[Advances in vestibular function and rehabilitation of large vestibular aqueduct syndrome].

Large vestibular aqueduct syndrome（LVAS） is a common recessive hereditary hearing loss disease, and some patients may also experience vestibular dysfunction. With the wide application of cochlear implant（CI） and the development of vestibular medicine, the pathophysiological mechanism of LVAS and the influence mechanism of CI on vestibular function are gradually elucidated. Consequently, the evaluation and rehabilitation of vestibular dysfunction function have also become research hotspots. This article reviews studies on vestibular function and related rehabilitation in patients with large vestibular aqueduct syndrome.

Feasibility of a randomized, sham-controlled pilot study for accelerated rTMS-treatment of the cerebellum plus physiotherapy in CANVAS patients.

BACKGROUND: Cerebellar ataxia, neuropathy and bilateral vestibular areflexia (CANVAS) is a rare neurodegenerative disease affecting the cerebellum, the peripheral nervous system and the vestibular system. Due to the lack of approved drugs, therapy comprises physiotherapy and speech therapy. Transcranial magnetic stimulation is a promising non-invasive therapeutic option to complement classical symptomatic therapies. OBJECTIVE: To test feasibility of the combination of transcranial magnetic stimulation using an accelerated protocol and standard symptomatic therapy in patients with CANVAS. METHODS: Eight patients with genetically confirmed CANVAS were assigned to either verum or sham cerebellar transcranial magnetic stimulation using an accelerated protocol. Treatment duration was limited to 5 days. Additionally, patients in both groups received symptomatic therapy (speech and physiotherapy) for the duration of the study. RESULTS: All patients completed the stimulation protocol. Adverse events were rare. Ataxia severity improved in the verum group only. CONCLUSION: The combination of transcranial magnetic stimulation and classic symptomatic therapy is feasible in a neuro-rehabilitation setting and potentially ameliorates ataxia severity.

Remote Delivery of Vestibular Rehabilitation for Vestibular Dysfunction: A Systematic Review.

BACKGROUND: People with vestibular dysfunction encounter many obstacles when seeking vestibular rehabilitation treatment. Remote delivery of vestibular rehabilitation may offer a promising avenue for overcoming these barriers, ensuring uninterrupted and cost-effective care. OBJECTIVE: To evaluate clinical trials studying telerehabilitation and virtual reality devices as therapeutic interventions for individuals with vestibular dysfunction. METHODS: A PRISMA systematic review of PubMed, EMBASE, Cochrane, Web of Science, and SCOPUS was conducted for randomized controlled trials describing the use of remote care delivery for vestibular rehabilitation. Bias of studies was assessed with the revised Cochrane risk-of-bias tool (RoB2). RESULTS: The search identified 1,358 unique articles and 14 articles matched the search criteria. Study samples size ranged from 20 to 337, with mean ages ranging from 29.3 to 77.7 years. Interventions included telephone and online communication, exergaming devices, web-based applications, and head-mounted devices to deliver vestibular rehabilitation. Outcomes included validated questionnaires, objective clinical tests, and physical examinations. CONCLUSIONS: The studies reviewed in this article reported greater or equivalent outcomes when incorporating remote care options as supplements or alternatives to standard care for patients with vestibular dysfunction. Further research is required to address limitations in these studies such as heterogeneity of control groups and cost-effectiveness of these interventions.

Effects of Cawthorne-Cooksey exercises on vestibular symptoms: A systematic review of randomized controlled trials.

OBJECTIVES: To examine the effects of Cawthorne-Cooksey exercises on individuals with vestibular dysfunction symptoms. METHODS: Systematic search was conducted using PubMed, EBSCO SCOPUS, Web of Science, and Google Scholar from inception to March 2023. The Physiotherapy Evidence Database (PEDro) scale was employed to evaluate the risk of bias in the included studies. RESULTS: Ten randomized controlled trials met the eligibility criteria. In total, 610 participants, 41.31 % of whom were men were included in this review. The PEDro scale scores ranged from 6 to 8 with a median of 6.5/10. Our findings revealed improvements in patients' vestibular dysfunction symptoms after Cawthorne-Cooksey exercises and other conventional interventions. CONCLUSIONS: The initial findings showed that Cawthorne-Cooksey exercises are not superior to other concurrent vestibular rehabilitation interventions in improving vestibular dysfunction symptoms. Additional trials with long-term follow-ups are strongly recommended to understand the impacts of Cawthorne-Cooksey exercises on vestibular dysfunction symptoms.

