Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Updated Clinical Practice Guideline From the Academy of Neurologic Physical Therapy of the American Physical Therapy Association.

BACKGROUND: Uncompensated vestibular hypofunction can result in symptoms of dizziness, imbalance, and/or oscillopsia, gaze and gait instability, and impaired navigation and spatial orientation; thus, may negatively impact an individual's quality of life, ability to perform activities of daily living, drive, and work. It is estimated that one-third of adults in the United States have vestibular dysfunction and the incidence increases with age. There is strong evidence supporting vestibular physical therapy for reducing symptoms, improving gaze and postural stability, and improving function in individuals with vestibular hypofunction. The purpose of this revised clinical practice guideline is to improve quality of care and outcomes for individuals with acute, subacute, and chronic unilateral and bilateral vestibular hypofunction by providing evidence-based recommendations regarding appropriate exercises. METHODS: These guidelines are a revision of the 2016 guidelines and involved a systematic review of the literature published since 2015 through June 2020 across 6 databases. Article types included meta-analyses, systematic reviews, randomized controlled trials, cohort studies, case-control series, and case series for human subjects, published in English. Sixty-seven articles were identified as relevant to this clinical practice guideline and critically appraised for level of evidence. RESULTS: Based on strong evidence, clinicians should offer vestibular rehabilitation to adults with unilateral and bilateral vestibular hypofunction who present with impairments, activity limitations, and participation restrictions related to the vestibular deficit. Based on strong evidence and a preponderance of harm over benefit, clinicians should not include voluntary saccadic or smooth-pursuit eye movements in isolation (ie, without head movement) to promote gaze stability. Based on moderate to strong evidence, clinicians may offer specific exercise techniques to target identified activity limitations and participation restrictions, including virtual reality or augmented sensory feedback. Based on strong evidence and in consideration of patient preference, clinicians should offer supervised vestibular rehabilitation. Based on moderate to weak evidence, clinicians may prescribe weekly clinic visits plus a home exercise program of gaze stabilization exercises consisting of a minimum of: (1) 3 times per day for a total of at least 12 minutes daily for individuals with acute/subacute unilateral vestibular hypofunction; (2) 3 to 5 times per day for a total of at least 20 minutes daily for 4 to 6 weeks for individuals with chronic unilateral vestibular hypofunction; (3) 3 to 5 times per day for a total of 20 to 40 minutes daily for approximately 5 to 7 weeks for individuals with bilateral vestibular hypofunction. Based on moderate evidence, clinicians may prescribe static and dynamic balance exercises for a minimum of 20 minutes daily for at least 4 to 6 weeks for individuals with chronic unilateral vestibular hypofunction and, based on expert opinion, for a minimum of 6 to 9 weeks for individuals with bilateral vestibular hypofunction. Based on moderate evidence, clinicians may use achievement of primary goals, resolution of symptoms, normalized balance and vestibular function, or plateau in progress as reasons for stopping therapy. Based on moderate to strong evidence, clinicians may evaluate factors, including time from onset of symptoms, comorbidities, cognitive function, and use of medication that could modify rehabilitation outcomes. DISCUSSION: Recent evidence supports the original recommendations from the 2016 guidelines. There is strong evidence that vestibular physical therapy provides a clear and substantial benefit to individuals with unilateral and bilateral vestibular hypofunction. LIMITATIONS: The focus of the guideline was on peripheral vestibular hypofunction; thus, the recommendations of the guideline may not apply to individuals with central vestibular disorders. One criterion for study inclusion was that vestibular hypofunction was determined based on objective vestibular function tests. This guideline may not apply to individuals who report symptoms of dizziness, imbalance, and/or oscillopsia without a diagnosis of vestibular hypofunction. DISCLAIMER: These recommendations are intended as a guide to optimize rehabilitation outcomes for individuals undergoing vestibular physical therapy. The contents of this guideline were developed with support from the American Physical Therapy Association and the Academy of Neurologic Physical Therapy using a rigorous review process. The authors declared no conflict of interest and maintained editorial independence.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A369).

Balance in multiple sclerosis: relationship to central brain regions.

