Auditory brainstem function in women with vestibular migraine: a controlled study.

BACKGROUND: Vestibular migraine (VM) has been recognized as a diagnostic entity over the past three decades. It affects up to 1% of the general population and 7% of patients seen in dizziness clinics. It is still underdiagnosed; consequently, it is important to conduct clinical studies that address diagnostic indicators of VM. The aim of this study was to assess auditory brainstem function in women with vestibular migraine using electrophysiological testing, contralateral acoustic reflex and loudness discomfort level. METHODS: The study group consisted of 29 women with vestibular migraine in the interictal period, and the control group comprised 25 healthy women. Auditory brainstem response, frequency following response, binaural interaction component and assessment of contralateral efferent suppression were performed. The threshold of loudness discomfort and the contralateral acoustic reflex were also investigated. The results were compared between the groups. RESULTS: There was a statistically significant difference between the groups in the frequency following response and the loudness discomfort level. CONCLUSIONS: The current study suggested that temporal auditory processing and loudness discomfort levels are altered in VM patients during the interictal period, indicating that these measures may be useful as diagnostic criteria.

Comparative Postural Control in COPD Patients and Healthy Individuals During Dynamic and Static Activities.

PURPOSE: Patients with chronic obstructive pulmonary disease (COPD) have body balance deficits, with consequent fall risk. It is possible that body sway in patients with COPD affects their ability to perform daily activities. The purpose of this study was to determine whether body balance is similar in patients with COPD and healthy persons when performing static and dynamic activities. In addition, we wanted to assess whether impairment of balance is related to the presence of falls in patients with COPD. METHODS: This is a cross-sectional study, in which every spirometric classification in patients with COPD (mild, moderate, severe, and very severe degrees) and age-matched healthy subjects was assessed. Subjects who were current smokers and patients who underwent physical training in the last 6 months prior to the start of the study were excluded. Static balance was assessed by computerized posturography and dynamic body balance using the Berg Balance Scale. RESULTS: Ninety-three patients with COPD and 39 healthy persons were evaluated. Mean age was 67.3 (10.8) and 65.1 (9.7) years and mean forced expiratory volume in 1 second (FEV1) was 50.4 (19.0) and 89.2 (23.6) for patients with COPD and healthy individuals, respectively. The impairment of body balance was higher for the group of patients with COPD (P = .0005). Patients with greater impairment in body balance had greater incidence of falls, and body balance was more affected with age in patients with COPD than in healthy persons. CONCLUSION: Impairment of body balance is more frequent in patients with COPD than in healthy persons while performing dynamic activities, and a greater incidence of falls activities was also found for this group.

Challenges in conducting a randomized clinical trial of older people with chronic dizziness: before, during and after vestibular rehabilitation.

PURPOSE: This study aims to describe the process of conducting a randomized clinical trial of elderly with chronic dizziness subjected to vestibular rehabilitation (VR) and to verify its effectiveness on dizziness intensity. METHODS: Older adults (≥65 years) with chronic dizziness from vestibular disorders referred to VR were enrolled to the trial. The control group (n=40) was submitted to the Cawthorne & Cooksey protocol and the experimental group (n=42) to the modified Cawthorne & Cooksey protocol which included multiple components. Protocols were performed during individual 50-minute sessions, twice-weekly, for eight weeks. Main measures were: recruitment data (refusal and eligibility), baseline characteristics, dropout rate, session attendance, protocol adherence, adverse effects, exercise adaptation and follow-up events. The Visual Analog Scale (VAS) was used to measure dizziness intensity. RESULTS: 144 elderly were referred to VR, 26.4% declined to participate and 16.7% were ineligible. There were 51 session non-attendances, with disease being the most frequent reason. Regardless of VR protocol, VAS dizziness intensity diminished along sessions (p<0.001). 88.6% of the participants reported improvement after treatment, and 22.9% mentioned an increase in dizziness on follow-up. Home exercises were no longer being performed by 21.4% of the subjects after 3 months from discharge. The final dropout rate was 14.6%. There were no differences between VR protocols on recruitment, dropout, session's attendance, adherence to protocol and treatment effects. CONCLUSIONS: Our results revealed many challenges in conducting a rehabilitation trial with an elderly sample. The VR protocols showed to be feasible and suitable to reduce dizziness in older adults.