Pitfalls, patience and patients: developing a physiotherapy-led balance clinic.

BACKGROUND: Balance dysfunction and vestibular conditions are major problems requiring significant resources. There is significant national and international variation in management pathways for such patients. METHODS: This paper outlines a collaborative project run by the ENT department and two vestibular rehabilitation trained physiotherapists to establish a clinic to manage patients referred to ENT with vestibular and/or balance complaints. As part of a six-month pilot, two physiotherapy-led balance clinics were provided per week. RESULTS: A total of 159 new patients were seen, with only 15 needing ENT consultant input. This led to the successful creation of substantive posts; the clinic has seen 698 patients in its first two years. CONCLUSION: Patient outcomes and experience have been positive, and accompanied by reduced waiting and in-service times. The authors discuss some of the pitfalls, challenges and opportunities of developing this type of clinic.

Vestibular Rehabilitation: Intelligent or Traditional?

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Effectiveness of vestibular rehabilitation on postural balance in Parkinson's disease: a systematic review and meta-analysis of randomized controlled trials.

INTRODUCTION: Postural balance impairment can affect the quality of life of patients with Parkinson's disease. Previous studies have described connections of the vestibular system with postural functions, suggesting a potential participation of the basal ganglia in receiving vestibular stimuli. This systematic review aims to summarize the evidence on the effectiveness of vestibular rehabilitation on postural balance in patients with Parkinson's disease. METHODS: A systematic review was conducted using the electronic databases: PubMed, Embase, Scopus and PEDro. The study selection was independently conducted by two reviewers, and disagreements were evaluated by a third reviewer. The included studies had no restrictions on publication dates or languages and the last update occurred in July 2023. RESULTS: From the 485 studies found in the searches, only 3 studies were deemed eligible for the systematic review involving a total of 130 participants. The Berg Balance Scale was described as the tool for evaluation of postural balance in all studies. The meta-analysis showed statistically significant results in favor of vestibular rehabilitation (MD = 5.35; 95% CI = 2.39, 8.31; P < 0.001), regardless of the stage of Parkinson's disease. Although the effect size was suggested as a useful functional gain, the analysis was done with caution, as it only included 3 randomized controlled trials. The risk of bias using the RoB-2 was considered as being of "some concern" in all studies. Furthermore, the quality of the evidence based on the Grading of Recommendations Assessment Development and Evaluation system, produced by pooling the included studies was considered very low. CONCLUSION: Compared to other interventions, vestibular rehabilitation has potential to assist the postural balance of patients with Parkinson's disease. However, the very low quality of the evidence demonstrates uncertainty about the impact of this clinical practice. More robust studies are needed to confirm the benefits of this therapy in patients with Parkinson's disease. This study was prospectively registered in PROSPERO: CRD42020210185.

Guidelines of the French Society of Otorhinolaryngology and Head and Neck Surgery (SFORL) for vestibular rehabilitation in children with vestibular dysfunction. A systematic review.

INTRODUCTION: The consequence of complete or partial uncompensated vestibular dysfunction in children is usually balance disorders, with the risk of falls and increased fatigue, particularly during tasks requiring postural control. The aim of these recommendations is to establish guidelines for vestibular rehabilitation (VR) in children with vestibular impairment. MATERIAL AND METHODS: The guidelines were developed based on a systematic review of the international literature, validated by a multidisciplinary group of French-speaking otorhinolaryngologists, scientists, and physiotherapists. They are classified as grade A, B, C, or expert opinion according to a decreasing level of scientific evidence. RESULTS: A PubMed search of studies published between January 1990 and December 2021 was carried out using the keywords "vestibular," "rehabilitation," and "children". After filtering and reviewing the articles, a total of 10 publications were included to establish the recommendations. CONCLUSION: It is recommended that a vestibular assessment be carried out before VR, including a study of vestibulo-ocular reflex, otolithic function, and postural control. In cases of vestibular dysfunction, physiotherapy treatment is recommended from an early age to train different aspects of postural control, including anticipatory and reactive postural adjustments. VR adapted to the pediatric population is recommended for children whose vestibular dysfunction leads to functional disorders or symptoms of vertigo for those who have suffered head trauma. It is recommended that children with bilateral vestibular impairment be treated using gaze stabilization exercises for adaptation and substitution. Optokinetic stimulation and virtual reality are not recommended for children and young adolescents.

[Expert consensus on vestibular rehabilitation in vestibular disorders].

