Introduction to the assessment and management of persistent postural-perceptual dizziness.

OBJECTIVE: Persistent postural-perceptual dizziness classifies patients with chronic dizziness, often triggered by an acute episode of vestibular dysfunction or threat to balance. Unsteadiness and spatial disorientation vary in intensity but persist for over three months, exacerbated by complex visual environments. METHOD: Literature suggests diagnosis relies on a clinical history of persistent subjective dizziness and normal vestibular and neurological examination findings. Behavioural diagnostic biomarkers have been proposed, to facilitate diagnosis. RESULTS: Research has focused on understanding the neural mechanisms that underpin this perceptual disorder, with imaging data supporting altered connectivity between neural brain networks that process vision, motion and emotion. Behavioural research identified the perceptual and motor responses to a heightened perception of imbalance. CONCLUSION: Management utilises head and body motion detection, and downregulation of visual motion excitability, reducing postural hypervigilance and anxiety. Combinations of physical and cognitive therapies, with antidepressant medications, help if the condition is associated with mood disorder.

Assessment and management of vestibular migraine within ENT.

OBJECTIVE: Vestibular migraine is a newly recognised and debilitating condition. This article aims to provide an overview of what is known of vestibular migraine, delineating its diagnostic criteria and presenting some initial management strategies to aid ENT professionals in delivering optimal care when patients first present to the otolaryngology clinic. METHOD: Although traditionally underdiagnosed, there are now clearly defined diagnostic criteria to aid accurate diagnosis of vestibular migraine. RESULTS: A detailed history and clinical examination are the cornerstone of the diagnostic process, but supportive evidence is required from appropriate audio-vestibular tests and imaging. CONCLUSION: This is a unique condition that commonly initially presents to ENT. This article provides a summary of diagnostic and management strategies to facilitate early diagnosis and first-line treatment that can be employed in general ENT settings, which may be particularly useful given the limited availability of specialist audio-vestibular medicine and neuro-otology services.

Practice Patterns of Audiologists Involved in Assessment and Management of Vestibular Disorders: An Indian Cross-Sectional Survey.

BACKGROUND: As the incidence of vestibular disorders continues to rise, the role of the audiologists in assessing and providing effective intervention has become increasingly important. To date, there have been no studies investigating the practice patterns of Indian audiologists towards the assessment and management of vestibular disorders. METHOD: An electronic survey consisting of 29 questions across demographics, vestibular assessment, and management emailed to 704 members of the Indian Speech and Hearing Association (ISHA). Additionally, the questionnaire was circulated to audiologists through social media groups. The participants were provided with a two weeks' time limit for completing the survey. RESULTS: 704 participants were contacted to take part in the survey, and only 243 responses were received resulting in a 34.66 % response rate. Among the 243 participants who responded, 127 participants were currently not involved in the assessment and/or management of vestibular disorders in India. The responses were analyzed descriptively according to each section of the questionnaire. The study also sheds light on vestibular assessment, rehabilitation trends, and perceived barriers/facilitators among Indian audiologists. CONCLUSION: We observed major discrepancies between practice patterns of audiologists in India. Like any other developing nation, India has challenges of its own. Proper planning in terms of resource allocation is needed to address the barriers in access to instrumentation, and limited workforce.

Assessment, diagnosis and management of the dizzy patient.

Dizziness and balance disorders are very common problems. Having a structured approach, including adequate history taking and clinical examination, in a multidisciplinary environment allows for effective management of patients with these complex symptoms. Hearing assessment is an integral part of the assessment of patients with dizziness, along with the occasional need for further testing. Identifying red flags, along with the ability to involve different medical specialties, are prerequisites for safe management and a successful outcome. While surgical intervention has a small role in the management of balance disorders, vestibular rehabilitation remains the cornerstone of treatment, along with different supportive measures. This article outlines the approach used in the authors' centre to manage patients with dizziness and balance disorders.

Vestibular disease in dogs under UK primary veterinary care: Epidemiology and clinical management.