Dizziness, postural instability, and ataxia are among the most debilitating symptoms of multiple sclerosis (MS), reflecting, in large part, dysfunctional integration of visual, somatosensory, and vestibular sensory cues. However, the role of MS-related supratentorial lesions in producing such symptoms is poorly understood. In this study, motor control test (MCT) and dynamic sensory organization test (SOT) scores of 58 MS patients were compared to those of 72 healthy controls; correlations were determined between the MS scores of 49 patients and lesion volumes within 26 brain regions. Depending upon platform excursion direction and magnitude, MCT latencies, which were longer in MS patients than controls (p < 0.0001), were correlated with lesion volumes in the cortex, medial frontal lobes, temporal lobes, and parietal opercula (r's ranging from 0.20 to 0.39). SOT test scores were also impacted by MS and correlated with lesions in these same brain regions as well as within the superior frontal lobe (r's ranging from - 0.28 to - 0.40). The strongest and most consistent correlations occurred for the most challenging tasks in which incongruent visual and proprioceptive feedback were given. This study demonstrates that supratentorial lesion volumes are associated with quantitative balance measures in MS, in accord with the concept that balance relies upon highly convergent and multimodal neural pathways involving the skin, muscles, joints, eyes, and vestibular system.

Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Evidence-Based Clinical Practice Guideline: FROM THE AMERICAN PHYSICAL THERAPY ASSOCIATION NEUROLOGY SECTION.

BACKGROUND: Uncompensated vestibular hypofunction results in postural instability, visual blurring with head movement, and subjective complaints of dizziness and/or imbalance. We sought to answer the question, "Is vestibular exercise effective at enhancing recovery of function in people with peripheral (unilateral or bilateral) vestibular hypofunction?" METHODS: A systematic review of the literature was performed in 5 databases published after 1985 and 5 additional sources for relevant publications were searched. Article types included meta-analyses, systematic reviews, randomized controlled trials, cohort studies, case control series, and case series for human subjects, published in English. One hundred thirty-five articles were identified as relevant to this clinical practice guideline. RESULTS/DISCUSSION: Based on strong evidence and a preponderance of benefit over harm, clinicians should offer vestibular rehabilitation to persons with unilateral and bilateral vestibular hypofunction with impairments and functional limitations related to the vestibular deficit. Based on strong evidence and a preponderance of harm over benefit, clinicians should not include voluntary saccadic or smooth-pursuit eye movements in isolation (ie, without head movement) as specific exercises for gaze stability. Based on moderate evidence, clinicians may offer specific exercise techniques to target identified impairments or functional limitations. Based on moderate evidence and in consideration of patient preference, clinicians may provide supervised vestibular rehabilitation. Based on expert opinion extrapolated from the evidence, clinicians may prescribe a minimum of 3 times per day for the performance of gaze stability exercises as 1 component of a home exercise program. Based on expert opinion extrapolated from the evidence (range of supervised visits: 2-38 weeks, mean = 10 weeks), clinicians may consider providing adequate supervised vestibular rehabilitation sessions for the patient to understand the goals of the program and how to manage and progress themselves independently. As a general guide, persons without significant comorbidities that affect mobility and with acute or subacute unilateral vestibular hypofunction may need once a week supervised sessions for 2 to 3 weeks; persons with chronic unilateral vestibular hypofunction may need once a week sessions for 4 to 6 weeks; and persons with bilateral vestibular hypofunction may need once a week sessions for 8 to 12 weeks. In addition to supervised sessions, patients are provided a daily home exercise program. DISCLAIMER: These recommendations are intended as a guide for physical therapists and clinicians to optimize rehabilitation outcomes for persons with peripheral vestibular hypofunction undergoing vestibular rehabilitation.Video Abstract available for more insights from the author (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A124).

Adverse effects of health anxiety on management of a patient with benign paroxysmal positional vertigo, vestibular migraine and chronic subjective dizziness.

INTRODUCTION: Care of patients with vestibular symptoms focuses primarily on physical otoneurologic disorders; however, psychological factors can sustain symptoms, confound assessment, and adversely affect treatment. Health anxiety is a particularly pernicious process that simultaneously magnifies physical symptoms and inhibits medical care. OBJECTIVE: To demonstrate the excess morbidity caused by vestibular health anxiety and its successful management in a patient with otoneurologic disease. METHOD: Report of a 41-year-old woman with recurrent benign paroxysmal positional vertigo, vestibular migraine, and chronic subjective dizziness, who expressed grave concerns about her health, repeatedly questioned her otoneurologic diagnoses, and failed physical therapy and medication treatment until her health anxiety and otoneurologic illnesses were addressed simultaneously. CONCLUSION: Health anxiety is an empirically validated concept that explains troublesome health-related beliefs and behaviors. It is frustrating for patients and health care teams, but can be treated successfully in otoneurology practice, thereby reducing physical symptoms, emotional distress, functional impairment, and health care overutilization.