Vestibular rehabilitation therapy (VRT) is a highly effective treatment approach for addressing both peripheral and central vestibular disorders, offering the ability to significantly improve patients' coordination and control across the vestibular, visual, and proprioceptive systems, all of which are crucial factors in maintaining balance. By promoting vestibular compensation, VRT has been shown to mitigate or even eliminate symptoms of dizziness, vertigo, and instability. With the rapid development of vestibular research, VRT has evolved into a more individualized and precise treatment approach based on evidence-based medicine. Its clinical effectiveness has been increasingly validated in numerous studies. With the involvement of multidisciplinary experts, this article aims to reach a consensus on the pre-treatment evaluation, formulation/implementation of treatment plans, and evidence-based treatment recommendations for common vestibular disorders, focusing on the prospects of vestibular rehabilitation. The goal is to further standardize and update VRT protocols for different vestibular disorders, providing comprehensive and context-specific guidance primarily tailored to the Chinese healthcare landscape, with a notable emphasis on its clinical applicability. Concurrently, it aspires to present new insights and serve as a valuable reference point for forthcoming high-quality clinical research on vestibular rehabilitation in China.

Barriers and Facilitators of Vestibular Rehabilitation: Patients and Physiotherapists' Perspectives.

BACKGROUND AND PURPOSE: Poor adherence to vestibular rehabilitation protocols is a known barrier to optimal care. Vestibular clinicians' comprehensive understanding of the barriers and facilitators to vestibular home exercise programs (VHEP) is a key element to achieving optimal care in the context of vestibular rehabilitation. The aims of this study are as follows: (1) to identify primary barriers and facilitators to VHEP from the perspective of patients with vestibular dysfunction and vestibular physical therapists (PTs); and (2) to provide strategies for clinicians to improve adherence and outcomes of VHEP. METHODS: A qualitative research with single-session focus groups conducted separately for: (1) patients with vestibular disorders and (2) vestibular PTs. Six focus groups were conducted, 3 for each population, with a total of 39 participants. An online survey was conducted to evaluate the estimates of adherence rates, followed by a structured discussion over barriers and facilitators to VHEP as perceived by patients and PTs. Thematic data analyses were performed using a mixed deductive-inductive approach. RESULTS: Eighteen patients with vestibular disorders and 21 experienced vestibular PTs participated in this study. Six barrier categories and 5 facilitator categories were identified. Barriers included motivation aspects, provocation of symptoms, time management, associated impairments, missing guidance and feedback, and psychosocial factors. Facilitators included motivation aspects, time management, patient education and exercise instructions, exercise setting, and associated symptom management. DISCUSSION AND CONCLUSIONS: Clinicians who prescribe home exercise to patients with vestibular disorders can use this information about common barriers and facilitators for patient education and to provide optimal care and improve rehabilitation outcomes. VIDEO ABSTRACT AVAILABLE: for more insights from the authors (see the video, Supplemental Digital Content, available at: http://links.lww.com/JNPT/A467 ).

Effect of vestibular rehabilitation games in patients with persistent postural perceptual dizziness and its relation to anxiety and depression: prospective study.

PURPOSE: To evaluate the efficacy of vestibular rehabilitation therapy (VRT) for management of patients with persistent postural perceptual dizziness (PPPD) utilizing subjective and objectives outcome measures and to study the effect of degree of both anxiety and depression in patients on the response of vestibular rehabilitation therapy. METHODS: Thirty-three PPPD patients participated in this study. Selection of patients was based on the diagnostic criteria for PPPD stated by Barany society in the International Classification of Vestibular Disorders (2017). Every patient was subjected to history taking, anxiety and depression assessment, Arabic version of Dizziness Handicap Inventory (DHI), and sensory organization test (SOT). All patients received vestibular rehabilitations therapy. Assessment of VRT outcome was conducted after 6 weeks of VRT. RESULTS: The mean patients' age was 40.9 ± 16.3 years, and nearly equal gender distribution. Vestibular migraine was the most precipitating condition (24.2%) in patients with PPPD. (39.4%) of patients had abnormal scores of anxiety and depression tests, all patients had from moderate to severe degrees of handicap caused by dizziness as measured by DHI, most of patients had abnormal findings in all conditions of SOT. After vestibular rehabilitation therapy, DHI and SOT scores showed significant improvement after VRT. More improvement was found among the group with no anxiety and depression. CONCLUSION: VRT were effective in improving balance abnormalities in patients with PPPD evidenced by subjectively by DHI scores and objectively by SOT results. PPPD patients with concomitant psychiatric disorders; anxiety and depression experienced the least degree of improvement.