BACKGROUND: Vestibular disease (VD), central or peripheral, can be a dramatic primary-care presentation. Current literature describes mostly dogs examined in referral centers. HYPOTHESIS/OBJECTIVES: Describe the prevalence, presentation, clinical management, and outcomes of VD in dogs under primary veterinary care at UK practices participating in VetCompass. ANIMALS: Seven hundred and fifty-nine vestibular cases identified out of 905 544 study dogs. METHODS: Retrospective cohort study. Potential VD cases clinically examined during 2016 were verified by reviewing clinical records for signalment, presenting clinical signs, treatments, and outcomes. Multivariable logistic regression was used to evaluate factors associated with VD. RESULTS: The overall prevalence of VD was 8 per 10 000 dogs (95% CI = 7-9). Median age at first diagnosis was 12.68 years (interquartile range [IQR], 11.28-14.64). Compared with crossbreeds, breeds with the highest odds of VD diagnosis included French Bulldogs (odds ratio [OR] = 9.25, 95% CI = 4.81-17.76, P < .001), Bulldogs (OR = 6.53, 95% CI = 2.66-16.15, P < .001), King Charles Spaniels (OR = 4.96, 95% CI = 2.52-9.78, P < .001), Cavalier King Charles Spaniels (OR = 3.56, 95% CI = 2.50-5.06, P < .001), and Springer Spaniels (OR = 3.37, 95% CI = 2.52-4.52, P < .001). The most common presenting signs were head tilt (69.8%), nystagmus (68.1%), and ataxia (64.5%). The most frequently used treatments were antiemetics (43.2%), systemic glucocorticoids (33.1%), antimicrobials (25%), and propentofylline (23.25%). There were 3.6% of cases referred. Improvement was recorded in 41.8% cases after a median of 4 days (IQR, 2-10.25). CONCLUSIONS: Our study identifies strong breed predispositions for VD. The low referral rates suggest that primary-care data sources offer more generalizable information for benchmarking to help clinicians review their own clinical activities.

Observational Gait Assessment Scales in Patients with Walking Disorders: Systematic Review.

OBJECTIVE: To compile and analyze the characteristics and methodological quality of observational gait assessment scales validated to date. METHODS: PubMed, Scopus, the Cochrane Library, Physiotherapy Evidence Database, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Dialnet, Spanish Medical Index, and Nursing, Physiotherapy, and Podiatry databases were searched up to August 2019. The main inclusion criteria were validated tools based on a conceptual framework developed to evaluate gait, validation design studies of observational scales in their entirety, and articles written in English or Spanish. Evaluators extracted descriptive information of the scales and the metric properties of the studies, which were further analyzed with Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) and COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN checklist). RESULTS: Eighteen articles based on 14 scales were included. The populations were neurological patients (72.22%), musculoskeletal disorders (11.11%), and other areas such as vestibular disorders (11.11%). The most addressed items were orthopedic aids (64.29%); phases of the gait cycle and kinematics of the leg and trunk (57.14% each one); and spatial and temporal parameters (50%). All studies analyzed criterion validity, and five included content or structural validity (27.78%). Fifteen articles considered reliability (83.33%). Regarding the seven-item scale QUADAS-2, five studies obtained six results on "low" risk of bias or "low" concerns regarding applicability. Nine articles obtained at least a "fair" result on COSMIN checklist. CONCLUSIONS: A necessary compilation of the observational gait assessment scales validated to date was conducted. Besides, their characteristics and methodological quality were analyzed. Most scales were applied in neurological signs. The most approached topics were orthopedic aids, phases of the gait cycle, and kinematics of the leg and trunk. The scale that demonstrated a higher methodological quality was Visual Gait Assessment Scale, followed by CHAGS, Salford Gait Tool, and Edinburgh Visual Gait Score.

Balance Disorders in Older Adults.

Balance disorders are common in the elderly and can lead to falls, with resultant severe morbidity and even mortality. Progressive loss of vestibular function begins in middle age and is affected by multiple disease processes. Polypharmacy impacts many disease processes in the elderly, with balance function being one of the most susceptible. Evaluation of the older patient with a balance disorder is critical for the well-being of these patients, as it may drive intervention. This article reviews balance disorders often encountered in older patients and makes recommendations regarding education of nonotolaryngologists.

Geriatric vestibulopathy assessment and management.

PURPOSE OF REVIEW: This review discusses the demographics of dizziness in the older person, the evaluation of the older dizzy patient and how the treatment of dizziness in older patients differs from that in younger individuals. RECENT FINDINGS: Seven percent of all visits to primary care physicians for patients older than 65 years of age are for dizziness, and dizziness is the most common complaint for patients older than 75 years. In a German study, the 12-month prevalence of vertigo in the general population was 5% with an incidence of 1.4% in adults overall. For individuals aged 60-69 the 12-month prevalence was found to be 7.2% and in individuals 70 years of age or older 8.9%. Data from the United States National Health and Nutrition Examination Surveys indicated that the prevalence of vestibular dysfunction for individuals in the seventh decade of life, eighth decade of life, and older was 49.4, 68.7, and 84.8 percent, respectively. Only subtle age effects are seen on caloric and rotational testing whereas vestibular evoked myogenic potentials (VEMPs) change somewhat with age. Particle repositioning for benign paroxysmal positional vertigo combined with vestibular rehabilitation is more effective than only performing the repositioning maneuver. Tai Chi appears to be an effective intervention for older adults at risk for falling. SUMMARY: When caring for an older dizzy patient always assess medication use, perform a Dix-Hallpike maneuver, obtain orthostatic vital signs, discuss fall risk precautions, and consider referral for vestibular rehabilitation.

