The Role of Prediagnosis Audiovestibular Dysfunction Versus Distress, Illness-Related Cognitions, and Behaviors in Predicted Ongoing Dizziness Handicap.

OBJECTIVE: People with chronic vestibular diseases experience variable degrees of self-perceived disability. However, longitudinal data examining the predictive validity of relevant clinical variables alongside psychological variables are limited. The present study examined whether these factors predict self-reported dizziness handicap 3 months after assessment and diagnosis. METHODS: Patients were recruited from a waiting list of a tertiary neuro-otology clinic and completed standardized mood, cognitive, behavioral, and dizziness handicap questionnaires before and 3 months after their initial consultation and diagnosis. All patients were clinically assessed and underwent comprehensive audiovestibular investigations. RESULTS: Seventy-three percent of participants responded at follow-up (n = 135, 73% female, mean [standard deviation] age = 54.23 [17.53] years), of whom 88% were diagnosed with a neurotological condition. There were significant improvements in handicap, depression, and anxiety at 3 months. Thirty (22%) of 135 showed clinically meaningful improvement in handicap. The percentage of case-level depression and anxiety remained the same. Negative illness perceptions and symptom responses reduced, although participants still tended to view their condition negatively. Vestibular tests and type of diagnosis were not associated with self-reported handicap. Most baseline psychological variables significantly correlated with handicap at 3 months. When adjusting for baseline handicap and demographics, the baseline psychological variables only explained a significant ~3% of the variance in dizziness handicap at follow-up, with baseline handicap explaining most of the variance. All-or-nothing behavior was the most significant predictor. CONCLUSIONS: Tertiary patients with vertigo and dizziness report negative illness perceptions and cognitive and behavioral responses to symptoms that are associated with self-reported handicap over time. Future studies are needed to investigate whether targeting these factors alongside traditional treatment approaches improves handicap in patients with chronic dizziness.

The Pediatric Vestibular Symptom Questionnaire: A Validation Study.

OBJECTIVE: To develop and validate the Pediatric Vestibular Symptom Questionnaire (PVSQ) and quantify subjective vestibular symptom (ie, dizziness, unsteadiness) severity in children. STUDY DESIGN: One hundred sixty-eight healthy children (female, n = 91) and 56 children with postconcussion dizziness or a vestibular disorder (female, n = 32), between ages 6 and 17 years, were included. The PVSQ contains questions regarding vestibular symptom frequency during the previous month. The Strengths and Difficulties Questionnaire (SDQ), a brief behavioral screening instrument, was also completed. RESULTS: The PVSQ showed high internal consistency (10 items; Cronbach α = 0.88). A significant between-group difference was noted with higher (ie, worse) PVSQ scores for children with vestibular symptoms (P < .001); no significant differences were noted between patient groups. The optimal cut-off score for discriminating between individuals with and without abnormal levels of vestibular symptoms was 0.68 out of 3 (sensitivity 95%, specificity 85%). Emotional and hyperactivity SDQ subscale scores were significantly worse for patients compared with healthy participants (P ≤ .01). A significant relationship was noted between mean PVSQ and SDQ (parent-rated version) hyperactivity and total scores for patients (P ≤ .01) and the SDQ (self-rated) emotional, hyperactivity, and total score (P ≤ .01) in healthy controls. However, mean SDQ subscale and total scores were within normal ranges for both groups. CONCLUSIONS: Self-reported vestibular symptoms, measured by the PVSQ, discriminated between children presenting with vestibular symptoms and healthy controls and should be used to identify and quantify vestibular symptoms that require additional assessment and management.

Effect of Developmental Binocular Vision Abnormalities on Visual Vertigo Symptoms and Treatment Outcome.