Efetividade da reabilitação vestibular no equilíbrio, tontura, funcionalidade e sintomas depressivos em idosos / Effectiveness of vestibular rehabilitation on balance, dizziness, functioning, and depressive symptoms in older adults

RESUMO Objetivo Avaliar a efetividade da reabilitação vestibular na funcionalidade, ganho dos canais semicirculares ao Video Head Impulse Test (v-HIT), nas respostas ao Potencial Evocado Miogênico Vestibular (VEMP), sintomas depressivos, equilíbrio e tontura em idosos. Métodos Estudo longitudinal, quase experimental e analítico, realizado entre dezembro de 2019 e julho de 2022, com 50 idosos com disfunção vestibular, submetidos à reabilitação vestibular e à aplicação dos exames VEMP, v-HIT, dos questionários e escalas Escala Visual Analógica, Dizziness Handicap Inventory e Escala de Equilíbrio de Berg, além do Questionário de Atividades Funcionais de Pfeffer e Escala de Depressão Geriátrica. Todos os exames e questionários foram aplicados antes e após oito sessões semanais de reabilitação vestibular. A análise estatística foi realizada pelo programa SPSS, por meio do teste Wilcoxon (p<0,05). Resultados Observou-se melhora do ganho do canal semicircular anterior direito (0,71/0,78), redução do incômodo da tontura (7/5), do impacto da tontura na qualidade de vida (35/15), melhora do equilíbrio (45/51), além de melhora da funcionalidade (2/1) e redução dos sintomas depressivos (5/3). Conclusão Idosos com disfunção vestibular submetidos à reabilitação vestibular apresentaram melhora do ganho do reflexo vestíbulo-ocular, do equilíbrio, da funcionalidade, redução do impacto da tontura na qualidade de vida e dos sintomas depressivos.

ABSTRACT Purpose To assess the effectiveness of vestibular rehabilitation on functioning, gains in semicircular canals in the Video Head Impulse Test (v-HIT), on responses to the vestibular evoked myogenic potentials (VEMP), depressive symptoms, balance, and dizziness in older adults. Methods Longitudinal, quasi-experimental, analytical study conducted between December 2019 and July 2022, in 50 older adults with vestibular disorders, submitted to vestibular rehabilitation and examinations: VEMP, v-HIT, the questionnaires, visual analog scale, Dizziness Handicap Inventory, Berg Balance Scale, Pfeffer's Functional Activities Questionnaire, and Geriatric Depression Scale. All examinations and questionnaires were applied before and after eight weekly vestibular rehabilitation sessions. Statistical analysis was performed in SPSS, with the Wilcoxon test (p<0.05). Results There was a gain in the anterior right semicircular canal (0.71/0.78), reduction in dizziness discomfort (7/5) and in the impact of dizziness on the quality of life (35/15), improvement in balance (45/51) and functioning (2/1), and reduction in depressive symptoms (5/3). Conclusion Older adults with vestibular disorder submitted to vestibular rehabilitation improved their gain in vestibulo-ocular reflex, balance, and functional activities and reduced their depressive symptoms and the impact of dizziness on their quality of life.

Terapia de rehabilitación vestibular en alteración mixta (central y periférica). Reporte de un caso / Vestibular rehabilitation therapy in mixed (central and peripheral) disorder. A case report

La terapia de rehabilitación vestibular es el tratamiento con mayor evidencia en la recuperación para la mayoría de los trastornos de equilibrio. En los casos que presentan una alteración estable del procesamiento central del equilibrio, o mixta, es decir, acompañada de una alteración a nivel del sistema nervioso periférico, la terapia de rehabilitación vestibular no se excluye como tratamiento. No obstante, los progresos suelen ser limitados y requieren de una mayor cantidad de sesiones. En este trabajo analizaremos un caso mixto, un paciente con síndrome de núcleo fastigial y el vértigo posicional paroxístico benigno (VPPB), desde la pesquisa y evaluación hasta el tratamiento y alta, en el Hospital Clínico Universidad de Chile.

Vestibular rehabilitation therapy is the treatment with the greatest evidence of recovery for most balance disorders. In the cases that have a loss of central balance processing, or mixed, that is, stable accompanied by a disorder of the peripheral nervous system the vestibular rehabilitation therapy is not excluded as a treatment; however, progress is usually limited and requires a greater number of sessions. In this work we will analyse a mixed case, a patient with nucleus fastigial syndrome and a benign paroxysmal positional vertigo, from the investigation and evaluation to the treatment and discharge, at the Hospital Clínico Universidad de Chile.

