Vestibular rehabilitation in multiple sclerosis: study protocol for a randomised controlled trial and cost-effectiveness analysis comparing customised with booklet based vestibular rehabilitation for vestibulopathy and a 12 month observational cohort study of the symptom reduction and recurrence rate following treatment for benign paroxysmal positional vertigo.

BACKGROUND: Symptoms arising from vestibular system dysfunction are observed in 49-59% of people with Multiple Sclerosis (MS). Symptoms may include vertigo, dizziness and/or imbalance. These impact on functional ability, contribute to falls and significant health and social care costs. In people with MS, vestibular dysfunction can be due to peripheral pathology that may include Benign Paroxysmal Positional Vertigo (BPPV), as well as central or combined pathology. Vestibular symptoms may be treated with vestibular rehabilitation (VR), and with repositioning manoeuvres in the case of BPPV. However, there is a paucity of evidence about the rate and degree of symptom recovery with VR for people with MS and vestibulopathy. In addition, given the multiplicity of symptoms and underpinning vestibular pathologies often seen in people with MS, a customised VR approach may be more clinically appropriate and cost effective than generic booklet-based approaches. Likewise, BPPV should be identified and treated appropriately. METHODS/ DESIGN: People with MS and symptoms of vertigo, dizziness and/or imbalance will be screened for central and/or peripheral vestibulopathy and/or BPPV. Following consent, people with BPPV will be treated with re-positioning manoeuvres over 1-3 sessions and followed up at 6 and 12 months to assess for any re-occurrence of BPPV. People with central and/or peripheral vestibulopathy will be entered into a randomised controlled trial (RCT). Trial participants will be randomly allocated (1:1) to either a 12-week generic booklet-based home programme with telephone support or a 12-week VR programme consisting of customised treatment including 12 face-to-face sessions and a home exercise programme. Customised or booklet-based interventions will start 2 weeks after randomisation and all trial participants will be followed up 14 and 26 weeks from randomisation. The primary clinical outcome is the Dizziness Handicap Inventory at 26 weeks and the primary economic endpoint is quality-adjusted life-years. A range of secondary outcomes associated with vestibular function will be used. DISCUSSION: If customised VR is demonstrated to be clinically and cost-effective compared to generic booklet-based VR this will inform practice guidelines and the development of training packages for therapists in the diagnosis and treatment of vestibulopathy in people with MS. TRIAL REGISTRATION: ISRCTN Number: 27374299 Date of Registration 24/09/2018 Protocol Version 15 25/09/2019.

Sex Differences on Vestibular and Ocular Motor Assessment in Youth Athletes.

CONTEXT: The Vestibular/Ocular Motor Screening (VOMS) is a newly developed measure that evaluates vestibular and ocular motor symptom provocation after sport-related concussion. The effects of sex on baseline VOMS scores in youth athletes have not been established. OBJECTIVE: To examine sex differences on baseline VOMS assessment among youth athletes. RESULTS: No sex differences were demonstrated between male and female youth athletes on individual VOMS items (P range = .07-.98). Female sex was not associated with increased odds for VOMS scores over clinical-cutoff levels (range: odds ratio = 0.64; 95% confidence interval = 0.35, 1.15; P = .13; odds ratio = 0.91; 95% confidence interval = 0.48, 1.71; P = .77). CONCLUSIONS: No sex differences were present on baseline VOMS scores in youth athletes, nor was sex a risk factor for an abnormal VOMS score. These findings highlight the need for continual baseline and postconcussion assessments using multifaceted assessment strategies.

Balance Assessment in Traumatic Brain Injury: A Comparison of the Sensory Organization and Limits of Stability Tests.

Balance problems are common after a traumatic brain injury (TBI). Symptoms of dizziness, unsteadiness, or imbalance have been most frequently attributed to sensory organization problems involving the use of visual, proprioceptive, and/or vestibular information for postural control. These problems can be assessed with the Sensory Organization Test (SOT). However, as head trauma can affect any brain region, areas responsible for voluntary control of movements involved in dynamic balance tasks, such as the motor cortex and its projections, could also be compromised, which would likely affect one's limits of stability. The Limits of Stability (LOS) balance test has received little attention in TBI. In the present study, we compared the prevalence of SOT versus LOS abnormalities in a cohort of 48 patients, the majority classified as having mild or moderate chronic TBI. Compared with a normative database provided by the balance testing manufacturer, a larger portion of our cohort presented abnormalities in the LOS test. Dizziness Handicap Inventory (DHI) results indicated mild disability, with the five activities most frequently endorsed as problematic being: looking up, performing quick head movements, performing ambitious such as sports or dancing activities, feeling frustrated, and performing strenuous house/yard work. Although regression analysis revealed that both tests significantly predicted subjective scores on the DHI, more LOS than SOT testing variables were important predictors of DHI results indicating disability. These results suggest that the LOS test is an informative tool that should be included in any objective balance evaluations that screen TBI patients with balance complaints.

