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1.
Emerg Med Clin North Am ; 38(2): 523-537, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32336338

RESUMO

A careful history and thorough physical examination are necessary in patients presenting with acute neurologic dysfunction. Patients presenting with headache should be screened for red-flag criteria that suggest a dangerous secondary cause warranting imaging and further diagnostic workup. Dizziness is a vague complaint; focusing on timing, triggers, and examination findings can help reduce diagnostic error. Most patients presenting with back pain do not require emergent imaging, but those with new neurologic deficits or signs/symptoms concerning for acute infection or cord compression warrant MRI. Delay to diagnosis and treatment of acute ischemic stroke is a frequent reason for medical malpractice claims.


Assuntos
Serviço Hospitalar de Emergência , Doenças do Sistema Nervoso/diagnóstico , Dor nas Costas/diagnóstico , Dor nas Costas/etiologia , Dor nas Costas/terapia , Tontura/diagnóstico , Tontura/etiologia , Tontura/terapia , Cefaleia/diagnóstico , Cefaleia/etiologia , Cefaleia/terapia , Humanos , Imperícia , Doenças do Sistema Nervoso/terapia , Gestão de Riscos , Convulsões/diagnóstico , Convulsões/etiologia , Convulsões/terapia
2.
Ann Emerg Med ; 75(4): 459-470, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31866170

RESUMO

STUDY OBJECTIVE: We evaluated a strategy to increase use of the test (Dix-Hallpike's test [DHT]) and treatment (canalith repositioning maneuver [CRM]) for benign paroxysmal positional vertigo in emergency department (ED) dizziness visits. METHODS: We conducted a stepped-wedge randomized trial in 6 EDs. The population was visits with dizziness as a principal reason for the visit. The intervention included educational sessions and decision aid materials. Outcomes were DHT or CRM documentation (primary), head computed tomography (CT) use, length of stay, admission, and 90-day stroke events. The analysis was multilevel logistic regression with intervention, month, and hospital as fixed effects and provider as a random effect. We assessed fidelity with monitoring intervention use and semistructured interviews. RESULTS: We identified 7,635 dizziness visits during 18 months. The DHT or CRM was documented in 1.5% of control visits (45/3,077; 95% confidence interval 1% to 1.9%) and 3.5% of intervention visits (159/4,558; 95% confidence interval 3% to 4%; difference 2%, 95% confidence interval 1.3% to 2.7%). Head CT use was lower in intervention visits compared with control visits (44.0% [1,352/3,077] versus 36.9% [1,682/4,558]). No differences were observed in admission or 90-day subsequent stroke risk. In fidelity evaluations, providers who used the materials typically reported positive clinical experiences but provider engagement was low at facilities without an emergency medicine residency program. CONCLUSION: These findings provide evidence that an implementation strategy of a benign paroxysmal positional vertigo-focused approach to ED dizziness visits can be successful and safe in promoting evidence-based care. Absolute rates of DHT and CRM use, however, were still low, which relates in part to our broad inclusion criteria for dizziness visits.


Assuntos
Vertigem Posicional Paroxística Benigna/diagnóstico , Vertigem Posicional Paroxística Benigna/terapia , Serviço Hospitalar de Emergência , Prática Clínica Baseada em Evidências , Posicionamento do Paciente , Adulto , Vertigem Posicional Paroxística Benigna/diagnóstico por imagem , Tontura/etiologia , Tontura/terapia , Feminino , Fidelidade a Diretrizes , Humanos , Incidência , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Posicionamento do Paciente/efeitos adversos , Posicionamento do Paciente/métodos , Modelos de Riscos Proporcionais , Acidente Vascular Cerebral/epidemiologia
3.
Artigo em Russo | MEDLINE | ID: mdl-31793549

RESUMO

The review of domestic and foreign literature was conducted to identify the current terminology, diagnostic criteria, mechanisms of ethiopathogenesis, and the methods of treatment of psychogenic vertigo. The article covers the questions of combined approach to treatment, including vestibular rehabilitation combined with cognitive behavioral therapy.