Performance of Fukuda Stepping Test as a function of the severity of caloric weakness in chronic dizzy patients.

BACKGROUND: The purpose of the Fukuda Stepping Test (FST) is to measure asymmetrical vestibulospinal reflex tone resulting from labyrinthine dysfunction. The FST is a low cost evaluation for dizzy patients; however, when compared with gold standard caloric irrigation unilateral weakness (UW) value ≥25%, the FST has not been shown to be a sensitive tool for identifying unilateral vestibular hypofunction. PURPOSE: The purpose of this technical report is to further evaluate the clinical utility of FST with and without headshake as a function of increased caloric asymmetry for individuals with unilateral peripheral vestibular pathology. RESEARCH DESIGN: Retrospective review of FST results with and without head shaking component as compared to gold standard, caloric irrigation UW outcome values at four severity levels: 0-24% UW (normal caloric value); 25-50% UW (mild caloric UW); 51-75% UW (moderate caloric UW); 76-100% UW (severe caloric UW). STUDY SAMPLE: 736 chronic (≥8 wk symptom complaints) dizzy patients. RESULTS: Standard FST and FST following a head shake task are insensitive to detecting mild to moderate peripheral vestibular paresis. Increased test performance was observed for patients with severe canal paresis (>76% UW); however, continued inconsistencies were found in turn direction toward the severe unilateral vestibular dysfunction. CONCLUSIONS: Overall, the FST provides little benefit to clinicians when used in the vestibular bedside examination.

Characterization of Postural Sway in Patients With Persistent Postural-Perceptual Dizziness (PPPD) Using Wearable Motion Sensors.

OBJECTIVE: To extend previous investigations of postural control in patients with persistent-postural perceptual dizziness (PPPD). STUDY DESIGN: Case-controlled, cross-sectional, observational investigation. SETTING: Tertiary care center. PATIENTS: Fifteen patients with PPPD, 15 control volunteers. INTERVENTIONS: Measurement of anterior-posterior (AP) and medial-lateral (ML) sway at the waist using wearable accelerometers during posturography; assessment of reach and gait. MAIN OUTCOME MEASURES: Peak-to-peak AP and ML sway displacement on the six conditions of the Sensory Organization Test (SOT); Scores on the SOT, Functional Reach Test (FRT), and Dynamic Gait Index (DGI). RESULTS: Compared to control volunteers, patients with PPPD had significantly greater sway displacement at the waist in the AP direction in SOT conditions 3, 5, and 6 and in the ML direction in SOT conditions 2 and 4, resulting in significantly lower median equilibrium scores on the composite index and all six SOT conditions. Patients with PPPD had significantly lower scores on the FRT and DGI that were not correlated with SOT performance. AP sway in conditions 3 and 6 differentiated patients with PPPD from controls with high sensitivity (≥0.87) and specificity (≥0.87). CONCLUSIONS: This study replicated previous work showing poor SOT performance by patients with PPPD who had greater AP sway associated with visual dependence and greater ML sway in low demand conditions than controls. Patients with PPPD also performed poorer on the FRT and DGI, but lack of correlation with SOT scores suggested different mechanisms of impairment in postural control, reach, and ambulation. AP sway demonstrated potential as a diagnostic marker.

Fukuda stepping test: sensitivity and specificity.

BACKGROUND: A vestibulospinal test known as the Fukuda stepping test (FST) has been suggested to be a measure of asymmetrical labyrinthine function. However, an extensive review of the performance of this test to identify a peripheral vestibular lesion has not been reported. PURPOSE: The purpose of this study was to evaluate the sensitivity and specificity of the standard FST and a head shaking variation for identification of a peripheral vestibular system lesion. RESEARCH DESIGN: In this retrospective review, we compared performance on the FST with and without a head shaking component to electronystagmography (ENG) caloric irrigation unilateral weakness results. STUDY SAMPLE: We studied these factors in 736 chronic dizzy patients. RESULTS: Receiving operating characteristics (ROC) analysis and area under the curve (AUC) indicated no significant benefit to performance from the head shaking variation compared to the standard FST in identifying labyrinthine weakness as classified by caloric unilateral weakness results. CONCLUSIONS: These findings suggest that the FST with and without head shake component is not a reliable screening tool for peripheral vestibular asymmetry in chronic dizzy patients; however, future research may hold promise for the FST as a tool for patients with acute unilateral disorders.