[Etiology analysis and vestibular assessment of bilateral vestibular vestibulopathy].

Objective:To define clinical and laboratory characteristics of bilateral vestibulopathy(BVP) and to propose diagnostic criteria of this disorder based on clinical and laboratory vestibular function test findings.Method:Forty-two case series with a clinical suspicion of BVP were retrospectively analyzed, in an attempt to determine etiology. Presenting auditory-vestibular symptoms, bedside dynamic visual acuity tests and laboratory test were reviewed, including bithermal caloric test, rotatory chair tests, video head impulse test (vHIT), vestibular-evoked myogenic potentials (VEMP).Result:Among these 42 patients, dizziness was seen in 42 cases(100%), oscillopsia was seen in 21 cases(50%), hearing loss was seen in 30(71.4%). Eight cases(19%) had tinnitus. Twenty-five cases showed vestibular loss in dynamic visual acuity test (69.4%). Definite diagnosis of complete BVP was made in 36 patients when the patients showed abnormal findings on caloric test, rotatory chair test and vHIT in addition to the symptoms. Whereas probable diagnosis of partial BVP was obtained in 6 patients with abnormal caloric test and rotatory chair test but no pathological vHIT. VEMP (ocular or cervical) could be recorded in 20 patients. Fourteen cases were caused by ototoxic drugs while no causes could be determined in 6 cases among these 42 cases.Conclusion:The diagnosis of BVP is a challenge. Vestibular laboratory test battery which reflect full frequency function of VOR has great value to confirming the diagnosis and differentiate complete BVP to partial BVP. Diagnosis standard shall be made combining clinical history, characteristic symptoms and the results of auditory-vestibular function testing. Ototoxic drugs contribute most considering etiology.

Vestibular Function and Gross Motor Development in 195 Children With Congenital Hearing Loss-Assessment of Inner Ear Malformations.

OBJECTIVES: To evaluate the relationship between vestibular function and gross motor development in children with inner ear malformations. METHODS: A total of 195 children (average age: 2.4 ±â€Š1.6 yr) with profound hearing loss, defined as a hearing threshold greater than 80 dB, participated in this study. Evaluation of vestibular function was assessed in all children using a damped rotational chair test. Gross motor development was assessed by examining the age of acquisition of head control and independent walking. Temporal bone computed tomography scans were conducted in 190 of the 195 children. RESULTS: Among the 195 children, 31 children (15.9%) showed a reduced response in the rotational chair test. Of the 17 children who were followed up with repeat rotational chair tests, 16 showed more obvious nystagmus during follow-up compared with the initial examination. The reduced response group showed significant delays in head control and independent walking compared with the normal response group (p < 0.01). Forty-one children (21.6%) demonstrated inner ear malformations and showed significantly delayed acquisition of head control and independent walking (p < 0.01) compared with children with normal vestibular function. Children with inner ear malformations with a reduced response in the rotational chair test had severe vestibular (p < 0.05) and lateral semicircular canal (p < 0.01) malformations as the most common findings. CONCLUSIONS: Structural inner ear malformations are associated with vestibular dysfunction and delayed gross motor development. Our findings confirm that there is a higher incidence of reduced vestibulo-ocular reflex in children with vestibular and semicircular canal malformations.

Assessment of vestibular-evoked myogenic potentials and video head impulse test in type 2 diabetes mellitus patients with or without polyneuropathy.

