AND METHODS: Older adults within five years of completing primary treatment for any cancer completed standardized questionnaires and performance-based tests to measure physical functioning. Continuous passive data from smartphones and consumer wearable devices were collected for four weeks and linked to patient-reported and performance-based physical functioning as well as patient-reported falls or near falls at the end of the four-week monitoring period. To examine associations between sensor variables and physical functioning, we conducted bivariate Pearson correlations as well as multivariable linear regression analyses. To examine associations between sensor variables and falls, we conducted exploratory receiver operating characteristic curve and multivariable logistic regression analyses. RESULTS: We enrolled 40 participants (mean age 73 years old, range 65-83; 98% White; 50% female). In bivariate analyses, consumer wearable device features reflecting greater amount and speed and lower fragmentation of walking in daily life were significantly related to better patient-reported function (r= 0.43-0.65) and performance-based physical function (r = 0.56-0.72), while smartphone features reflecting more geographic mobility were related to better performance-based physical function (r = 0.40-0.42) but not patient-reported function. After adjusting for age and comorbidities, only consumer wearable device features remained associated with performance-based physical functioning. In exploratory analyses, peak gait cadence was associated with fall risk even after covariate adjustment. DISCUSSION: This study provides preliminary evidence that real-world data from consumer devices may be useful for estimating functional performance among older cancer survivors and potentially for remotely and longitudinally monitoring functioning in older patients during and after cancer treatment.

Type, dose, and outcomes of physical therapy interventions for unilateral peripheral vestibular hypofunction: protocol for a systematic review.

BACKGROUND: Unilateral peripheral vestibular hypofunction can result in symptoms of dizziness, gaze and gait instability, and impaired navigation and spatial orientation. These impairments and activity limitations may negatively impact an individual's quality of life, ability to perform activities of daily living, drive, and work. There is strong evidence supporting vestibular physical therapy for reducing symptoms, improving gaze and postural stability, and improving function in individuals with vestibular hypofunction. However, there is great variability in clinical practice with regard to the type of interventions and only weak evidence to guide optimal exercise dosage. It is important to identify the most appropriate interventions and exercise dosage to optimize and accelerate recovery of function and to decrease distress. The objective of this systematic review is to determine which interventions and which doses are most effective in decreasing dizziness or vertigo, improving postural control, and improving quality of life in adults with unilateral peripheral vestibular hypofunction. METHODS: The literature will be systematically searched using the following online databases: PubMed/MEDLINE, EMBASE, Web of Science (Science and Social Science Citation Index), Cumulative Index for Nursing and Allied Health Literature (CINAHL), and The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials [CENTRAL], Cochrane Methodology Register). The review will include randomized controlled trials (RCTs), including cluster RCTs, to assess the beneficial effects of the interventions. Assessment of methodological quality and risk of bias will be performed by two independent, blinded reviewers using the PEDro scale and Cochrane Risk of Bias version 2, respectively. The primary outcome measure will be change in self-perceived handicap related to dizziness from baseline to the end of the study, measured using the Dizziness Handicap Inventory. Other relevant outcome measures will include self-reported change in symptoms (to include severity, frequency, and duration) such as verbal or visual analog scales for dizziness. Tertiary outcome measures will include questionnaires related to disability and/or quality of life. DISCUSSION: This systematic review will identify, evaluate, and integrate the evidence on the effectiveness of physical therapy interventions for unilateral peripheral vestibular hypofunction in an adult population. We anticipate our findings may inform individualized treatment and future research. Clinical recommendations generated from this systematic review may inform vestibular physical therapy treatment of individuals with unilateral peripheral vestibular hypofunction. TRIAL REGISTRATION: In accordance with the guidelines, our systematic review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 06 August 2021 (registration number CRD42021266163 ). In the event of protocol amendments, the date of each amendment will be accompanied by a description of the change and the rationale.

The Psychometric Properties of the 9-Item Vestibular Activities Avoidance Instrument.