Head shake computerized dynamic posturography in peripheral vestibular lesions.

PURPOSE: To determine the sensitivity of a head shake modification to the Sensory Organization Test (SOT) of dynamic posturography in identifying (a) those patients with unilateral, peripheral vestibular hypofunction as indicated by caloric irrigation findings and (b) those patients who report that head movements provoke disruption in postural control. METHOD: A prospective, single-blinded, random selection methodology was used with 91 patients stratified by the presence or absence of a significant caloric asymmetry and by the presence or absence of head movement provoked symptoms (independent variables). Postural control performance, as measured by EquiTest during the standard test and a head shake modification, served as the dependent variables. RESULTS: Receiver operating characteristic curves demonstrated only minor improvement in sensitivity (a) with the head shake modification for unilateral peripheral asymmetry and (b) for identification of those with complaints of head movement provoked imbalance. CONCLUSIONS: The head shake modification to standard SOT increased the test sensitivity to identification of patients with unilateral, peripheral vestibular hypofunction and those with head movement provoked symptoms. However, this occurred with low specificity, resulting in no significant improvement in overall performance with this head shake protocol. Suggestions for further research to improve the performance of the head shake modification of SOT for clinical application are discussed.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on Intraoperative Cranial Nerve Monitoring in Vestibular Schwannoma Surgery.

Question 1: Does intraoperative facial nerve monitoring during vestibular schwannoma surgery lead to better long-term facial nerve function? Target Population: This recommendation applies to adult patients undergoing vestibular schwannoma surgery regardless of tumor characteristics. Recommendation: Level 3: It is recommended that intraoperative facial nerve monitoring be routinely utilized during vestibular schwannoma surgery to improve long-term facial nerve function. Question 2: Can intraoperative facial nerve monitoring be used to accurately predict favorable long-term facial nerve function after vestibular schwannoma surgery? Target Population: This recommendation applies to adult patients undergoing vestibular schwannoma surgery. Recommendation: Level 3: Intraoperative facial nerve can be used to accurately predict favorable long-term facial nerve function after vestibular schwannoma surgery. Specifically, the presence of favorable testing reliably portends a good long-term facial nerve outcome. However, the absence of favorable testing in the setting of an anatomically intact facial nerve does not reliably predict poor long-term function and therefore cannot be used to direct decision-making regarding the need for early reinnervation procedures. Question 3: Does an anatomically intact facial nerve with poor electromyogram (EMG) electrical responses during intraoperative testing reliably predict poor long-term facial nerve function? Target Population: This recommendation applies to adult patients undergoing vestibular schwannoma surgery. Recommendation: Level 3: Poor intraoperative EMG electrical response of the facial nerve should not be used as a reliable predictor of poor long-term facial nerve function. Question 4: Should intraoperative eighth cranial nerve monitoring be used during vestibular schwannoma surgery? Target Population: This recommendation applies to adult patients undergoing vestibular schwannoma surgery with measurable preoperative hearing levels and tumors smaller than 1.5 cm. Recommendation: Level 3: Intraoperative eighth cranial nerve monitoring should be used during vestibular schwannoma surgery when hearing preservation is attempted. Question 5: Is direct monitoring of the eighth cranial nerve superior to the use of far-field auditory brain stem responses? Target Population: This recommendation applies to adult patients undergoing vestibular schwannoma surgery with measurable preoperative hearing levels and tumors smaller than 1.5 cm. Recommendation: Level 3: There is insufficient evidence to make a definitive recommendation. The full guideline can be found at: https://www.cns.org/guidelines/guidelines-manage-ment-patients-vestibular-schwannoma/chapter_4.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on Hearing Preservation Outcomes in Patients With Sporadic Vestibular Schwannomas.