BACKGROUND AND PURPOSE: Customized vestibular rehabilitation incorporating optokinetic (OK) stimulation improves visual vertigo (VV) symptoms; however, the degree of improvement varies among individuals. Binocular vision abnormalities (misalignment of ocular axis, ie, strabismus) may be a potential risk factor. This study aimed to investigate the influence of binocular vision abnormalities on VV symptoms and treatment outcome. METHODS: Sixty subjects with refractory peripheral vestibular symptoms underwent an orthoptic assessment after being recruited for participation in an 8-week customized program incorporating OK training via a full-field visual environment rotator or video display, supervised or unsupervised. Treatment response was assessed at baseline and at 8 weeks with dynamic posturography, Functional Gait Assessment (FGA), and questionnaires for symptoms, symptom triggers, and psychological state. As no significant effect of OK training type was noted for any variables, data were combined and new groups identified on the basis of the absence or presence of a binocular vision abnormality. RESULTS: A total of 34 among 60 subjects consented to the orthoptic assessment, of whom 8 of the 34 had binocular vision abnormalities and 30 of the 34 subjects completed both the binocular function assessment and vestibular rehabilitation program. No significant between-group differences were noted at baseline. The only significant between-group difference was observed for pre-/post-VV symptom change (P = 0.01), with significant improvements noted only for the group without binocular vision abnormalities (P < 0.0005). Common vestibular symptoms, posturography, and the FGA improved significantly for both groups (P < 0.05). DISCUSSION AND CONCLUSIONS: Binocular vision abnormalities may affect VV symptom improvement. These findings may have important implications for the management of subjects with refractory vestibular symptoms.Video Abstract available for insights from the authors regarding clinical implication of the study findings (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A115).

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

BACKGROUND: vestibular disorders are common in the general population, increasing with age. However, it is unknown whether older adults who fall have a higher proportion of vestibular impairment compared with age-matched older adult non-fallers. OBJECTIVE: to identify whether a greater proportion of older adult fallers have a peripheral vestibular impairment compared with age-matched healthy controls. DESIGN: case-controlled study. SETTING: tertiary falls and neuro-otology clinics and local community centres, London, UK. PARTICIPANTS AND METHODS: community-dwelling older adults experiencing: (i) ≥2 unexplained falls within the previous 12-months (Group F, n = 25), (ii) a confirmed peripheral vestibular disorder (Group PV, n = 15) and (iii) healthy non-fallers (Group H, n = 16). All the participants completed quantitative vestibular function tests, the functional gait assessment (FGA), physiological profile assessment (PPA) and subjective measures for common vestibular symptoms (i.e. giddiness), balance confidence during daily activities and psychological state. RESULTS: a clinically significant vestibular impairment was noted for 80% (20/25) of Group F compared with 18.75% (3/16) for Group H (P < 0.01). Group F performed less well in complex gait tasks (FGA), and reported a greater number of falls than both Groups H and PV (P < 0.05). Vestibular symptom scores showed no significant difference between Groups F and PV. CONCLUSION: vestibular dysfunction is significantly more prevalent in older adult fallers versus non-fallers. Individuals referred to a falls clinic are older, more impaired and report more falls than those referred to a neuro-otology department. A greater awareness of vestibular impairments may lead to more effective management and treatment for older adult fallers.

Feasibility and effect of supplementing a modified OTAGO intervention with multisensory balance exercises in older people who fall: a pilot randomized controlled trial.