Assuntos
Tontura , Transtornos Psicofisiológicos , Vertigem , Terapia Cognitivo-Comportamental , Tontura/psicologia , Tontura/terapia , Humanos , Transtornos Psicofisiológicos/terapia , Vertigem/psicologia , Vertigem/terapia
4.
Chiropr Man Therap ; 27: 65, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31867101

RESUMO

Background: Neck pain is a leading cause of individual and societal burden worldwide, affecting an estimated 1 in 5 people aged 70 years and older. The nature and outcomes of chiropractic care for older adults with neck pain, particularly those with co-morbid headaches, remains poorly understood. Therefore, we sought to ascertain: What proportion of Australian chiropractors' caseload comprises older adults with neck pain (with or without headache); How are these conditions treated; What are the reported outcomes? Methods: An online survey examining practitioner and practice characteristics, clinical patient presentations, chiropractic treatment methods and outcomes, and other health service use, was distributed to a random nationally representative sample of 800 Australian chiropractors. Quantitative methods were used to analyze the data. Results: Two hundred eighty-eight chiropractors (response rate = 36%) completed the survey between August and November 2017. Approximately one-third (M 28.5%, SD 14.2) of the chiropractors' patients were older adults (i.e. aged ≥65 years), of which 45.5% (SD 20.6) presented with neck pain and 31.3% (SD 20.3) had co-morbid headache. Chiropractors reported to combine a range of physical and manual therapy treatments, exercises and self-management practices in their care of these patients particularly: manipulation of the thoracic spine (82.0%); activator adjustment of the neck (77.3%); and massage of the neck (76.5%). The average number of visits required to resolve headache symptoms was reported to be highest among those with migraine (M 11.2, SD 8.8). The majority of chiropractors (57.3%) reported a moderate response to treatment in reported dizziness amongst older adults with neck pain. Approximately 82% of older adult patients were estimated to use at least one other health service concurrently to chiropractic care to manage their neck pain. Conclusion: This is the first known study to investigate chiropractic care of older adults living with neck pain. Chiropractors report using well-established conservative techniques to manage neck pain in older adults. Our findings also indicate that this target group of patients may frequently integrate chiropractic care with other health services in order to manage their neck pain. Further research should provide in-depth investigation of older patients' experience and other patient-reported outcomes of chiropractic treatment.


Assuntos
Quiroprática , Tontura/terapia , Cefaleia/terapia , Manipulação da Coluna , Cervicalgia/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Austrália , Feminino , Pessoal de Saúde/psicologia , Humanos , Masculino , Pessoa de Meia-Idade , Autorrelato , Inquéritos e Questionários , Resultado do Tratamento
5.
Medicine (Baltimore) ; 98(48): e18130, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31770245

RESUMO

BACKGROUND: Almost 40% of individuals with chronic whiplash-associated disorders (WAD) report headache after 5 years, making it one of the most common persistent symptoms besides neck pain, but randomized treatment studies are lacking. This study aimed to evaluate the effect of 3 different exercise approaches on headache in chronic WAD grades 2 and 3, and to identify potential factors associated with such headache, and whether they differ depending on 3 different aspects of such headache (current headache, maximum headache, or headache bothersomeness). METHODS: This was an analysis of a randomized clinical trial of people with chronic WAD and headache (n = 188), who were randomized to either 12 weeks of neck-specific exercise without (NSE) or with a behavioral approach (NSEB) or physical activity prescription (PPA). Data were collected at baseline and at 3, 6, and 12 months. Physical and psychosocial factors were tested for association with headache. Multivariate regression models and linear mixed models were used. RESULTS: The NSE/NSEB groups reported reduced headache both over time and compared to PPA. Up to 51% (NSE) and 61% (NSEB) reported at least 50% reduction in their headache at 12 months. The PPA group was not improved over time. Neck pain and dizziness were associated with headache regardless of aspect of headache. The only associated psychosocial factor was anxiety, which was associated with headache bothersomeness. Other factors were mainly physical, and up to 51% of the variance was explained. CONCLUSION: Headache in chronic WAD, may be reduced with neck-specific exercise with or without a behavioral approach. Chronic headache was associated with neck pain and dizziness regardless of aspect tested. Other factors associated with headache in chronic WAD were mainly physical rather than psychosocial. TRIAL REGISTRATION NUMBER: Clinical Trials.gov, no: NCT015285.


Assuntos
Terapia Comportamental/métodos , Terapia por Exercício/métodos , Cefaleia/terapia , Cervicalgia/terapia , Traumatismos em Chicotada/terapia , Adulto , Ansiedade/etiologia , Ansiedade/terapia , Doença Crônica , Terapia Combinada , Tontura/etiologia , Tontura/terapia , Exercício Físico , Feminino , Cefaleia/etiologia , Cefaleia/psicologia , Humanos , Masculino , Pessoa de Meia-Idade , Cervicalgia/etiologia , Cervicalgia/psicologia , Análise de Regressão , Resultado do Tratamento , Traumatismos em Chicotada/complicações , Traumatismos em Chicotada/psicologia
6.
Trials ; 20(1): 575, 2019 Oct 07.
Artigo em Inglês | MEDLINE | ID: mdl-31590692