Question 1: What is the overall probability of maintaining serviceable hearing following stereotactic radiosurgery utilizing modern dose planning, at 2, 5, and 10 yr following treatment? Recommendation: Level 3: Individuals who meet these criteria and are considering stereotactic radiosurgery should be counseled that there is moderately high probability (>50%-75%) of hearing preservation at 2 yr, moderately high probability (>50%-75%) of hearing preservation at 5 yr, and moderately low probability (>25%-50%) of hearing preservation at 10 yr. Question 2: Among patients with AAO-HNS (American Academy of Otolaryngology-Head and Neck Surgery hearing classification) class A or GR (Gardner-Robertson hearing classification) grade I hearing at baseline, what is the overall probability of maintaining serviceable hearing following stereotactic radiosurgery, utilizing modern dose planning, at 2, 5, and 10 yr following treatment? Recommendation: Level 3: Individuals who meet these criteria and are considering stereotactic radiosurgery should be counseled that there is a high probability (>75%-100%) of hearing preservation at 2 yr, moderately high probability (>50%-75%) of hearing preservation at 5 yr, and moderately low probability (>25%-50%) of hearing preservation at 10 yr. Question 3: What patient- and tumor-related factors influence progression to nonserviceable hearing following stereotactic radiosurgery using ≤13 Gy to the tumor margin? Recommendation: Level 3: Individuals who meet these criteria and are considering stereotactic radiosurgery should be counseled regarding the probability of successful hearing preservation based on the following prognostic data: the most consistent prognostic features associated with maintenance of serviceable hearing are good preoperative word recognition and/or pure tone thresholds with variable cut-points reported, smaller tumor size, marginal tumor dose ≤12 Gy, and cochlear dose ≤4 Gy. Age and sex are not strong predictors of hearing preservation outcome. Question 4: What is the overall probability of maintaining serviceable hearing following microsurgical resection of small to medium-sized sporadic vestibular schwannomas early after surgery, at 2, 5, and 10 yr following treatment? Recommendation: Level 3: Individuals who meet these criteria and are considering microsurgical resection should be counseled that there is a moderately low probability (>25%-50%) of hearing preservation immediately following surgery, moderately low probability (>25%-50%) of hearing preservation at 2 yr, moderately low probability (>25%-50%) of hearing preservation at 5 yr, and moderately low probability (>25%-50%) of hearing preservation at 10 yr. Question 5: Among patients with AAO-HNS class A or GR grade I hearing at baseline, what is the overall probability of maintaining serviceable hearing following microsurgical resection of small to medium-sized sporadic vestibular schwannomas early after surgery, at 2, 5, and 10 yr following treatment? Recommendation: Level 3: Individuals who meet these criteria and are considering microsurgical resection should be counseled that there is a moderately high probability (>50%-75%) of hearing preservation immediately following surgery, moderately high probability (>50%-75%) of hearing preservation at 2 yr, moderately high probability (>50%-75%) of hearing preservation at 5 yr, and moderately low probability (>25%-50%) of hearing preservation at 10 yr. Question 6: What patient- and tumor-related factors influence progression to nonserviceable hearing following microsurgical resection of small to medium-sized sporadic vestibular schwannomas? Recommendation: Level 3: Individuals who meet these criteria and are considering microsurgical resection should be counseled regarding the probability of successful hearing preservation based on the following prognostic data: the most consistent prognostic features associated with maintenance of serviceable hearing are good preoperative word recognition and/or pure tone thresholds with variable cut-points reported, smaller tumor size commonly less than 1 cm, and presence of a distal internal auditory canal cerebrospinal fluid fundal cap. Age and sex are not strong predictors of hearing preservation outcome. Question 7: What is the overall probability of maintaining serviceable hearing with conservative observation of vestibular schwannomas at 2, 5, and 10 yr following diagnosis? Recommendation: Level 3: Individuals who meet these criteria and are considering observation should be counseled that there is a high probability (>75%-100%) of hearing preservation at 2 yr, moderately high probability (>50%-75%) of hearing preservation at 5 yr, and moderately low probability (>25%-50%) of hearing preservation at 10 yr. Question 8: Among patients with AAO-HNS class A or GR grade I hearing at baseline, what is the overall probability of maintaining serviceable hearing with conservative observation at 2 and 5 yr following diagnosis? Recommendation: Level 3: Individuals who meet these criteria and are considering stereotactic radiosurgery should be counseled that there is a high probability (>75%-100%) of hearing preservation at 2 yr, and moderately high probability (>50%-75%) of hearing preservation at 5 yr. Insufficient data were available to determine the probability of hearing preservation at 10 yr for this population subset. Question 9: What patient and tumor-related factors influence progression to nonserviceable hearing during conservative observation? Recommendation: Level 3: Individuals who meet these criteria and are considering observation should be counseled regarding probability of successful hearing preservation based on the following prognostic data: the most consistent prognostic features associated with maintenance of serviceable hearing are good preoperative word recognition and/or pure tone thresholds with variable cut-points reported, as well as nongrowth of the tumor. Tumor size at the time of diagnosis, age, and sex do not predict future development of nonserviceable hearing during observation. The full guideline can be found at: https://www.cns.org/guidelines/guidelines-manage-ment-patients-vestibular-schwannoma/chapter_3.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on Otologic and Audiologic Screening for Patients With Vestibular Schwannomas.