Evaluation of properties of the Vestibular Disorders Activities of Daily Living Scale (Brazilian version) in an elderly population

Background: The Vestibular Disorders Activities of Daily Living Scale (VADL) is considered an important subjective assessment to evaluate patients suffering from dizziness and imbalance. Although frequently used, its metric characteristics still require further investigation. Objective: This paper aims to analyze the psychometric properties of the Brazilian version of the VADL in an elderly population. Method: The sample comprises patients (≥65 years old) with chronic dizziness resulting from vestibular disorders. For discriminant analysis, patients were compared to healthy subjects. All subjects answered the VADL-Brazil by interview. To examine the VADL validity, patients filled out the Dizziness Handicap Inventory (DHI) and the ABC scale and were tested on the Dynamic Gait Index (DGI). To evaluate the VADL responsiveness, 20 patients were submitted to rehabilitation. Results: Patients (n=140) had a VADL total score of 4.1±1.6 points. Healthy subjects scored significantly less than patients in all the subscales and in the VADL total score. The VADL-Brazil was weakly correlated with the DHI and moderately to the ABC scale and the DGI. Instead of the original 3 subscales, factor analysis resulted in 6 factors. The VADL was capable of detecting changes after rehabilitation, which means that the instrument has responsiveness. Conclusions: This study provided more data about the psychometric properties and usefulness of the VADL-Brazil. The use of such a reliable and valid instrument increases the knowledge about disability in patients with vestibular disorders. .

Evaluation of properties of the Vestibular Disorders Activities of Daily Living Scale (Brazilian version) in an elderly population.

BACKGROUND: The Vestibular Disorders Activities of Daily Living Scale (VADL) is considered an important subjective assessment to evaluate patients suffering from dizziness and imbalance. Although frequently used, its metric characteristics still require further investigation. OBJECTIVE: This paper aims to analyze the psychometric properties of the Brazilian version of the VADL in an elderly population. METHOD: The sample comprises patients (≥ 65 years old) with chronic dizziness resulting from vestibular disorders. For discriminant analysis, patients were compared to healthy subjects. All subjects answered the VADL-Brazil by interview. To examine the VADL validity, patients filled out the Dizziness Handicap Inventory (DHI) and the ABC scale and were tested on the Dynamic Gait Index (DGI). To evaluate the VADL responsiveness, 20 patients were submitted to rehabilitation. RESULTS: Patients (n=140) had a VADL total score of 4.1 ± 1.6 points. Healthy subjects scored significantly less than patients in all the subscales and in the VADL total score. The VADL-Brazil was weakly correlated with the DHI and moderately to the ABC scale and the DGI. Instead of the original 3 subscales, factor analysis resulted in 6 factors. The VADL was capable of detecting changes after rehabilitation, which means that the instrument has responsiveness. CONCLUSIONS: This study provided more data about the psychometric properties and usefulness of the VADL-Brazil. The use of such a reliable and valid instrument increases the knowledge about disability in patients with vestibular disorders.

A multicenter observational study on the role of comorbidities in the recurrent episodes of benign paroxysmal positional vertigo.

OBJECTIVE: Primary objective of this study was to find a statistical link between the most worldwide comorbidities affecting the elderly population (hypertension, diabetes, osteoarthrosis, osteoporosis and depression) and recurrent episodes of BPPV. Secondary objective was defining possible "groups of risk" for people suffering recurrent positional vertigo related to the presence of a well documented comorbidity. METHODS: This was an observational, cross-sectional, multicenter, spontaneous, non-pharmacological study. The data of 1092 patients suffering BPPV evaluated in 11 different Departments of Otolaryngology, Otoneurology and Neurology, referring Centers for positional vertigo evaluation, were retrospectively collected. RESULTS: Regarding evaluated comorbidities (hypertension, diabetes, osteoarthrosis, osteoporosis and depression), data analysis showed the presence of at least one comorbid disorder in 216 subjects (19.8%) and 2 or more in 408 subjects (37.4%). Moreover there was a statistical significant difference between the number of comorbidities and the number of recurrences, otherwise said as comorbidity disorders increased the number of relapses increased too. CONCLUSION: The presence of a systemic disease may worsen the status of the posterior labyrinth causing a more frequent otolith detachment. This condition increases the risk for patients suffering BPPV to have recurrent episodes, even if correctly managed by repositioning maneuvers. The combination of two or more of aforementioned comorbidities further increases the risk of relapsing BPPV, worsened by the presence of osteoporosis. On the basis of this results it was possible to define "groups of risk" useful for predicting BPPV recurrence in patients with one or more comorbidity.

A systematic review about the effects of the vestibular rehabilitation in middle-age and older adults.