Habilidades cognitivas envolvidas na avaliação e reabilitação vestibular: revisão integrativa / Cognitive skills involved in vestibular assessment and rehabilitation: an integrative review / Habilidades cognitivas involucradas en la evaluación y rehabilitación vestibular: revisión integrativa

Introdução: a literatura relata a associação entre o desequilíbrio e o comprometimento cogntivo, porém não é clara sobre quais habilidades cognitivas estão envolvidas com o sistema vestibular. Objetivo: avaliar quais habilidades cognitivas então envolvidas na avaliação e reabilitação vestibular em indivíduos jovens adultos e idosos. Estratégia de pesquisa: trata-se de uma revisão integrativa de literatura realizada entre julho e outubro de 2020, os artigos foram selecionados por meio das principais bases de dados da saúde MEDLINE via PubMed, LILACS via Portal Regional da BVS; Cochrane, Scopus, Web of Science, e CINAHL acesso via Portal CAPES, utilizando os descritores "Cognition" OR "Cognitive Dysfunction" AND "Vestibular Function Tests" AND "Vertigo" AND "Vestibular Rehabilitation" e seus correlatos em português e espanhol. Critérios de seleção: Foram incluídos artigos publicados até 2020 que investigaram a cognição com avaliação e reabilitação vestibular (tradicional e/ou com tecnologias) em indivíduos acima de 18 anos. Foram excluídos artigos que não possuíam texto completo disponível ou que utilizaram outra forma de tratamento. Resultados: dos 6965 artigos resultantes da busca inicial, 16 foram incluídos na presente revisão por satisfazerem os critérios de inclusão. Destes, 12 são estudos transversais, e quatro, estudos longitudinais. Conclusão: observou-se relação entre disfunção vestibular uni e bilateral com a memória de trabalho, funções executivas, navegação espacial e atenção. Nos estudos que realizaram a reabilitação vestibular encontrou-se melhora das habilidades cognitivas em geral, capacidade visuoespacial, atenção, funções executivas, memória de trabalho espacial, aumento do ganho do reflexo vestíbulo-ocular, do controle postural e uma diminuição do sofrimento psicológico.

Introduction: The literature reports an association between imbalance and cognitive impairment. However, it is not yet clear which cognitive skills are involved with the vestibular system. Objective: To evaluate which cognitive skills are involved in vestibular assessment and rehabilitation in young and older adults. Research strategy: This is an integrative review of the literature, conducted between July and October 2020. The articles were selected through search in the main health databases - MEDLINE via PubMed, LILACS via Regional Portal of VHL, Cochrane, Scopus, Web of Science, and CINAHL, accessed via Portal CAPES, using the following descriptors "Cognition" OR "Cognitive Dysfunction" AND "Vestibular Function Tests" AND "Vertigo" AND "Vestibular Rehabilitation", and their equivalent terms in Portuguese and Spanish. Selection criteria: Articles published until 2020, investigating cognition with vestibular assessment or traditional and/or technology rehabilitation in subjects aged 18 years or older were included. Articles not available in full text or that used other types of treatment were excluded. Results: 16 out of the 6,965 articles initially retrieved met the inclusion criteria and were included in this review; 12 of them are cross-sectional, and four longitudinal studies. Conclusion: There was a relationship between uni- and bilateral vestibular dysfunction and working memory, executive functions, spatial navigation, and attention. The studies that conducted vestibular rehabilitation found improved overall cognitive skills, visuospatial capacity, attention, executive functions, spatial working memory, increased vestibulo-ocular reflex, postural control gains, and diminished psychological suffering.

Introducción: la literatura reporta la asociación entre desequilibrio y deterioro cognitivo, pero no está claro qué habilidades cognitivas están involucradas con el sistema vestibular. Objetivo: evaluar qué habilidades cognitivas están involucradas en la evaluación y rehabilitación vestibular en adultos jóvenes y ancianos. Estrategia de búsqueda: se trata de una revisión integradora de la literatura realizada entre julio y octubre de 2020, los artículos fueron seleccionados a través de las principales bases de datos en salud MEDLINE vía PubMed, LILACS vía Portal Regional BVS; Acceso a Cochrane, Scopus, Web of Science y CINAHL a través del Portal CAPES, utilizando los descriptores "Cognición" O "Disfunción cognitiva" Y "Pruebas de función vestibular" Y "Vértigo" Y "Rehabilitación vestibular" y sus correlatos en portugués y español. Criterios de selección: Se incluyeron artículos publicados hasta 2020 que investigaban la cognición con valoración vestibular y rehabilitación (tradicional y / o con tecnologías) en mayores de 18 años. Se excluyeron los artículos que no tenían el texto completo disponible o que usaban otra forma de tratamiento. Resultados: de los 6965 artículos resultantes de la búsqueda inicial, 16 se incluyeron en esta revisión por cumplir con los criterios de inclusión. De estos, 12 son estudios transversales y cuatro estudios longitudinales. Conclusión: hubo relación entre la disfunción vestibular uni y bilateral con la memoria de trabajo, funciones ejecutivas, navegación espacial y atención. En estudios que realizaron rehabilitación vestibular se encontró una mejora en las habilidades cognitivas en general, capacidad visuoespacial, atención, funciones ejecutivas, memoria de trabajo espacial, aumento de ganancia en el reflejo vestibular-ocular, control postural y una disminución del malestar psicológico.