QUESTION 1: What is the expected diagnostic yield for vestibular schwannomas when using a magnetic resonance imaging (MRI) to evaluate patients with previously published definitions of asymmetric sensorineural hearing loss? TARGET POPULATION: These recommendations apply to adults with an asymmetric sensorineural hearing loss on audiometric testing. RECOMMENDATION: Level 3: On the basis of an audiogram, it is recommended that MRI screening on patients with ≥10 decibels (dB) of interaural difference at 2 or more contiguous frequencies or ≥15 dB at 1 frequency be pursued to minimize the incidence of undiagnosed vestibular schwannomas. However, selectively screening patients with ≥15 dB of interaural difference at 3000 Hz alone may minimize the incidence of MRIs performed that do not diagnose a vestibular schwannoma. QUESTION 2: What is the expected diagnostic yield for vestibular schwannomas when using an MRI to evaluate patients with asymmetric tinnitus, as defined as either purely unilateral tinnitus or bilateral tinnitus with subjective asymmetry? TARGET POPULATION: These recommendations apply to adults with subjective complaints of asymmetric tinnitus. RECOMMENDATION: Level 3: It is recommended that MRI be used to evaluate patients with asymmetric tinnitus. However, this practice is low yielding in terms of vestibular schwannoma diagnosis (<1%). QUESTION 3: What is the expected diagnostic yield for vestibular schwannomas when using an MRI to evaluate patients with a sudden sensorineural hearing loss? TARGET POPULATION: These recommendations apply to adults with a verified sudden sensorineural hearing loss on an audiogram. RECOMMENDATION: Level 3: It is recommended that MRI be used to evaluate patients with a sudden sensorineural hearing loss. However, this practice is low yielding in terms of vestibular schwannoma diagnosis (<3%). The full guideline can be found at: https://www.cns.org/guidelines/guidelines-management-patients-vestibular-schwannoma/chapter_2.

The canalith repositioning procedure with and without mastoid oscillation for the treatment of benign paroxysmal positional vertigo.

OBJECTIVE: To evaluate the efficacy of mastoid oscillation performed with a canalith repositioning procedure (CRP) for the treatment of benign paroxysmal positional vertigo (BPPV). STUDY DESIGN: A total of 137 patients with posterior canal BPPV were treated with an Epley CRP with or without mastoid oscillation at a tertiary care, university-based balance center. Data were collected prospectively from all patients via a preprinted diary which they maintained for 14 days after the maneuver. Patients underwent office evaluation at 2 weeks after the maneuver. RESULTS: A total of 137 patients were divided equally between the treatment groups. At 48 h post-treatment, 61% (with vibration) and 64% (without vibration) of patients were free of vertigo. At 2 weeks' post-treatment, 74% (with vibration) and 85% (without vibration) were vertigo-free. Residual symptoms of lightheadedness/imbalance were experienced by 32% of patients with vibration and 40% of patients without vibration. None of these differences between groups were statistically significant. CONCLUSION: The addition of mastoid oscillation to the positioning maneuver does not add any therapeutic benefit.

Effects of Device on Video Head Impulse Test (vHIT) Gain.

