Relationship between Location of Focal Traumatic Brain Injury and Canal Involved in Benign Paroxysmal Positional Vertigo.

INTRODUCTION: Benign paroxysmal positional vertigo (BPPV) has a prevalence of 58% in a traumatic brain injury (TBI) population. Research on idiopathic BPPV has demonstrated a higher prevalence of right-sided canal involvement. While many studies have investigated the epidemiology of canal involvement in BPPV in both idiopathic and traumatic BPPV (BPPV associated with a fall), there has been no assessment of trauma location as a predictor of the location of BPPV. OBJECTIVES: The aim of this study was to assess the relationship between the location of a focal TBI and canal involvement in BPPV. METHODS: Patients who were admitted to an inpatient rehabilitation unit with a diagnosis of TBI were screened for BPPV. The primary outcome of this study was the side of the TBI, the BPPV type (posterior, horizontal, or anterior canal), and the side of the BPPV (right, left, or bilateral). RESULTS: There were 42 people who had BPPV. Twenty-one had right-sided canal involvement, 14 had left-sided involvement, and 7 had bilateral involvement. Sixteen had right-side tissue involvement, 13 had left-side involvement, and 13 had bilateral involvement. There was no significant correlation between variables (χ2 = 1.70, p = 0.80). CONCLUSION: All patients with a TBI should have all canals assessed for BPPV as there is no relationship between the side of focal damage and canal involvement.

Surveying physical therapists' understanding of benign paroxysmal positional vertigo.

Introduction: Benign paroxysmal positional vertigo (BPPV) is a common condition with disabling symptoms that is diagnosed and effectively treated at the bedside. Our encounter with patients experiencing prolonged BPPV who may not have received appropriate physical therapy prompted us to explore barriers to the diagnosis and treatment for BPPV among physical therapists, which has not been extensively investigated. We hypothesize that a potential barrier may be a lack of understanding of subtle symptoms of BPPV that deviate from the classical presentation. The gold standard for diagnosing definite BPPV is subjective dizziness or vertigo with nystagmus in response to positional testing. There are variants of BPPV including subjective BPPV (subjective dizziness or vertigo without nystagmus) and vestibular agnosia (nystagmus without subjective dizziness or vertigo) that do not meet the diagnostic criteria for definite BPPV but are equally responsive to the same repositioning maneuvers. The purpose of this project was to survey physical therapists for their understanding of BPPV including subjective BPPV and vestibular agnosia. Methods: A panel of experts created a 16-question survey, designed for physical therapists, with three categories: (1), inquiring if they treat persons with BPPV, (2) three clinical vignettes for definite BPPV, subjective BPPV, and BPPV with vestibular agnosia, and (3) demographic information. Data collection occurred at two large physical therapy meetings, one of which was a national professional meeting and the other was a professional continuing medical education course geared towards advancing vestibular rehabilitation skills. Results: There were 426 people who completed the survey, 364 of whom treat BPPV in their practice. In the first clinical vignette created to assess the respondents' understanding of definite BPPV, 229 (62%) of respondents would always assess a patient for BPPV based on complaints of a "room spinning" vertigo from head movement. When asked if the complaint was lingering "lightheadedness or feelings of imbalance" from head movement, only 158 (43%) reported they would perform positional testing to reassess. In the BPPV variant vignettes, 187 (51%) identified the patient with subjective BPPV as having BPPV and 305 (85%) identified the patient with vestibular agnosia as having BPPV. Discussion: The results of this survey demonstrate gaps in knowledge regarding BPPV across practice settings and experience, with opportunities to bridge these gaps to improve treatment for BPPV.

Head and vestibular kinematics during vertical semicircular canal impulses.

BACKGROUND: The video head impulse test (vHIT) is a common assessment of semicircular canal function during high-speed impulses. Reliability of the vHIT for assessing vertical semicircular canals is uncertain. Vertical head impulses require a complex head movement, making it difficult to isolate a single semicircular canal and interpret resulting eye rotations. OBJECTIVE: The purpose of this study was to provide descriptive head kinematics and vestibular stimuli during vertical plane impulses to ultimately improve impulse delivery and interpretation of vHIT results for vertical semicircular canals. METHODS: Six participants received right anterior (RA) and left posterior (LP) semicircular canal impulses. Linear displacements, rotational displacements, and rotational velocities of the head were measured. Peak velocities in semicircular canal planes and peak-to-peak gravitoinertial accelerations at the otolith organs were derived from head kinematics. RESULTS: The largest rotational velocities occurred in the target semicircular canal plane, with non-negligible velocities occurring in non-target planes. Larger vertical displacements and accelerations occurred on the right side of the head compared to the left for RA and LP impulses. CONCLUSIONS: These results provide a foundation for designing protocols to optimize stimulation applied to a singular vertical semicircular canal and for interpreting results from the vHIT for vertical semicircular canals.

Vestibular Rehabilitation Telehealth During the SAEA-CoV-2 (COVID-19) Pandemic.

During the COVID-19 pandemic, physical therapists transitioned to provide telehealth in the United States. We sought to determine the experiences of physical therapists delivering telerehabilitation for vestibular disorders including barriers, preferences, and concerns. A survey was created using the results of a focus group and previously published studies. The survey was distributed across social media sites and through email- the link was sent to the orthopedic, neurologic, and geriatric academies of the American Physical Therapy Association list serves. The email was also shared with each of the 50 state chapters of the American Physical Therapy Association. The survey was broken down into five sections: demographic information, physical therapists' general impressions of telehealth, physical therapists' comfort level treating various vestibular diagnoses, and common barriers physical therapists experienced during telehealth sessions. There were 159 completed surveys. More than 80% of physical therapists surveyed agreed that telehealth was an effective platform for vestibular physical therapy. When asked whether physical therapists felt the patient had similar health outcomes with telehealth versus clinic care 68% of physical therapists agreed. For the physical therapists who treated posterior or horizontal canal benign paroxysmal positional vertigo via telehealth, more than 50% were comfortable treating these conditions via telehealth. In analyzing common peripheral vestibular diagnoses treated via telehealth including bilateral vestibular loss, Meniere's disease, and vestibular neuritis more than 75% of the physical therapists reported comfort treating these diagnoses. Similarly, more than 75% of physical therapists who treated central vestibular diagnoses- including mild traumatic brain injury and vestibular migraine- via telehealth reported being comfortable treating these diagnoses. Physical therapists reported several barriers to tele healthcare ranging from concerns about testing balance with no caregiver present (94%) to challenges with providing a written home exercise program (33%). Physical therapists report that telehealth is a viable mechanism for providing rehabilitation for persons with balance and vestibular disorders. For common diagnoses, most physical therapists were comfortable treating vestibular disorders via telehealth. While barriers remain including maintaining patient safety and being able to complete a thorough vestibular exam, telehealth for vestibular physical therapy services holds promise for the delivery of virtual care.