OBJECTIVE: To investigate the feasibility and comparative effect of supplementing a modified OTAGO falls rehabilitation programme with multisensory balance exercises and informed sample size calculation for a definitive trial. DESIGN: Single-blinded randomized controlled trial with pre/postcomparisons using a per-protocol analysis. SETTING: Secondary care-based falls clinic, London, UK. SUBJECTS: Community-dwelling older people (n = 21) experiencing ≥2 non-syncopal falls during previous 12 months. INTERVENTION: Modified OTAGO exercise classes supplemented with supervised home-based rehabilitation consisting of multisensory balance or stretching exercises. Group classes and home sessions each occurred twice-weekly for eight weeks. MEASUREMENTS: A computerised randomization was used for group allocation. A rater, blinded to intervention, performed the assessment including the Functional Gait Assessment (primary outcome), Physiological Profile Assessment, and questionnaires relating to symptoms, balance confidence, and psychological state (secondary outcomes). RESULTS: Significant within-group improvements were noted for the Functional Gait (p < 0.01, r = -0.63) and Physiological Profile Assessments (p < 0.05, r = -0.63) in the OTAGO+multisensory rehabilitation group only and for balance confidence scores in the OTAGO+stretching group (p < 0.01, r = -0.63). Between-group differences were noted for the Functional Gait (p < 0.01, r = -0.71) and Physiological Profile (p < 0.05, r = -0.54) assessments with the OTAGO+multisensory group showing significantly greater improvement. The drop-out rate was similar for both groups (~30%). No serious adverse events were reported. CONCLUSIONS: Supplementing the OTAGO programme with multisensory balance exercises is feasible in older people who fall and may have a beneficial effect on falls risk as measured using the Functional Gait and Short-form Physiological Profile Assessments. An adequately powered randomized controlled trial would require 36 participants to detect an effect size of 1.35 on the Functional Gait Assessment.

The effectiveness of mental imagery on motor, cognitive and emotional status of older people with early-stage dementia: A study protocol.

Dementia involves the loss of cognitive abilities and represents a decline from the prior level of function which impairs functional abilities in day-to-day life. No previous experimental research has been done to assess mental imagery (MI) effectiveness in the motor, cognitive and emotional status of individuals with early-stage dementia. One hundred and forty older individuals with early-stage dementia from the Day Care Centre of the Alzheimer Association in Athens will take part in this study. The sample will be randomly divided into three groups: MI and physical exercise (intervention group), only physical exercise (1st control group), and neither MI nor physical exercise (2nd control group). Assessment will be obtained one week prior to the program, in the middle of the program (6th week of the intervention program) and after the end of the program (13th week of the intervention program). Participants of the intervention group will perform a 30-minute MI programme after the end of every physiotherapy session. Reliable and valid instruments will be used to assess the primary outcomes, i.e., balance and functional status as well as the secondary outcomes i.e., cognitive ability, emotional state and quality of life. The two-way Mixed ANOVA with factors 'intervention' (between groups) and 'time' (within group) will be used as a statistical analysis. Approvals of clinical trial protocol: a) UNIWA Research Committee study protocol approval: 93292 - 26/10/2021. b) ClinicalTrials.gov: ID NCT05232526.

The interplay between cognition, functional and dual-task gait in persons with a vestibular disorder versus healthy controls.

Close links exist between vestibular function and cognition. Dual-task (DT) tests may have ecological validity to assess the impact of daily life cognitive-motor demands in people with vestibular dysfunction (PwVD), functional gait and falls risk. The present paper aimed at building predictive models for functional gait under DT conditions, while clarifying the impact of vestibular dysfunction, individual characteristics, varying task types and motor-cognitive demands. Case-controlled observational study with 39 PwVD and 62 healthy participants. The Functional Gait Assessment (FGA), with and without an additional motor, numeracy, or literacy task, was completed. Multiple linear regression was used to fit models to predict FGA under single and DT performance. Dual task cost (DTC, %) was calculated to assess DT interference on FGA performance using the equation: 100*(single task score-dual task score)/single-task score. Following Bonferroni corrections for multiple comparisons (corrected alpha level of 0.003), PwVD had poorer performance than controls for all FGA conditions (p < 0.001), motor (- 3.94%; p = 0.002) and numeracy (- 22.77%; p = 0.001) DTCs and spatial working memory (p = 0.002). The literacy DTC was marginally significant (- 19.39% p = 0.005). FGA single and DT motor, numeracy, and literacy models explained 76%, 76%, 66% and 67% of the variance respectively for PwVD. Sustained attention, visual memory and sex contributed to all models; short-term visual recognition memory, balance confidence, and migraine contributed to some models. Cognitive performance is impaired in PwVD. Motor, numeracy and literacy tasks impair functional gait performance. Cognitive assessment and FGA with a numeracy or literacy cognitive component should be included within assessment protocols and considered in the provision of targeted interventions for PwVD.