BACKGROUND: Numerous video head impulse test (vHIT) devices are available commercially; however, gain is not calculated uniformly. An evaluation of these devices/algorithms in healthy controls and patients with vestibular loss is necessary for comparing and synthesizing work that utilizes different devices and gain calculations. PURPOSE: Using three commercially available vHIT devices/algorithms, the purpose of the present study was to compare: (1) horizontal canal vHIT gain among devices/algorithms in normal control subjects; (2) the effects of age on vHIT gain for each device/algorithm in normal control subjects; and (3) the clinical performance of horizontal canal vHIT gain between devices/algorithms for differentiating normal versus abnormal vestibular function. RESEARCH DESIGN: Prospective. STUDY SAMPLE: Sixty-one normal control adult subjects (range 20-78) and eleven adults with unilateral or bilateral vestibular loss (range 32-79). DATA COLLECTION AND ANALYSIS: vHIT was administered using three different devices/algorithms, randomized in order, for each subject on the same day: (1) Impulse (Otometrics, Schaumberg, IL; monocular eye recording, right eye only; using area under the curve gain), (2) EyeSeeCam (Interacoustics, Denmark; monocular eye recording, left eye only; using instantaneous gain), and (3) VisualEyes (MicroMedical, Chatham, IL, binocular eye recording; using position gain). RESULTS: There was a significant mean difference in vHIT gain among devices/algorithms for both the normal control and vestibular loss groups. vHIT gain was significantly larger in the ipsilateral direction of the eye used to measure gain; however, in spite of the significant mean differences in vHIT gain among devices/algorithms and the significant directional bias, classification of "normal" versus "abnormal" gain is consistent across all compared devices/algorithms, with the exception of instantaneous gain at 40 msec. There was not an effect of age on vHIT gain up to 78 years regardless of the device/algorithm. CONCLUSIONS: These findings support that vHIT gain is significantly different between devices/algorithms, suggesting that care should be taken when making direct comparisons of absolute gain values between devices/algorithms.

Cervical and Ocular VEMP Testing in Diagnosing Superior Semicircular Canal Dehiscence.

Objective To determine the sensitivity and specificity of ocular and cervical vestibular evoked myogenic potentials (VEMPs) in the diagnosis of superior semicircular canal dehiscence (SCD) and to describe the VEMP response characteristics that are most sensitive to SCD and compare the findings to previous reports. Study Design Case series with chart review. Setting Two tertiary neurotologic referral centers. Subjects and Methods Cervical and ocular VEMP peak-to-peak amplitudes and thresholds from 39 adult patients older than 18 years with surgically confirmed SCD were compared with 84 age-matched controls. Results Using receiver operating characteristic (ROC) curves, cervical VEMP (cVEMP) amplitudes, cVEMP thresholds, and ocular VEMP (oVEMP) amplitudes had areas under the curve of 0.731, 0.912, and 0.856, respectively, all of which were statistically significant ( P < .0001). For cVEMP thresholds, at the clinical equivalent ≤85-dB normalized hearing level (nHL) threshold, the sensitivity and specificity were 97.3% and 31.3%, respectively. At the ≤70-dB nHL threshold, the sensitivity and specificity were 73.0% and 94.0%, respectively. For oVEMP amplitudes >12.0 µV, the sensitivity and specificity were 78.6% and 81.7%, respectively. Conclusion Data from this multicenter study suggest that both cVEMP thresholds and oVEMP amplitudes remain good diagnostic tests for identifying SCD, with each test dependent on a number of factors. The sensitivity and specificity of these individual tests may vary slightly between centers depending on testing parameters used.

Differentiation of Ménière's disease and migraine-associated dizziness: a review.

A significant body of literature exists demonstrating a relationship between migraine disorders and dizziness. In the characterizations of the migraine-associated dizziness, the signs and symptoms show overlap with those characterizing Meniere's disease. There has been literature, beginning with Ménière himself, suggesting a relationship between Ménière's disease and migraine-associated dizziness. This implicates a possible underlying link in pathogenesis. This review article presents a discussion of the overlap in signs and symptoms between the two disorders. Suggestions for differentiating between the disorders based on recent literature protocols and use of test results are also discussed. Vestibular and balance rehabilitation programs have a role in both of the disorders but differ in the overall management aspects of the disorders. The distinction in the use of vestibular rehabilitation is discussed.

Modified head shake sensory organization test: Sensitivity and specificity.