OBJECTIVE: to summarize the results of clinical trials on vestibular rehabilitation (VR) in middle-aged and elderly people with vestibular disorders. METHODS: a search for relevant trials was performed in the databases LILACS, EMBASE, MEDLINE, SciELO, Cochrane, ISI Web of Knowledge and virtual libraries of theses and dissertations. Randomized controlled trials published in the last 10 years and written in English, Portuguese or Spanish were included. The methodological quality of the studies was assessed by the PEDro scale. Results from the included studies were analyzed through a critical review of content. RESULTS: nine studies were included in the review. Four studies reported on participants aged over 40 years (middle-aged and elderly) and five studies consisted exclusively of elderly subjects (over 60 years). Findings of vestibular dysfunction were diverse and the most common complaints were body imbalance or postural instability (3 studies), and vertigo or dizziness (3 studies). The Visual Analogue Scale (VAS) was the most commonly used instrument to assess subjective perception of symptoms of vestibular dysfunction (4 studies). According to the PEDro scale, four studies were considered to be of good quality. The most common experimental intervention was the Cawthorne & Cooksey protocol (4 studies). For most outcome measures, the studies comparing VR with another type of intervention showed no differences between the groups after the therapy. CONCLUSIONS: the studies included in this review provide evidence for the positive effects of VR in elderly and middle-aged adults with vestibular disturbances.

Head and shoulder alignment among patients with unilateral vestibular hypofunction.

OBJECTIVES: To investigate head and shoulder alignment among patients with unilateral vestibular hypofunction (UVH), using computerized biophotogrammetry (CB) and to correlate these measurements with gender, age, duration of clinical evolution, self-perception of intensity of dizziness and occurrences of falls. METHODS: This was a cross-sectional study. Thirty individuals with UVH and 30 with normal vestibular function and without complaints of dizziness underwent CB in the anterior, right and left and posterior views, in an upright standing position. Alcimage™ 2.0 was used to evaluate three angles in order to verify the anterior deviation and inclination of the head, and the alignment of the shoulders. The groups were paired according to age, gender and height. The statistical analysis consisted of the Mann-Whitney test, Kruskal-Wallis test followed by the Dunn test, and the Spearman Correlation Coefficient. RESULTS: The patients with UVH had greater forward (55.44 ± 16.33) and lateral (2.03 ± 1.37) head deviation angles than did the normal individuals (34.34 ± 4.60 and 1.34 ± 1.05 respectively), with a statistically significant difference (p<0.001). The increment of forward and lateral deviation in the UVH group was 38.05% and 33.78% respectively. Forward head was associated with the duration of clinical symptoms of the vestibular disease (p=0.003), age (p=0.006), intensity of dizziness (p<0.001) and occurrence of falls (p=0.002). CONCLUSIONS: Patients with UVH had greater forward and lateral head deviations. Forward head deviation increased with age, duration of clinical symptoms and greater self-perception of the intensity of dizziness. Forward head deviation was also greater among patients who reported having had falls.

Revisão sistemática sobre os efeitos da reabilitação vestibular em adultos de meia-idade e idosos / A systematic review about the effects of the vestibular rehabilitation in middle-age and older adults

OBJETIVO: Sistematizar os resultados de ensaios clínicos sobre reabilitação vestibular (RV) em indivíduos de meia-idade e idosos com distúrbios vestibulares. MÉTODOS: A busca de publicações sobre a RV em indivíduos com distúrbios vestibulares foi realizada nas bases de dados LILACS, EMBASE, MEDLINE, SciELO, Cochrane, ISI Web of Knowledge e bibliotecas virtuais de teses e dissertações. Foram selecionados ensaios clínicos aleatórios e controlados dos últimos 10 anos em língua inglesa, portuguesa e espanhola. A qualidade metodológica dos estudos foi avaliada pela escala PEDro. A análise dos resultados dos estudos foi feita por meio de revisão crítica dos conteúdos. RESULTADOS: Nove estudos foram revisados na íntegra, sendo a faixa etária dos participantes acima de 40 anos (n=4) e composta exclusivamente por idosos (n=5). Os achados de disfunção vestibular foram diversificados, sendo os mais comuns queixa de desequilíbrio corporal ou instabilidade postural (n=3) e queixa de vertigem ou tontura (n=3). A Escala Visual Analógica (EVA) foi o instrumento mais utilizado para avaliar a percepção subjetiva da sintomatologia da disfunção vestibular (n=4). A escala PEDro revelou que quatro dos artigos apresentaram delineamento de boa qualidade para a condução do estudo experimental. A proposta de intervenção mais utilizada foi o protocolo de Cawthorne & Cooksey (n=4). Os estudos que compararam a RV com outro tipo de intervenção não apresentaram, na maioria dos desfechos analisados, diferença entre os grupos após a terapia. CONCLUSÃO: Estudos aleatorizados controlados disponibilizaram evidências de efeitos positivos da RV em idosos e adultos de meia-idade com distúrbios vestibulares.