Transcranial Direct-Current Stimulation as an Adjunct to Verb Network Strengthening Treatment in Post-stroke Chronic Aphasia: A Double-Blinded Randomized Feasibility Study.

Background: Difficulties in discourse production are common in post-stroke chronic aphasia. Previous studies have found that speech and language therapy combined with transcranial direct-current stimulation (tDCS) may improve language skills like naming and enhance aphasia treatment outcomes. However, very few studies have investigated the effect of tDCS when combined with interventions for improving higher level language skills such as the Verb Network Strengthening Treatment (VNeST). Aims: This study aimed to determine the feasibility of anodal tDCS as an adjunct to VNeST to improve discourse production in post-stroke chronic aphasia. Methods: Six people with post-stroke chronic aphasia took part in this double-blinded randomized feasibility study. Participants were randomly allocated to either the experimental group receiving a 6-week block of once weekly VNeST sessions combined with active tDCS over the left inferior frontal gyrus (LIFG) or a control group that received VNeST with sham stimulation. Feasibility outcomes included screening, eligibility, retention, and completion rates, and adverse events. Preliminary response to intervention was also examined using discourse production, functional communication, quality of life, psychological state, and cognition outcomes. Results: Overall 19 individuals were screened and ten met the inclusion criteria. Six individuals provided consent and participated in the study giving a consent rate of 60%. Participant retention and completion rates were 100% and no adverse effects were reported. Exploratory analyses revealed promising changes (i.e., estimated large effect size) in discourse production measures across discourse language tasks and functional communication for the active tDCS group. Conclusions: Our results support the feasibility of tDCS as an adjunct to VNeST. Preliminary findings provide motivation for future large-scale studies to better understand the potential of tDCS as a safe and economical tool for enhancing rehabilitation in chronic aphasia.

Recommendations for physical activity in the elderly population: A scoping review of guidelines.

Physical inactivity and sedentary time are associated with all-cause mortality, chronic non-communicable diseases and falls in the elderly. Objective of this review is to assess and summarize recommendations from clinical guidelines for physical activity (PA) of older adults in general and related to falls. A scoping review of the existing clinical guidelines was conducted. The included studies should have been developed under the auspices of a health organization and their methodology should be described in detail. Nine clinical guidelines providing specific recommendations for the elderly were identified. There was a strong agreement across the guidelines regarding goals, activities parameters, adverse effects of PA, in addition to reference for preventing falls. Keeping even the minimum of physical activity, introducing balance exercises and strengthening exercises for preventing falls, avoiding unexpected accelerations in the intensity of the activities, applying the necessary precautions and consulting a health professional are the main pillars of recommendations. Despite any deficiencies in definitions, monitoring and optimal dosage consistency of recommendations, is an ideal incentive for countries and organizations to adopt and enhance physical activity as an antidote to the degeneration of human's health and quality of life.

The INVEST trial: a randomised feasibility trial of psychologically informed vestibular rehabilitation versus current gold standard physiotherapy for people with Persistent Postural Perceptual Dizziness.

BACKGROUND: Persistent postural perceptual dizziness (PPPD) is a common and disabling functional neuro-vestibular disorder. We aimed to determine the feasibility and acceptability of conducting a randomised controlled trial of cognitive-behavioural therapy informed vestibular rehabilitation (INVEST intervention) designed for persistent dizziness. METHODS: A two-armed parallel groups randomised feasibility study of INVEST vs. a time-matched gold standard vestibular rehabilitation (VRT) control. Participants with PPPD were recruited from a specialist vestibular clinic in London, UK. Participants were individually randomised using a minimisation procedure with allocation concealment. Measures of feasibility and clinical outcome were collected and assessed at 4 months. RESULTS: Forty adults with PPPD were randomised to six sessions of INVEST (n = 20) or gold standard VRT (n = 20). Overall, 59% of patients screened met the inclusion criteria, of which 80% enrolled. Acceptability of INVEST, as assessed against the theoretical framework of acceptability (TFA), was excellent and 80% adhered to all 6 sessions. There were small to moderate treatment effects in favour of INVEST across all measures, including dizziness handicap, negative illness perceptions, symptom focussing, fear avoidance, and distress (standardised mean difference [SMD]g = 0.45; SMDg = 0.77; SMDg = 0.56; SMDg = 0.50, respectively). No intervention-related serious adverse events were reported. CONCLUSIONS: The study results give strong support for the feasibility of a full-scale trial. Both arms had high rates of recruitment, retention, and acceptability. There was promising support of the benefits of integrated cognitive-behavioural therapy-based vestibular rehabilitation compared to gold standard vestibular rehabilitation. The study fulfilled all the a-priori criteria to advance to a full-scale efficacy trial. TRIAL REGISTRATION NUMBER: ISRCTN10420559.