This study aimed to compare cervical vestibular-evoked myogenic potentials (cVEMP), ocular vestibular-evoked myogenic potentials (oVEMP) and video head impulse test (vHIT) results between patients with type 2 diabetes mellitus (DM) or diabetic polyneuropathy (DPN) and healthy controls to determine vestibular end-organ pathologies. The participants in the present study consisted of three groups: the type 2 DM group (n = 33 patients), the DPN group (n = 33 patients), and the age- and sex-matched control group (n = 35). Cervical VEMP, oVEMP and vHIT were performed for each participant in the study and test results were compared between the groups. Peak-to-peak amplitudes of cVEMP (p13-n21) and oVEMP (n10-p15) were significantly lower in the DM and DPN groups than the control group. The values of vHIT were not statistically different between the groups. To our knowledge, the present study is the first report investigating oVEMP and cVEMP responses combined with vHIT findings in patients with DM and DPN. Vestibular end-organ pathologies can be determined via clinical vestibular diagnostic tools in spite of prominent vestibular symptoms in patients with type 2 DM as well as patients with DPN.

A Brief Vestibular/Ocular Motor Screening (VOMS) assessment to evaluate concussions: preliminary findings.

BACKGROUND: Vestibular and ocular motor impairments and symptoms have been documented in patients with sport-related concussions. However, there is no current brief clinical screen to assess and monitor these issues. PURPOSE: To describe and provide initial data for the internal consistency and validity of a brief clinical screening tool for vestibular and ocular motor impairments and symptoms after sport-related concussions. STUDY DESIGN: Cross-sectional study; Level of evidence, 2. METHODS: Sixty-four patients, aged 13.9 ± 2.5 years and seen approximately 5.5 ± 4.0 days after a sport-related concussion, and 78 controls were administered the Vestibular/Ocular Motor Screening (VOMS) assessment, which included 5 domains: (1) smooth pursuit, (2) horizontal and vertical saccades, (3) near point of convergence (NPC) distance, (4) horizontal vestibular ocular reflex (VOR), and (5) visual motion sensitivity (VMS). Participants were also administered the Post-Concussion Symptom Scale (PCSS). RESULTS: Sixty-one percent of patients reported symptom provocation after at least 1 VOMS item. All VOMS items were positively correlated to the PCSS total symptom score. The VOR (odds ratio [OR], 3.89; P < .001) and VMS (OR, 3.37; P < .01) components of the VOMS were most predictive of being in the concussed group. An NPC distance ≥5 cm and any VOMS item symptom score ≥2 resulted in an increase in the probability of correctly identifying concussed patients of 38% and 50%, respectively. Receiver operating characteristic curves supported a model including the VOR, VMS, NPC distance, and ln(age) that resulted in a high predicted probability (area under the curve = 0.89) for identifying concussed patients. CONCLUSION: The VOMS demonstrated internal consistency as well as sensitivity in identifying patients with concussions. The current findings provide preliminary support for the utility of the VOMS as a brief vestibular/ocular motor screen after sport-related concussions. The VOMS may augment current assessment tools and may serve as a single component of a comprehensive approach to the assessment of concussions.

Assessment of oculomotor control and balance post-concussion: a preliminary study for a novel approach to concussion management.

PRIMARY OBJECTIVE: Balance disturbances occur in ∼30% of concussion injuries, with vestibular dysfunction reported as the main contributor. However, few have studied oculomotor control post-concussion to assess vestibular dysfunction. RESEARCH DESIGN: The current research measured the differences in oculomotor control between athletes post-concussion (PC) and athletes without concussion (NC) during an active balance control task. METHODS: Nine PC and nine NC athletes wore a monocular eye tracking device, while balance tests were performed using the Nintendo WiiFit® soccer heading game. Average game scores, eye deviations from centre (Gaze Deviations) and gaze fixation (Percentage Time on Centre) were measured. RESULTS: PC made significantly greater Gaze Deviations from centre compared to NC (p < 0.001), however Percentage Time on Centre and game scores were not significantly different between groups. Correlations between gaze and balance within groups revealed a significant positive correlation in NC, while a significant negative correlation in PC. CONCLUSIONS: Results from this exploratory examination of oculomotor behaviour post-concussion revealed significant differences in gaze stability between athletes with a concussion and those without, suggesting vestibular involvement post-concussion. Assessment of oculomotor control during balance activities may provide further insight into dysfunction of the vestibular system following a concussion injury.

Neurocognitive measures in the assessment of vestibular disturbance in patients with brain injury.