The Sensory Organization Test (SOT) of Computerized Dynamic Posturography (EquiTest™ equipment) is a valuable tool for investigating how an individual uses balance system sensory input (vestibular, vision, proprioception/somatosensory) to maintain quiet stance; however, it is limited as a screening tool for identifying peripheral vestibular system dysfunction. Previous research has shown that adding horizontal head-shake to portions of the standard SOT battery improved the identification of peripheral vestibular system asymmetry; however, flaws in the methods were noted. The objective of this work was to evaluate the sensitivity and specificity of the modified head-shake SOT (HS-SOT) protocol for identification of peripheral vestibular system lesion. Fifteen patients with chief complaint of instability, vertigo, and/or lightheadedness, with and without a caloric unilateral weakness (UW) and fifteen age-matched healthy controls were included in the final analysis. Ten of the 15 patients demonstrated a caloric UW≥25%. Participants completed standard conditions 2 and 5 of SOT with head still and during four horizontal head-shaking tasks (i.e., HS-SOT2-60°/s, HS-SOT2-120°/s, HS-SOT5-15°/s, and HS-SOT5-60°/s). Average equilibrium scores decreased as condition difficulty increased (SOT2, HS-SOT2-60°/s, HS-SOT2-120°/s, SOT 5, HS-SOT5-15°/s, and HS-SOT5-60°/s) for each group; as expected, a lower decline was noted for controls (slope=-6.59) compared to patients (slope=-11.69). The HS-SOT5-15°/s condition was superior for identifying peripheral vestibular asymmetry (AUC=0.90 sensitivity=70%, specificity=100%), with the strongest correlation to caloric UW% (rs=-0.743, p=0.000006). HS-SOT5-15°/s appears to be a promising screening measure for peripheral vestibular asymmetry.

Retrospective review and telephone follow-up to evaluate a physical therapy protocol for treating persistent postural-perceptual dizziness: A pilot study.

BACKGROUND: Persistent postural-perceptual dizziness (PPPD) (formerly chronic subjective dizziness) may be treated using the habituation form of vestibular and balance rehabilitation therapy (VBRT), but therapeutic outcomes have not been formally investigated. OBJECTIVE: This pilot study gathered the first data on the efficacy of VBRT for individuals with well-characterized PPPD alone or PPPD plus neurotologic comorbidities (vestibular migraine or compensated vestibular deficits). METHODS: Twenty-six participants were surveyed by telephone an average of 27.5 months after receiving education about PPPD and instructions for home-based VBRT programs. Participants were queried about exercise compliance, perceived benefits of therapy, degree of visual or motion sensitivity remaining, disability level, and other interventions. RESULTS: Twenty-two of 26 participants found physical therapy consultation helpful. Fourteen found VBRT exercises beneficial, including 8 of 12 who had PPPD alone and 6 of 14 who had PPPD with co-morbidities. Of the 14 participants who found VBRT helpful, 7 obtained relief of sensitivity to head/body motion, 5 relief of sensitivity to visual stimuli, and 4 complete remission. Comparable numbers for the 12 participants who found VBRT not helpful were 1 (head/body motion), 3 (visual stimuli), and 0 (remission). CONCLUSIONS: This pilot study offers the first data supporting the habituation form of VBRT for treatment of PPPD.

Utility of an Abbreviated Dizziness Questionnaire to Differentiate Between Causes of Vertigo and Guide Appropriate Referral: A Multicenter Prospective Blinded Study.

OBJECTIVE: Test performance of a focused dizziness questionnaire's ability to discriminate between peripheral and nonperipheral causes of vertigo. STUDY DESIGN: Prospective multicenter. SETTING: Four academic centers with experienced balance specialists. PATIENTS: New dizzy patients. INTERVENTIONS: A 32-question survey was given to participants. Balance specialists were blinded and a diagnosis was established for all participating patients within 6 months. MAIN OUTCOMES: Multinomial logistic regression was used to evaluate questionnaire performance in predicting final diagnosis and differentiating between peripheral and nonperipheral vertigo. Univariate and multivariable stepwise logistic regression were used to identify questions as significant predictors of the ultimate diagnosis. C-index was used to evaluate performance and discriminative power of the multivariable models. RESULTS: In total, 437 patients participated in the study. Eight participants without confirmed diagnoses were excluded and 429 were included in the analysis. Multinomial regression revealed that the model had good overall predictive accuracy of 78.5% for the final diagnosis and 75.5% for differentiating between peripheral and nonperipheral vertigo. Univariate logistic regression identified significant predictors of three main categories of vertigo: peripheral, central, and other. Predictors were entered into forward stepwise multivariable logistic regression. The discriminative power of the final models for peripheral, central, and other causes was considered good as measured by c-indices of 0.75, 0.7, and 0.78, respectively. CONCLUSION: This multicenter study demonstrates a focused dizziness questionnaire can accurately predict diagnosis for patients with chronic/relapsing dizziness referred to outpatient clinics. Additionally, this survey has significant capability to differentiate peripheral from nonperipheral causes of vertigo and may, in the future, serve as a screening tool for specialty referral. Clinical utility of this questionnaire to guide specialty referral is discussed.