The role of motivation factors in exergame interventions for fall prevention in older adults: A systematic review and meta-analysis.

Balance disorders and falls are common in the elderly population. Regular balance exercises are an evidence-based physical intervention to prevent falls in older adults, while patient motivation and adherence are important factors for intervention outcome. Exergames are a relatively new, alternative intervention for physical rehabilitation as they improve balance and strength in older adults. The aims of this systematic review and meta-analysis were to assess the (1) effect of motivation factors as per the Capability, Opportunity and Motivation model of Behavior change (COM-B) on the effectiveness of exergame interventions in healthy older adults, (2) effectiveness of exergames to improve balance in older healthy adults and, (3) impact of exergames on cognitive outcomes. Results show that motivation and capability components influence the general outcome of the exergame training. Motivational factors should thus be considered when setting-up an exergame intervention. Furthermore, exergame intervention appears to be a promising training method in comparison to traditional exercise training. However, exergame training in itself might not be sufficient to improve fall risk and cognitive performance.

Emotional Models for the Estimation of Arousal and Pleasure in Older Adults During Balance Rehabilitation Training.

Emotional computing has been previously applied to assess physiological behavior in a wide variety of tasks and activities. This study extends for the first time the use of emotional computing in the field of balance rehabilitation training. A proof-of-concept study was conducted to assess arousal and pleasure response to a range of physical exercises from the OTAGO and HOLOBALANCE balance rehabilitation programs with varying levels of difficulty and physical demand. Eleven participants were enrolled and performed a set of exercises wearing an ECG sensor, reporting arousal and pleasure at the end of each session. A dataset of 264 unique sessions was collected and used to extract heart rate variability (HRV) features from the measured RR intervals and automatically assess user arousal and pleasure, evaluating different classification algorithms. The results suggested that assessment of both emotions is feasible, reaching an accuracy of 72% and 74% for arousal and pleasure estimation, resnectively. Clinical Relevance- Arousal and pleasure are clinically useful indicators of patient's experience and engagement while performing balance rehabilitation exercises with novel sensing technologies and monitoring platforms.

Vestibular Rehabilitation Therapy for the Treatment of Vestibular Migraine, and the Impact of Traumatic Brain Injury on Outcome: A Retrospective Study.

INTRODUCTION: Vestibular migraine (VM) is a common condition; individuals experience dizziness with migraine symptoms. Vestibular rehabilitation therapy (VRT) has been reported as an effective treatment for VM, however, evidence is limited. VM and traumatic brain injury (TBI) can co-occur, and some suggest that TBI can induce VM. There is limited evidence on the effect a history of TBI has on VRT in patients with VM. METHODS: Retrospective case series of 93 (f = 63, m = 30) participants with VM and underwent VRT (mean age 48.62; SD 15.92). Pre- and post-treatment self-reported outcome measures and functional gait assessment were extracted from the participants health records and evaluated. The impact of TBI on VRT outcome in participants with VM was analyzed. Individuals with TBI and no history of migraine (n = 40) were also extracted to act as a control. RESULTS: VRT significantly improved self-reported dizziness on the Dizziness Handicap Inventory (DHI), with a mean change of -18 points (p < 0.000) and +5 points on the functional gait assessment (FGA) (p < 0.000) in patients with VM. A history of TBI significantly impacted outcome on the DHI (p = 0.018) in patients with VM.VRT significantly improved all outcome measures for individuals with TBI, with a mean change of -16 points on the DHI (p = 0.001) and +5 points on the FGA (p < 0.000). VM presence significantly impacted outcome. CONCLUSION: VRT should be considered as a treatment option to reduce dizziness and the risk of falls in individuals with VM. TBI may negatively impact VRT outcomes in individuals with VM.