INTRODUCTION: Problems with balance and dizziness are one of the most common complaints of individuals who have experienced a brain injury and are reported in up to 90% of cases. Despite the ubiquity of vestibular disturbance in this population, there remains a dearth of research on the interaction between physiological and cognitive systems responsible for maintaining balance. PURPOSE: The purpose of this article is to review studies on the interaction of physiological and cognitive processes required to maintain balance that may aide assessment and recovery of balance disturbance in patients with brain injury. SUMMARY: This article provides a review of research on the role of higher order cognitive processes in maintaining balance and rational for further inclusion of neurocognitive measures in the assessment of vestibular disturbance. CONCLUSION: Greater inclusion of neurocognitive measures in assessment of vestibular disturbance provides a method of assessment containing increased ecological validity compared to traditional assessments, better prepares patients for discharge, and may reduce the incidence of future injury.

Assessment and treatment of common persistent sequelae following blast induced mild traumatic brain injury.

The ongoing wars in Iraq and Afghanistan and terrorist activity worldwide have been associated with an increased incidence of blast injuries. While blast injuries share similarities with blunt or penetrating traumatic injuries, there are unique mechanistic elements of blast injury that create increased vulnerability to damage of specific organs. This review highlights the mechanism of blast-related injury, describes the common sequelae of blast exposure that may impact rehabilitation care, and summarizes the intervention strategies for these blast-related sequelae.

Development and evaluation of low cost game-based balance rehabilitation tool using the Microsoft Kinect sensor.

The use of the commercial video games as rehabilitation tools, such as the Nintendo WiiFit, has recently gained much interest in the physical therapy arena. Motion tracking controllers such as the Nintendo Wiimote are not sensitive enough to accurately measure performance in all components of balance. Additionally, users can figure out how to "cheat" inaccurate trackers by performing minimal movement (e.g. wrist twisting a Wiimote instead of a full arm swing). Physical rehabilitation requires accurate and appropriate tracking and feedback of performance. To this end, we are developing applications that leverage recent advances in commercial video game technology to provide full-body control of animated virtual characters. A key component of our approach is the use of newly available low cost depth sensing camera technology that provides markerless full-body tracking on a conventional PC. The aim of this research was to develop and assess an interactive game-based rehabilitation tool for balance training of adults with neurological injury.

[Assessment of dynamic posture equilibrium function after traumatic brain injury].

OBJECTIVE: To explore characteristics and causes of equilibrium function deficits after traumatic brain injury(TBI). METHODS: Ninety-five patients after TBI in traffic accidents were tested using computerized dynamic posturography (CDP). The CDP findings of patients were compared with normal value. The patients were grouped based on TBI and audition disorders degrees. The results were compared within the patients groups. RESULTS: The equilibrium scores of the TBI group were significantly lower than the normal value. The utilization rate decreased for vision and vestibular sensation information in the TBI group, especially for vestibular sensation. The primary TBI degree and audition decrease had no significant affect on posture stability. CONCLUSION: The poor posture stability was observed in TBI patients without limbs disturbance. The response and adaptation abilities decrease in these patients. This could be explained by the damage to peripheral vestibular and central balance structures.

Neurootological contributions to the diagnostic follow-up after whiplash injuries.

Only in 1992 we had to deal with about 197,731 cases of whiplash injuries due to traffic accidents on the roads of Germany. About 80% recover within a few months. However, about 15%-20% develop the so-called late whiplash injury syndrome with many complaints of the cervico-encaphalic syndrome including headache, vertigo, instability, nausea, tinnitus, hearing loss etc. The orthopedic as well as the radiological findings are mostly unsatisfactory with respect to the neurosensorial complaints. Therefore problems of evidence arise in compensation claims calling for additional neurootological medical expertise. When analysing 124 expert examinations of our patients suffering from late whiplash injury syndrome we found that the average case had already seen 3.83 medical experts elsewhere including 18 different medical specialities. At the most, we observed 17 expertise visits/case prior to the patients visit to us. In the present study we compared the results from 42 neurootological expertise cases with 206 cases of late whiplash injury syndrome, who only came for treatment purposes to our neurootological practice. Al our patients underwent a systematic history (NOASC I) and a functional neurootological, audiometric and equilibriometric examination. Thus we tried to assess the location and nature of the functional degeneration underlying the posttraumatic residual vertigo symptoms, etc. The objective and quantitative equilibrium investigations included several ENGs and an analysis of the cranio-corpo-gram, thus obtaining a record of the gait and standing patterns by means of a radar-like image of the marker tracings from the head and the shoulders during stepping and standing, as well as during bending, extending and turning the neck (computer CCG). Thus individual patterns of functional lesions in the neurootological pathways can simultaneously? objectively and quantatively be worked out for both the groups confirming the subjective complaints.