OBJECTIVE: The purpose of this study was to establish the psychometric properties of the 9-Item Vestibular Activities Avoidance Instrument (VAAI-9), a patient-reported outcome measure developed to identify fear avoidance beliefs in persons with vestibular disorders. METHODS: This prospective cohort study included 100 participants 18 years and older seeking care at a balance disorders clinic for dizziness. Participants completed the VAAI-9, the Dizziness Handicap Inventory (DHI), and other patient-reported outcomes at the initial visit and the 3-month follow-up. To measure test-retest reliability, the VAAI-9 was completed again 5 days after the initial visit and was analyzed using a 2-way mixed ICC for absolute agreement. Internal consistency was determined using the Cronbach alpha. The Spearman correlation coefficient was used to assess convergent validity of the VAAI-9 with other outcomes. Receiver operating characteristic curves were used to identify baseline VAAI-9 cutoff scores for those who reported mild (DHI ≤ 30) or moderate or severe (DHI > 30) perceived disability at the 3-month follow-up. RESULTS: The mean age of the study cohort was 49 (SD = 16) years; 73 (73%) were women. Seventy-one participants completed the 5-day follow-up, and 68 completed the 3-month follow-up. The VAAI-9 demonstrated excellent internal consistency (α = 0.91) and test-retest reliability (ICC = 0.90). Baseline VAAI-9 scores had moderate to strong associations with other outcome measures at baseline and 3 months. A baseline VAAI-9 score of 26 or higher had a sensitivity of 80.6% and a specificity of 78.4% for identifying a DHI score of >30 at 3 months (area under the curve = 0.86). CONCLUSIONS: The results provide evidence of excellent reliability and validity for the 9-item VAAI in persons with vestibular disorders. A baseline VAAI-9 score of ≥26 identified individuals at risk of persistent moderate to severe disability due to dizziness. IMPACT: Initial levels of fear avoidance beliefs measured using the VAAI-9 provided important prognostic information about outcomes for persons with vestibular symptoms.

The development and validation of the vestibular activities and participation measure.

OBJECTIVES: To develop and validate a new self-report outcome measure named the Vestibular Activities and Participation (VAP) for people with vestibular disorders to examine their activities and participation according to the International Classification of Functioning Disability and Health. DESIGN: Delphi iterative survey for the development of the VAP and validation study. SETTING: Tertiary balance clinic. PARTICIPANTS: A panel of worldwide experts (n=17) in vestibular dysfunction participated in the development of the VAP, and patients (N=58) with vestibular disorders were enrolled in the validation of the VAP. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: For the development of the VAP, an Internet-based survey of 55 activities and participation items was presented to the panel of experts and the percentage agreement per item was calculated. For the validation of the VAP, the VAP was completed twice to examine the test-retest reliability, the World Health Organization Disability Assessment Schedule II (WHODAS II) was used to examine the concurrent validity with the VAP, and the Dizziness Handicap Inventory (DHI) was used to examine the convergent validity of the VAP. RESULTS: After 2 rounds of the Delphi technique, the VAP was developed. The VAP total score had excellent test-retest reliability (intraclass correlation coefficient=.95; confidence interval=.91-.97) and good to excellent agreement per item indicated by the unweighted kappa (.41-.80) and the weighted kappa (.58-.94). The minimum detectable change at 95% confidence level of the VAP score was .58. The VAP had strong correlation (ρ=.70; P<.05) with the WHODAS II and moderate to strong correlations (ρ=.54-.74) with the DHI subscale and total scores. After adjustment for age, we found sex and self-reported imbalance to be independent explanatory variables of the transformed VAP total score. CONCLUSIONS: The VAP measure was developed to examine the disabling effect of vestibular disorders on people's activities and participation based on a standardized framework (the International Classification of Functioning Disability and Health). The VAP demonstrated excellent reliability and was validated with external instruments in people with vestibular disorders.

Rating of perceived difficulty scale for measuring intensity of standing balance exercises in individuals with vestibular disorders.

BACKGROUND: A method for prescribing the difficulty or intensity of standing balance exercises has been validated in a healthy population, but requires additional validation in individuals with vestibular disorders. OBJECTIVE: This study validated the use of ratings of perceived difficulty for estimation of balance exercise intensity in individuals with vestibular disorders. METHODS: Eight participants with a confirmed diagnosis of a vestibular disorder and 16 healthy participants performed two sets of 16 randomized static standing exercises across varying levels of difficulty. Root Mean Square (RMS) of trunk angular velocity was recorded using an inertial measurement unit. In addition, participants rated the perceived difficulty of each exercise using a numerical scale ranging from 0 (very easy) to 10 (very difficult). To explore the concurrent validity of rating of perceived difficulty scale, the relationship between ratings of perceived difficulty and sway velocity was assessed using multiple linear regression for each group. RESULTS: The rating of perceived difficulty scale demonstrated moderate positive correlations RMS of trunk velocity in the pitch (r = 0.51, p < 0.001) and roll (r = 0.73, p < 0.001) directions in participants with vestibular disorders demonstrating acceptable concurrent validity. CONCLUSIONS: Ratings of perceived difficulty can be used to estimate the intensity of standing balance exercises in individuals with vestibular disorders.