Automated Assessment of Balance Rehabilitation Exercises With a Data-Driven Scoring Model: Algorithm Development and Validation Study.

BACKGROUND: Balance rehabilitation programs represent the most common treatments for balance disorders. Nonetheless, lack of resources and lack of highly expert physiotherapists are barriers for patients to undergo individualized rehabilitation sessions. Therefore, balance rehabilitation programs are often transferred to the home environment, with a considerable risk of the patient misperforming the exercises or failing to follow the program at all. Holobalance is a persuasive coaching system with the capacity to offer full-scale rehabilitation services at home. Holobalance involves several modules, from rehabilitation program management to augmented reality coach presentation. OBJECTIVE: The aim of this study was to design, implement, test, and evaluate a scoring model for the accurate assessment of balance rehabilitation exercises, based on data-driven techniques. METHODS: The data-driven scoring module is based on an extensive data set (approximately 1300 rehabilitation exercise sessions) collected during the Holobalance pilot study. It can be used as a training and testing data set for training machine learning (ML) models, which can infer the scoring components of all physical rehabilitation exercises. In that direction, for creating the data set, 2 independent experts monitored (in the clinic) 19 patients performing 1313 balance rehabilitation exercises and scored their performance based on a predefined scoring rubric. On the collected data, preprocessing, data cleansing, and normalization techniques were applied before deploying feature selection techniques. Finally, a wide set of ML algorithms, like random forests and neural networks, were used to identify the most suitable model for each scoring component. RESULTS: The results of the trained model improved the performance of the scoring module in terms of more accurate assessment of a performed exercise, when compared with a rule-based scoring model deployed at an early phase of the system (k-statistic value of 15.9% for sitting exercises, 20.8% for standing exercises, and 26.8% for walking exercises). Finally, the resulting performance of the model resembled the threshold of the interobserver variability, enabling trustworthy usage of the scoring module in the closed-loop chain of the Holobalance coaching system. CONCLUSIONS: The proposed set of ML models can effectively score the balance rehabilitation exercises of the Holobalance system. The models had similar accuracy in terms of Cohen kappa analysis, with interobserver variability, enabling the scoring module to infer the score of an exercise based on the collected signals from sensing devices. More specifically, for sitting exercises, the scoring model had high classification accuracy, ranging from 0.86 to 0.90. Similarly, for standing exercises, the classification accuracy ranged from 0.85 to 0.92, while for walking exercises, it ranged from 0.81 to 0.90. TRIAL REGISTRATION: ClinicalTrials.gov NCT04053829; https://clinicaltrials.gov/ct2/show/NCT04053829.

Protocol for a randomised controlled feasibility study of psychologically informed vestibular rehabilitation for people with persistent dizziness: INVEST trial.

BACKGROUND: Dizziness is a common complaint that often persists and leads to disability and distress. Several cognitive and behavioural responses may contribute to the neurobiological adaptations that maintain persistent vestibular symptoms. This paper will present the protocol of a two-arm parallel group feasibility randomised controlled trial designed to determine whether a fully powered efficacy trial is achievable by examining the feasibility of recruitment, acceptability and potential benefits of an integrated cognitive behavioural therapy and vestibular rehabilitation (CBT-VR) treatment for people with persistent dizziness. METHODS: Forty adult patients will be recruited from a tertiary vestibular clinic with persistent movement-triggered dizziness for 3 months or longer who have moderate-high levels of dizziness handicap. Participants will be 1:1 randomised, using a minimisation procedure, to six sessions of either CBT-VR (intervention arm) or VR only (control arm). Measures will be collected at baseline and 4 months post randomisation. The primary feasibility outcomes include descriptive data on numbers meeting eligibility criteria, rates of recruitment, numbers retained post randomisation, treatment adherence and an acceptability questionnaire. Treatment effects on self-report outcomes will be estimated to determine that 95% confidence intervals for the effects are consistent with anticipated effects and minimum clinically important differences, and to provide information needed for the power calculation of an efficacy trial. A nested qualitative study will be conducted post-intervention (intervention group only) to explore the acceptability of the intervention and identify any areas in need of improvement. DISCUSSION: If a trial of CBT-VR is feasible, acceptability data will be used to enhance the intervention if needed and refine the multicentre RCT protocol. Future studies will need to consider the training required for other physiotherapists to deliver the intervention. TRIAL REGISTRATION: ClinicalTrials.gov, ISRCTN 10420559.