Interface entre as medidas de benefício após a reabilitação vestibular - relato de casos / Interface between measures of benefit after vestibular rehabilitation - case report

RESUMO Esta pesquisa teve como objetivo caracterizar o efeito da reabilitação vestibular (RV) sobre o ganho do reflexo vestíbulo-ocular (RVO), a ocorrência das sacadas compensatórias, bem como sobre o equilíbrio corporal e a qualidade de vida, em três pacientes com hipofunção vestibular periférica. Trata-se de um estudo descritivo. Participaram da pesquisa três pacientes do gênero feminino, duas com 55 anos e uma com 67 anos, com diagnóstico médico de disfunção vestibular periférica. As participantes foram submetidas à anamnese, questionário Dizziness Handicap Inventory (DHI), avaliação clínica do equilíbrio corporal e ao Vídeo Teste do Impulso Cefálico (vHIT), pré e após RV. A RV foi aplicada de forma personalizada, baseada no protocolo de Cawthorne e Cooksey, associada a estímulos de realidade virtual. Após a RV, observou-se a redução da média do escore total do DHI, sugestivo da diminuição na restrição de participação. Na avaliação clínica do equilíbrio obtiveram-se resultados dentro da normalidade para as provas alteradas, pré RV. Quanto ao vHIT, constatou-se aumento do ganho do RVO para os canais semicirculares anteriormente afetados, condizente com padrões de normalidade, e extinção ou diminuição de ocorrência das sacadas compensatórias, nos três casos avaliados. O aumento do ganho do RVO e a extinção ou redução das sacadas compensatórias, após a RV, evidenciam sinais sugestivos de compensação vestibular. Esses resultados mostraram-se compatíveis com o aumento da estabilidade postural e menor restrição da qualidade de vida. Os achados, em conjunto, demonstram o benefício proporcionado pela RV nos três casos avaliados.

ABSTRACT The purpose of this research is to characterize the vestibular rehabilitation (VR), vestibulo-ocular reflex (VOR) gain, the occurrence of compensatory saccades, the static and dynamic balance, and the impact on quality of life in three patients with peripheral vestibular hypofunction. This is a descriptive study, approved by the ethics in research committee, under number 4,462.519. Three female patients participated in the study, two aged 55 and one aged 67, with a medical diagnosis of peripheral vestibular dysfunction. The participants underwent anamnesis, Dizziness Handicap Inventory (DHI) questionnaire, clinical assessment of postural balance and Video Head Impulse Test (vHIT), pre and post VR. The VR was applied in a personalized manner, based on the Cawthorne and Cooksey protocol, associated with virtual reality stimuli. After VR, a reduction in the total score average of DHI was observed, suggesting a decrease in participation restriction. The clinical balance assessment results were within the normal range for the altered tests, pre VR. In the three evaluated cases, vHIT showed increased RVO gain for the previously affected semicircular ducts (SCDs), compatible with normality standards, and reduction or extinction in the occurrence of compensatory saccades. The increase in VOR gain and the reduction or suppression of compensatory saccades after VR are suggestive signs of vestibular compensation. These results were compatible with increased postural stability and less restricted quality of life. These findings demonstrate the benefit provided by VR in the three evaluated cases.