RESUMO

BACKGROUND: Dizziness is a common complaint, and the symptom often persists, together with additional complaints. A treatment combining Vestibular Rehabilitation (VR) and Cognitive Behaviour Therapy (CBT) is suggested. However, further research is necessary to evaluate the efficacy of such an intervention. The objective of this paper is to present the design of a randomised controlled trial aiming at evaluating the efficacy of an integrated treatment of VR and CBT on dizziness, physical function, psychological complaints and quality of life in persons with persistent dizziness. METHODS/DESIGN: The randomised controlled trial is an assessor-blinded, block-randomised, parallel-group design, with a 6- and 12-month follow-up. The study includes 125 participants from Bergen (Norway) and surrounding areas. Included participants present with persistent dizziness lasting for at least 3 months, triggered or exacerbated by movement. All participants receive a one-session treatment (Brief Intervention Vestibular Rehabilitation; BI-VR) with VR before being randomised into a control group or an intervention group. The intervention group will further be offered an eight-session treatment integrating VR and CBT. The primary outcomes in the study are the Dizziness Handicap Inventory and preferred gait velocity. DISCUSSION: Previous studies combining these treatments have been of varying methodological quality, with small samples, and long-term effects have not been maintained. In addition, only the CBT has been administered in supervised sessions, with VR offered as home exercises. The current study focusses on the integrated treatment, a sufficiently powered sample size, and a standardised treatment programme evaluated by validated outcomes using a standardised assessment protocol. TRIAL REGISTRATION: www.clinicaltrials.gov, ID: NCT02655575 . Registered on 14 January 2016.


Assuntos
Terapia Cognitivo-Comportamental , Tontura/terapia , Modalidades de Fisioterapia , Atenção Primária à Saúde , Vestíbulo do Labirinto/fisiopatologia , Adolescente , Adulto , Idoso , Terapia Combinada , Tontura/diagnóstico , Tontura/fisiopatologia , Tontura/psicologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Noruega , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
7.
Neurol Clin ; 37(4): 695-706, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31563227

RESUMO

The term vestibular migraine designates recurrent vertigo that is caused by migraine. Vestibular migraine presents with episodes of spontaneous or positional vertigo lasting seconds to days that are accompanied by migraine symptoms. Because headache is often absent during acute attacks, other migraine features have to be identified by thorough history taking. In contrast, vestibular testing serves mainly for the exclusion of other diagnoses. Treatment still lacks solid evidence. It is targeted at the underlying migraine and comprises explanation and reassurance, lifestyle modifications, and drugs.


Assuntos
Transtornos de Enxaqueca/diagnóstico , Transtornos de Enxaqueca/terapia , Doenças Vestibulares/diagnóstico , Doenças Vestibulares/terapia , Tontura/diagnóstico , Tontura/terapia , Humanos , Vertigem/diagnóstico , Vertigem/terapia
8.
J Neurol ; 266(11): 2829-2837, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31414191

RESUMO

BACKGROUND: Orthostatic tremor is a rare hyperkinetic movement disorder that is characterized by a 13-18 Hz tremor in both legs while standing. Deep-brain stimulation of the caudal zona incerta has re-emerged as an alternate target for tremor control in various etiologies. OBJECT: Explore the clinical efficacy and mechanism of action of caudal zona incerta deep-brain stimulation in orthostatic tremor. METHODS: Four patients (63.1 ± 4.1 years, female = 50%) with orthostatic tremor were recruited for this open label study (63.1 ± 4.1 years, female = 50%). In two patients, the electrodes were externalized to determine the effectiveness of caudal zona incerta as a target. Surface EMG (leg muscles), EEG (leg motor cortex) and caudal zona incerta local field potential recordings were recorded. Data were recorded in sitting and standing positions with stimulation OFF and ON. RESULTS: EMG frequency analysis showed tremor frequency at 13-17 Hz. EMG-EEG coherence was found in the tremor frequency band and double tremor frequency band. EMG-caudal zona incerta coherence was higher in the tremor frequency band, while EEG coherence was higher in the double tremor frequency band. Upon stimulation, there was a selective reduction in tremor frequency band EEG-EMG coherence in all patients. All the patients had reduction in feeling of unsteadiness and increase in the stance duration. CONCLUSIONS: Bilateral caudal zona incerta deep-brain stimulation is effective in refractory orthostatic tremor. Two independent central oscillations were found at tremor and double tremor frequency. Zona incerta DBS produces improvement in OT patients possibly by modifying the abnormal oscillatory proprioceptive input from leg muscles. Frequent changes in deep-brain stimulation settings were required for maintaining the clinical benefit.