Assessment of vibrotactile feedback on postural stability during pseudorandom multidirectional platform motion.

This study uses frequency-domain techniques and stabilogram diffusion analysis (SDA) to investigate the effect of vibrotactile feedback during continuous multidirectional perturbations of a support platform. Eight subjects with vestibular deficits were subjected to two-axis pseudorandom surface platform motion while donning a multiaxis vibrotactile feedback device that mapped body tilt estimates onto their torsos via a 3-row by 16-column array of tactile vibrators (tactors). Four tactor display configurations with spatial resolutions ranging between 22.5 degrees and 90 degrees, in addition to the tactors off configuration, were evaluated. Power spectral density functions of body sway in the anterior-posterior (A/P) and medial-lateral (M/L) directions, and transfer functions between platform motion and body sway, were computed at frequencies ranging from 0.0178 to 3.56 Hz. Cross-spectral analysis revealed that the A/P responses were not significantly driven by M/L inputs, and vice versa, thus supporting the notion of independent A/P and M/L postural control. Vibrotactile feedback significantly decreased A/P and M/L spectral power, decreased transfer function gains up to a frequency of 1.8 and 0.6 Hz in the A/P and M/L directions, respectively, and increased phase leads above 0.3 Hz. SDA showed significantly decreased transition time for both A/P and M/L tilts, and decreased transition displacement and short-term diffusion coefficients for A/P tilt. However, the spatial resolution of the tactor displays did not affect subjects' performance, thereby supporting the use of a lower spatial resolution display in future device designs.

Development and assessment of the vestibular system.

Paediatric vestibular assessment is necessary in various situations, yielding invaluable information relating to diagnoses and allowing for the formulation of appropriate rehabilitative strategies when considering the management of children with vestibular and balance problems, alone or in association with hearing impairment or other developmental disorders. The development and assessment of the vestibular system is considered in this article.

Incidence of complementary therapy use in patients undergoing vestibular assessment.

OBJECTIVES: To determine the incidence of use of complementary therapies in patients with vestibular symptoms undergoing vestibular assessment. DESIGN: A prospective, questionnaire-based study. SETTING: A UK university hospital department of audiology with secondary and tertiary referrals. PARTICIPANTS: A consecutive series of 80 patients seen for vestibular assessment between November 2004 and May 2005. MAIN OUTCOME MEASURES: Use of complementary therapies; actual therapies used and patients' subjective opinion of efficacy. RESULTS: Thirteen patients (16 per cent) had tried some form of complementary therapy for their vestibular symptoms. Ginkgo biloba and acupuncture were the two most popular treatments. Seven patients made their decision as to which treatment to try on the basis of personal recommendation. Six of the 13 patients (46 per cent) reported that their choice of treatment(s) helped them. CONCLUSIONS: Sixteen per cent of patients seen for vestibular assessment had tried some form of complementary therapy for their vestibular symptoms. Clinicians should be aware of this and of the potential interactions between complementary therapies and conventional medicine.

Web-based clinical decision support system for triage of vestibular patients.

OBJECTIVES: We sought to use a clinical decision support system (CDSS) to save costs and to improve scheduling of vestibular patients in an otolaryngology clinic. STUDY DESIGN AND SETTING: We conducted a concurrent review of 50 vestibular patients scheduled in the University of Missouri otolaryngology clinic with or without testing based on the outcome of a CDSS. The CDSS was implemented using Web-based technology. Charges incurred by the health care system through tests determined by the CDSS were compared with those incurred using the standard procedure of ordering hearing tests and electronystagmography for all patients. RESULTS: Thirty-nine tests were prescheduled using the CDSS. Twenty-five additional tests were ordered after the visit. The CDSS resulted in savings of $37,904.00 in charges to the health care system. The CDSS showed high specificity and variable sensitivity. CONCLUSION: A Web-based CDSS can be used to better manage and coordinate patient encounters. SIGNIFICANCE: One important reason to use a CDSS in health care management is to lower costs.