Proposal for a body balance training program for children through an integrative literature review / Proposta de programa de treinamento do equilíbrio corporal para público infantil por meio de revisão integrativa da literatura

ABSTRACT Objective: to verify, in the literature, the proposals to rehabilitate the vestibular function, so as to propose a training program for body balance for children. Methods: this article sought studies that proposed to rehabilitate or train body balance in the Medical Literature Analysis and Retrieval System Online (MEDLINE/PubMed) and Scientific Electronic Library Online (SCIELO) databases, in addition to digital sources from Brazilian public universities. As descriptors, the terms "rehabilitation", "balance" and "child" were used, combined with the Boolean operator AND. The variables analyzed were: public submitted to the intervention, number of subjects and age group, number and frequency of sessions, number and/or time of execution of the exercise, duration of the session and the program. Results: 17 (60.74%) articles were Brazilian, 14 (50%) used the Cawthorne and Cooksey protocol, 9 (32.14%) studied children, and the majority (67.85%) organized the program in weeks. A body balance training program, stimulating the three body balance systems, consisting of 30-minute sessions twice a week for 7 weeks, totaling 14 sessions, was developed. Conclusion: the analysis of the variable related to the protocol/strategy to rehabilitate the vestibular function indicated that no study proposed the stimulation of the three body balance systems, with no standardization for children, adults and the elderly. A vestibular function rehabilitation program was developed for children, with stimulation of these three systems, expanding the therapeutic possibilities in this area.

RESUMO Objetivo: verificar, na literatura, as propostas para reabilitar a função vestibular e propor um programa de treinamento do equilíbrio corporal para o público infantil. Metodos: buscou-se estudos propondo reabilitar/treinar o equilíbrio corporal nas bases de dados MEDLINE/PubMed e SCIELO, além das fontes digitais de universidades públicas brasileiras. Descritores utilizados: rehabilitation, balance e child, combinando-os com o operador boleano AND. Analisou-se as variáveis: público submetido à intervenção, número de sujeitos e faixa etária, número e periodicidade das sessões, número e/ou tempo de execução do exercício, duração da sessão e do programa. Resultados: 17 eram brasileiros, 14 utilizaram o protocolo de Cawthorne e Cooksey, nove estudaram crianças, a maioria organizou o programa em semanas. Elaborou-se um programa de treinamento do equilíbrio corporal que estimula os três sistemas do equilíbrio corporal, constituido por sessões de 30 minutos duas vezes por semana, durante 7 semanas, totalizando 14 sessões. Conclusão: a análise da variável relativa ao protocolo/estratégia para reabilitar a função vestibular indicou que nenhum estudo propôs a estimulação dos três sistemas do equilíbrio corporal, não havendo padronização para os públicos infantil, adulto e idoso. Elaborou-se um programa de reabilitação da função vestibular para crianças, com estimulação destes três sistemas, ampliando as possibilidades terapêuticas.

Reflexiones sobre rehabilitación vestibular a propósito de un caso con uso de paradigma de tareas dobles / Insights on vestibular rehabilitation concerning one case with the use of dual task paradigm

Resumen Se presenta una reflexión producto de la introducción del paradigma de tareas dobles en el abordaje terapéutico en un caso de vestibulopatía unilateral periférica. Se aplicaron pautas de autovaloración de la discapacidad y riesgo de caídas, complementándose con una completa evaluación del equilibrio funcional y la marcha. Se planificó una terapia personalizada, jerarquizándose objetivos con un criterio funcional. Se incorporó el paradigma de tareas dobles, incluyéndose tareas cognitivas simples a la terapia tradicional de rehabilitación vestibular, con el fin de reducir la influencia cortical sobre la ejecución motora, potenciar la ganancia y funcionalidad de los reflejos remanentes, estimular funciones cognitivas superiores y potenciar procesos atencionales subyacentes, necesarios para lograr la compensación. Los resultados de la reevaluación mostraron una evolución favorable, con remisión de la sintomatología, disminución significativa de los puntajes obtenidos en las diferentes pautas empleadas y una mejoría subjetiva en el equilibrio y marcha funcional después de la terapia. Lo anterior se asoció a la recuperación de la autonomía e independencia para la ejecución de actividades diarias, incidiendo favorablemente en la calidad de vida de la paciente. Los hallazgos confirman los beneficios del programa de rehabilitación vestibular diseñado. Se requieren estudios adicionales, orientados a evidenciar y corroborar el impacto específico de la incorporación del paradigma de tareas dobles en la rehabilitación de los trastornos del equilibrio y especialmente, en procesos de estimulación o rehabilitación vestibular en adultos mayores.