OBJECTIVE: To summarize the results of clinical trials on vestibular rehabilitation (VR) in middle-aged and elderly people with vestibular disorders. METHODS: A search for relevant trials was performed in the databases LILACS, EMBASE, MEDLINE, SciELO, Cochrane, ISI Web of Knowledge and virtual libraries of theses and dissertations. Randomized controlled trials published in the last 10 years and written in English, Portuguese or Spanish were included. The methodological quality of the studies was assessed by the PEDro scale. Results from the included studies were analyzed through a critical review of content. RESULTS: Nine studies were included in the review. Four studies reported on participants aged over 40 years (middle-aged and elderly) and five studies consisted exclusively of elderly subjects (over 60 years). Findings of vestibular dysfunction were diverse and the most common complaints were body imbalance or postural instability (3 studies), and vertigo or dizziness (3 studies). The Visual Analogue Scale (VAS) was the most commonly used instrument to assess subjective perception of symptoms of vestibular dysfunction (4 studies). According to the PEDro scale, four studies were considered to be of good quality. The most common experimental intervention was the Cawthorne & Cooksey protocol (4 studies). For most outcome measures, the studies comparing VR with another type of intervention showed no differences between the groups after the therapy. CONCLUSIONS: The studies included in this review provide evidence for the positive effects of VR in elderly and middle-aged adults with vestibular disturbances.

Alinhamento de cabeça e ombros em pacientes com hipofunção vestibular unilateral / Head and shoulder alignment among patients with unilateral vestibular hypofunction

OBJETIVOS: Avaliar o alinhamento de cabeça e ombros de pacientes com hipofunção vestibular unilateral (HVU) por meio da biofotogrametria computadorizada e associar esses dados com gênero, idade, tempo de evolução clínica, autopercepção da intensidade de tontura e ocorrência de quedas. MÉTODOS: Trata-se de estudo transversal em que 30 indivíduos com HVU e 30 indivíduos com função vestibular normal e sem queixa de tontura foram submetidos à biofotogrametria computadorizada. Foram registradas imagens em vistas anterior, posterior, laterais direita e esquerda em ortostatismo. O programa Alcimage® 2.0 foi usado para avaliar três ângulos que permitem verificar anteriorização e inclinação da cabeça e alinhamento dos ombros. Os grupos foram pareados por idade, gênero e estatura. Para a análise estatística, realizaram-se os testes de Mann-Whitney, Kruskal-Wallis, seguidos do teste de Dunn e Coeficiente de Correlação de Spearman. RESULTADOS: Pacientes com HVU apresentam maiores valores para os ângulos de anteriorização (55,44±16,33) e de inclinação lateral da cabeça (2,03±1,37) quando comparados aos indivíduos normais (34,3±44,60 e 1,34±1,05, respectivamente), com diferença estatisticamente significante (p<0,001). O aumento da anteriorização e da inclinação lateral da cabeça do grupo de indivíduos com HVU foi de 38,05 por cento e 33,78 por cento respectivamente. A anteriorização da cabeça foi associada com o tempo de evolução clínica da doença vestibular (p=0,003) com a idade (p=0,006), com a intensidade da tontura (p<0,001) e com a ocorrência de quedas (p=0,002). CONCLUSÃO: Pacientes com HVU apresentam maior anteriorização e inclinação lateral da cabeça. A anteriorização da cabeça aumenta com a idade, com o tempo de evolução clínica, maior auto-percepção da intensidade da tontura e nos pacientes que relataram quedas.