Assuntos
Estimulação Encefálica Profunda/métodos , Tontura/terapia , Tremor/terapia , Zona Incerta/fisiologia , Idoso , Eletrodos Implantados , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
10.
Tidsskr Nor Laegeforen ; 139(9)2019 May 28.
Artigo em Inglês, Norueguês | MEDLINE | ID: mdl-31140261

RESUMO

Persistent symptoms of dizziness may be due to inappropriate compensatory strategies following an episode of acute dizziness. Common symptoms are dizziness in an upright position that is aggravated by visual stimuli and passive movement. In the World Health Organization's new disease classification, ICD-11, the condition has been named persistent postural-perceptual dizziness. It is important to recognise this condition in order to avoid unnecessary investigation and to initiate the correct treatment.


Assuntos
Tontura , Tontura/diagnóstico , Tontura/fisiopatologia , Tontura/reabilitação , Tontura/terapia , Humanos , Equilíbrio Postural , Doenças Vestibulares/diagnóstico , Doenças Vestibulares/fisiopatologia , Doenças Vestibulares/reabilitação , Doenças Vestibulares/terapia
11.
J Int Adv Otol ; 15(1): 146-150, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31058604

RESUMO

OBJECTIVES: Despite increasing utilization of reposition devices in the management of benign paroxysmal positional vertigo (BPPV), knowledge on subjective outcomes is insufficient. The objective of the present study was to evaluate subjective vertigo complaints and vertigo-associated emotional distress during reposition chair management for refractory BPPV. MATERIALS AND METHODS: This was a prospective observational cohort study of subjective and objective data of 31 patients suffering from refractory BPPV representing failed conventional repositioning treatment. At the beginning of each visit, the patients filled out the Dizziness Handicap Inventory (DHI), the Visual Analog Scale (VAS), and the Hospital Anxiety and Depression Scale (HADS). Treatment and re-evaluation were repeated every 2 weeks until the patient was declared disease-free. RESULTS: Complete remission of BPPV required a mean of two treatments. Mean DHI score decreased from 45 points prior to first treatment to 22 points by finished treatment (p<0.001). Similarly, mean VAS score was reduced from 58 to 25 points (p<0.001), and HADS decreased from 8 to 5 points (p<0.001). Patients with cupulolithiasis reported worse vertigo complaints than those with canalolithiasis. All scores correlated positively. CONCLUSION: Patients with refractory BPPV improved significantly by reposition chair management according to all subjective outcomes. Thus, the reposition device could significantly reduce disease burden in the group of patients with BPPV who failed to respond to conventional management. The strong correlation between the scores suggests VAS as a useful tool for vertigo-related patient complaints.


Assuntos
Vertigem Posicional Paroxística Benigna/diagnóstico , Vertigem Posicional Paroxística Benigna/terapia , Posicionamento do Paciente/instrumentação , Vertigem/terapia , Adulto , Idoso , Ansiedade/etiologia , Ansiedade/psicologia , Vertigem Posicional Paroxística Benigna/fisiopatologia , Estudos de Coortes , Tontura/fisiopatologia , Tontura/psicologia , Tontura/terapia , Feminino , Movimentos da Cabeça/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Nistagmo Patológico/complicações , Nistagmo Patológico/diagnóstico , Nistagmo Patológico/fisiopatologia , Nistagmo Fisiológico , Posicionamento do Paciente/métodos , Modalidades de Fisioterapia , Estudos Prospectivos , Canais Semicirculares/patologia , Vertigem/complicações , Vertigem/fisiopatologia , Vertigem/psicologia , Escala Visual Analógica
12.
J Neurol ; 266(9): 2120-2128, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31119449