Functional Gait Can Be Affected by Noise: Effects of Age and Cognitive Function: A Pilot Study.

Background: The ageing process may degrade an individual's balance control, hearing capacity, and cognitive function. Older adults perform worse on simultaneously executed balance and secondary tasks (i.e., dual-task performance) than younger adults and may be more vulnerable to auditory distraction. Aim: The purpose of this study was to determine the effect of passive listening on functional gait in healthy older vs. younger adults, and to investigate the effect of age, functional gait, hearing ability and cognitive functioning on dual-task performance. Methods: Twenty young and 20 older healthy adults were recruited. Functional gait (Functional Gait Assessment in silent and noisy condition), hearing function (audiogram; Speech in Babble test), and cognitive ability (Cambridge Neuropsychological Test Automated Battery) were measured. Results: Overall, a significant difference between functional gait performance in silent vs. noisy conditions was found (p = 0.022), with no significant difference in dual-task cost between the two groups (p = 0.11). Correlations were found between increasing age, worse functional gait performance, poorer hearing capacity and lower performance on cognitive function tasks. Interestingly, worse performance on attention tasks appeared to be associated with a worse functional gait performance in the noisy condition. Conclusion: Passive listening to multi-talker babble noise can affect functional gait in both young and older adults. This effect could result from the cognitive load of the babble noise, due to the engagement of attention networks by the unattended speech.

A Novel Biopsychosocial Approach to Neck Pain in Military Helicopter Aircrew.

INTRODUCTION: Flight-related neck pain (FRNP) is a frequently reported musculoskeletal complaint among military helicopter aircrew. However, despite its prevalence and suspected causes, little is known of the underpinning pain mechanisms or the impact of neck pain on aircrews in-flight task performance. The biopsychosocial (BPS) approach to health, combined with the contemporary conceptualization of musculoskeletal pain, in which injury and pain are not necessarily synonymous, provides a relatively new holistic framework within which to consider the problem of FRNP in military helicopter aircrew. Combining these concepts, a new conceptual model is proposed to illustrate how biopsychosocial factors may influence pain perception, potentially affecting aircrews capacity to process information and, therefore, threatening in-flight task performance. Recommendations are made for considering the underlying pain mechanisms of FRNP to aid prognoses and guide the development of holistic evidence-based countermeasures for FRNP in military helicopter aircrew. Development of instruments able to measure psychosocial factors, such as self-efficacy and functional ability, validated in the military helicopter aircrew population, would assist this task.Vail RE, Harridge SDR, Hodkinson PD, Green NDC, Pavlou M. A novel biopsychosocial approach to neck pain in military helicopter aircrew. Aerosp Med Hum Perform. 2021; 92(5):333341.

Investigating the feasibility and acceptability of the HOLOBalance system compared with standard care in older adults at risk for falls: study protocol for an assessor blinded pilot randomised controlled study.