OBJECTIVES: To investigate head and shoulder alignment among patients with unilateral vestibular hypofunction (UVH), using computerized biophotogrammetry (CB) and to correlate these measurements with gender, age, duration of clinical evolution, self-perception of intensity of dizziness and occurrences of falls. METHODS: This was a cross-sectional study. Thirty individuals with UVH and 30 with normal vestibular function and without complaints of dizziness underwent CB in the anterior, right and left and posterior views, in an upright standing position. AlcimageTM 2.0 was used to evaluate three angles in order to verify the anterior deviation and inclination of the head, and the alignment of the shoulders. The groups were paired according to age, gender and height. The statistical analysis consisted of the Mann-Whitney test, Kruskal-Wallis test followed by the Dunn test, and the Spearman Correlation Coefficient. RESULTS: The patients with UVH had greater forward (55.44±16.33) and lateral (2.03±1.37) head deviation angles than did the normal individuals (34.34±4.60 and 1.34±1.05 respectively), with a statistically significant difference (p<0.001). The increment of forward and lateral deviation in the UVH group was 38.05 percent and 33.78 percent respectively. Forward head was associated with the duration of clinical symptoms of the vestibular disease (p=0.003), age (p=0.006), intensity of dizziness (p<0.001) and occurrence of falls (p=0.002). CONCLUSIONS: Patients with UVH had greater forward and lateral head deviations. Forward head deviation increased with age, duration of clinical symptoms and greater self-perception of the intensity of dizziness. Forward head deviation was also greater among patients who reported having had falls.

Interferência da tontura na qualidade de vida de pacientes com síndrome vestibular periférica / Impact of dizziness on the quality of life in patients with peripheral vestibular dysfunction

A tontura é considerada um dos sintomas mais comuns entre adultos, podendo interferir na qualidade de vida dos pacientes que apresentam este sintoma. OBJETIVOS: Descrever os resultados obtidos à aplicação do DHI brasileiro na população estudada e compará-los com a conclusão do exame vestibular dos respectivos pacientes. FORMA DE ESTUDO: Clínico randomizado. MATERIAL E MÉTODO: Vinte e cinco pacientes consecutivos que procuraram o Ambulatório da Disciplina de Otoneurologia da UNIFESP/EPM com queixa de tontura e hipótese diagnóstica de síndrome vestibular periférica submeteram-se ao questionário DHI brasileiro. Estes pacientes, adultos de ambos os sexos apresentaram idade variando entre 44 e 88 anos. Os resultados obtidos à aplicação do DHI foram comparados aos resultados do exame vestibular dos respectivos sujeitos. RESULTADOS: Os pacientes avaliados apresentaram prejuízo na qualidade de vida devido à tontura, principalmente nos aspectos funcionais avaliados pelo DHI brasileiro. Os aspectos funcionais apresentaram-se mais comprometidos nos pacientes com Síndrome Vestibular Periférica Deficitária (SVPD), independente do acometimento vestibular uni ou bilateral, e estas diferenças foram estatisticamente significantes. CONCLUSÕES: Os pacientes com tontura crônica apresentam prejuízo na qualidade de vida, em relação aos aspectos físicos, funcionais e emocionais verificados à aplicação do DHI brasileiro. Os pacientes com SVPD apresentam maior prejuízo na qualidade de vida nos aspectos funcionais à aplicação do DHI brasileiro, em relação aos pacientes com Síndrome Vestibular Periférica Irritativa.

Comparaçäo entre a levofloxacina oral e a associaçäo de amoxicilina e clavulanato de potássio no tratamento da sinusite bacteriana aguda em adultos / A comparison of oral levofloxacin and amoxicillin clavulanate for the treatment of acute bacterial sinusitis in adults

Os autores apresentam um estudo multicêntrico, aberto, randomizado para comparar a eficácia e tolerabilidade da Levofloxacina oral à associação de Amoxicilina e Clavulanato de potássio no tratamento de sinusite bacteriana aguda em adultos. A Levofloxacina foi administrada na dose de 500 mg 1 vez ao dia, enquanto a associação Amoxicilina (500mg)/Clavulanato de potássio (125 mg) foi administrada 3 vezes ao dia, ambos tratamentos com duração de 14 dias. Foram avaliados os sintomas dor facial, rinorréia purulenta e obstrução nasal e também os sinais hiperemia, edema, secreção purulenta e dor a palpação dos seios paranasais. Os pacientes foram avaliados na admissão, com 3 a 6 dias de tratamento, 2 a 5 dias pós terapia e com 28 a 32 dias após o término da terapia. Foram classificados de acordo com a eficácia do tratamento em curados, melhorados, com falha terapêutica ou incapazes de serem avaliados. Foram também submetidos a questionários para verificação da aceitação da medicação. Ao fim do estudo, os autores classificaram a eficácia e a tolerabilidade como boas em ambos os grupos de medicamentos, não havendo diferença estatisticamente significante entre os mesmos. Concluindo, a Levofloxacina oral mostrou-se tão eficaz e com boa tolerabilidade quanto a associação Amoxicilina/Clavulanato de potássio para o tratamento da sinusite bacteriana aguda em adultos.