Abstract This article presents the analysis and reflections evoked from an experience in vestibular rehabilitation with the introduction of the paradigm of dual task in a unilateral peripheral vestibulopathy case. First, disability self-assessment guidelines, risk of falls scales and assessment tools of functional balance and gait were applied in order to determine the main symptoms and the main difficulties observed. Afterwards, a personalized therapy was planned, in which work objectives were hierarchized based on a functional criterion, introducing "dual-task" strategies as tools for diminish cortical influence on motor performances, allowing the automation of the required task; enhance the gain and functionality of the remaining reflexes, especially vestibulo ocular and vestibulospinal reflex and stimulate superior cognitive functions and underlying attentional processes, necessary to achieve central compensation. The final assessment showed a favorable evolution, with a significant decrease in the after-therapy scores obtained in fear of falling and disability self-perception protocols, before and after therapy and, finally, an improvement in functional balance and gait, through the pre and post therapy performance in the timed up and go and assessment of unipedal stand tests. This allowed the patient to regain her autonomy and independence in daily life activities improving her quality of life, confirming the benefits of the designed vestibular rehabilitation program. However, more studies are needed to corroborate the specific contribution of the dual-task paradigm in vestibular rehabilitation and specially, in vestibular stimulation or rehabilitation processes in older adults.

Dosificación de tratamiento en terapia vestibular para lesiones vestibulares periféricas: una revisión / Treatment dosage in vestibular therapy for peripheral vestibular lesions: a review

La terapia vestibular ha mostrado una evolución constante hacia la práctica basada en evidencia principalmente en los últimos años, sin embargo, actualmente no existe consenso sobre la dosificación de tratamiento necesaria para generar resultados deseados en los usuarios. Por ello, el presente estudio pretende analizar la evidencia científica sobre la dosificación de tratamiento en la terapia vestibular para patologías vestibulares periféricas y su impacto en la práctica clínica. Se realizó una búsqueda bibliográfica en las bases de datos PubMed y Cochrane Library de acuerdo a términos claves. Los estudios incluidos fueron ensayos clínicos, revisiones sistemáticas y metaanálisis, publicados desde el año 2009 y realizado en seres humanos. Se encontraron 60 artículos relacionados con los términos claves utilizados, de los cuales 52 fueron eliminados por cumplir con los criterios de exclusión. Existe escasa literatura sobre la dosificación de tratamiento en terapia vestibular, demostrando formatos de aplicación muy disímiles. Resulta complejo establecer estándares para la dosis terapéutica producto de la heterogeneidad de las patologías vestibulares.

Recently, vestibular rehabilitation therapy has shown constant development towards evidence-based practice, however, at the present time, there is lack of consensus about treatment dosage needed to produce the desired results for the users. Therefore, the present study aimed to analyze scientific evidence relating to treatment dosage of vestibular rehabilitation therapy for peripheral vestibular pathologies, and its impact on clinical practice. We conducted a bibliographic search in PubMed, and Cochrane Library according to previously defined MeSH terms. Included studies were clinical trials, systematic revisions, and meta-analyses, that were published since 2009, and conducted with human participants. The initial search yielded 60 articles related to the MeSH terms chosen, from which 52 were eliminated according to exclusion criteria. There is a scarce number of scientific articles regarding treatment dosage, and also a heterogeneous application format. It is a complex task to establish standards regarding therapeutic doses, mainly due to the heterogeneity of vestibular pathologies.

Severe Dizziness Related to Postural Instability, Changes in Gait and Cognitive Skills in Patients with Chronic Peripheral Vestibulopathy

Abstract Introduction Peripheral vestibular disorders can lead to cognitive deficits and are more common in elderly patients. Objective To evaluate and correlate cognitive, balance and gait aspects in elderly women with chronic peripheral vestibular dizziness, and to compare them with elderly women without vestibular disorders. Methods Twenty-two women presenting peripheral vestibular dizziness episodes for at least six months participated in the study. The individuals were categorized by dizziness severity level: moderate (n = 11) or severe (n = 11). The control group (n = 11) included women showing no vestibulopathy, light-headedness or dizziness. Cognitive assessments and semi-static and dynamic balance assessments were performed with the Balance Master (Neurocom International, Inc., Clackamas, OR), while the Dizziness Handicap Inventory provided a score for the severity of the symptoms. The groups were submitted to statistics of inference and correlation between cognitive, balance and stability variables. Results The group with severe dizziness showed higher sway speed of the center of pressure in the anteroposterior direction, smaller step length, and slower gait than the control group. Regarding the cognitive variables, the group with severe dizziness symptoms presented significant correlations with stability and gait variables. Conclusion The relationship between cognitive aspects, balance and gait was stronger in women with severe dizziness than in those with no vestibulopathy.

Guía de rehabilitación vestibular / Vestibular Rehabilitation Guide

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