INTRODUCTION: Approximately one in three of all older adults fall each year, with wide ranging physical, psychosocial and healthcare-related consequences. Exercise-based interventions are the cornerstone for falls prevention programmes, yet these are not consistently provided, do not routinely address all components of the balance system and are often not well attended. The HOLOBalance system provides an evidence-based balance training programme delivered to patients in their home environment using a novel technological approach including an augmented reality virtual physiotherapist, exergames and a remote monitoring system. The aims of this proof-of-concept study are to (1) determine the safety, acceptability and feasibility of providing HOLOBalance to community dwelling older adults at risk for falls and (2) provide data to support sample size estimates for a future trial. METHODS: A single (assessor) blinded pilot randomised controlled proof of concept study. 120 participants will be randomised to receive an 8-week home exercise programme consisting of either: (1) HOLOBalance or (2) The OTAGO Home Exercise Programme. Participants will be required to complete their exercise programme independently under the supervision of a physiotherapist. Participants will have weekly telephone contact with their physiotherapist, and will receive home visits at weeks 0, 3 and 6. Outcome measures of safety, acceptability and feasibility, clinical measures of balance function, disability, balance confidence and cognitive function will be assessed before and immediately after the 8 week intervention. Acceptability and feasibility will be explored using descriptive statistics, and trends for effectiveness will be explored using general linear model analysis of variance. ETHICS AND DISSEMINATION: This study has received institutional ethical approvals in Germany (reference: 265/19), Greece (reference: 9769/24-6-2019) and the UK (reference: 19/LO/1908). Findings from this study will be submitted for peer-reviewed publications. TRIAL REGISTRATION NUMBER: NCT04053829. PROTOCOL VERSION: V.2, 20 January 2020.

The use of optokinetic stimulation in vestibular rehabilitation.

Individuals with vestibular dysfunction may experience visual vertigo (VV), in which symptoms are provoked or exacerbated by excessive or disorienting visual stimuli (eg, supermarkets). Individuals with VV are believed to be overly reliant on visual input for balance (ie, visually dependent). VV can significantly improve when customized vestibular rehabilitation exercises are combined with exposure to optokinetic stimuli. However, the frequency of treatment sessions (twice weekly for 8 weeks) and the equipment used (expensive and space consuming) make it difficult to incorporate these techniques into everyday clinical practice where exercises may be practiced unsupervised. The aim of this focused review is to provide an overview of recent findings investigating (a) responses of individuals with vestibular deficits to a customized exercise program incorporating exposure to optokinetic stimuli via a "high-tech" visual environment rotator or a "low-tech" DVD with and without supervision, and (b) the mechanism of recovery. Optokinetic stimulation will also be discussed in relation to other new innovations in vestibular rehabilitation techniques and future work.

Transcranial Direct-Current Stimulation May Improve Discourse Production in Healthy Older Adults.

Background: The use of transcranial direct-current stimulation (tDCS) for therapeutic and neurorehabilitation purposes has become increasingly popular in recent years. Previous research has found that anodal tDCS may enhance naming ability and verbal fluency in healthy participants. However, the effect of tDCS on more functional, higher level language skills such as discourse production has yet to be understood. Aims: The present study aimed to investigate in healthy, older adults (a) the effect of anodal tDCS on discourse production vs. sham stimulation and (b) optimal electrode placement for tDCS to target language improvement at the discourse level. Methods: Fourteen healthy, older right-handed participants took part in this sham controlled, repeated measures pilot study. Each participant experienced three different experimental conditions; anodal tDCS on the left inferior frontal gyrus (IFG), anodal tDCS on the right IFG and sham stimulation while performing a story telling task. Significant changes in language performance before and after each condition were examined in three discourse production tasks: recount, procedural and narrative. Results: Left and right IFG conditions showed a greater number of significant within-group improvements (p < 0.05) in discourse production compared to sham with 6/12 for left IFG, 4/12 for right IFG and 2/12 for sham. There were no significant differences noted between tDCS conditions. No relationship was noted between language performance and physical activity, age, or gender. Conclusions: This study suggests that anodal tDCS may significantly improve discourse production in healthy, older adults. In line with previous tDCS language studies, the left IFG is highlighted as an optimal stimulation site for the modulation of language in healthy speakers. The findings support further exploration of tDCS as a rehabilitative tool for higher-level language skills in persons with aphasia.