RESUMO

OBJECTIVES: Vertigo is a common reason for primary care consultations, and its diagnosis and treatment consume considerable medical resources. However, limited information on the specific cost of vertigo is currently available. The aim of this study is to analyse the health care costs of vertigo and examine which individual characteristics would affect these costs. STUDY DESIGN: We used cross-sectional data from the German KORA ("Cooperative Health Research in the Augsburg Region") FF4 study in 2013. METHODS: Impact of personal characteristics and other factors was modelled using a two-part model. Information on health care utilisation was collected by self-report. RESULTS: We included 2277 participants with a mean age of 60.8 (SD = 12.4), 48.4% male. Moderate or severe vertigo was reported by 570 (25.0%) participants. People with vertigo spent 818 Euro more than people without vertigo in the last 12 months (2720.9 Euro to 1902.9 Euro, SD = 4873.3 and 5944.1, respectively). Consultation costs at primary care physicians accounted for the largest increase in total health care costs with 177.2 Euro (p < 0.01). After adjusting for covariates, the presence of vertigo increased both the probability of having any health care costs (OR = 1.6, 95% CI =[1.2;2.4]) and the amount of costs (exp(ß) = 1.3, 95% CI = [1.1;1.5]). The analysis of determinants of vertigo showed that private insurance and a medium level of education decreased the probability of any costs, while higher income increased it. CONCLUSIONS: The presence of vertigo and dizziness required considerable health care resources and created significantly more related costs in different health care sectors for both primary and pertinent secondary care.


Assuntos
Tontura/economia , Tontura/epidemiologia , Custos de Cuidados de Saúde/tendências , Aceitação pelo Paciente de Cuidados de Saúde , Vertigem/economia , Vertigem/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Tontura/terapia , Feminino , Seguimentos , Alemanha/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Inquéritos Nutricionais/tendências , Vertigem/terapia
13.
Eur Arch Otorhinolaryngol ; 276(9): 2389-2396, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31098875

RESUMO

PURPOSE: This study aims to evaluate whether a management algorithm has improved the effectiveness of care for dizzy patients at Umeå University Hospital. METHODS: This was an interventional study using medical records to collect data for acute dizziness presentations before (period 1, 2012-2014) and after (period 2, 2016-2017) the implementation of a management algorithm. Outcomes were changes in a set of pre-defined effectiveness markers and health economic effects. RESULTS: Total n = 2126 and n = 1487 acute dizziness presentations were identified in period 1 and 2, respectively. Baseline characteristics were similar. The proportion of patients undergoing Dix-Hallpike testing increased, 20.8% [95% confidence interval (CI) 18.8-23.0%] vs. 37.7% (95% CI 35.2-40.2%), as did BPPV diagnoses, 7.6% (95% CI 6.6-8.8%) vs. 15.3% (95% CI 13.6-17.3%). Hospitalization became less common, 61.5% (95% CI 59.4-63.6%) vs. 47.6% (95% CI 45.1-50.2%). The proportion undergoing any neuroradiological investigation decreased, 44.8% (95% CI 42.7-47.0%) vs. 36.3% (95% CI 33.8-38.7%) with a shift from CT to MRI, with unchanged sensitivity for diagnosing cerebrovascular causes. The average cost for the care of one dizzy patient decreased from $2561 during period 1 to $1808 during period 2. CONCLUSIONS: This study shows that the implementation of a management algorithm for dizzy patients was associated with improved effectiveness of care.


Assuntos
Algoritmos , Tontura/terapia , Adulto , Idoso , Tontura/etiologia , Feminino , Hospitais Universitários , Humanos , Imagem por Ressonância Magnética/tendências , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Melhoria de Qualidade , Suécia , Tomografia Computadorizada por Raios X/tendências
14.
World Neurosurg ; 126: e1549-e1552, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30928582

RESUMO

OBJECTIVE: Superior semicircular canal dehiscence (SSCD) is caused by a deformity in the arcuate eminence, leading to various vestibular and auditory symptoms that can manifest unilaterally or bilaterally. The aim of the present study was to distinguish the differences in symptoms, treatment options, and outcomes between patients with unilateral and bilateral SSCD. METHODS: A retrospective medical record analysis was conducted to identify patients with SSCD treated at a tertiary care center from March 2011 to May 2017. The patient demographic data, preoperative symptom presentation, and postoperative outcomes were extracted. Statistical analyses were performed using IBM SPSS Statistics. Fisher's exact tests were computed to investigate the relationships between binary variables, with a significance level of P < 0.05. RESULTS: A total of 99 patients with SSCD had been treated at our institution from March 2011 to May 2017. Of these 99 patients, 41 (41.4%) had a diagnosis of bilateral SSCD. Of the 41 patients with bilateral SSCD, 27 (65.9%) were women, and the mean age was 53.6 ± 10.9 years (range, 31.7-73.9). The most common presenting symptom was tinnitus (n = 33; 80.4%) and dizziness (n = 33; 80.4%). Previous trauma to the head correlated with a bilateral SSCD presentation (P = 0.04). Trends were reported between female sex and bilateral SSCD [r(35) = 0.32379; P = 0.0506]. Postoperatively, trends were also found, with greater rates of dizziness in patients with bilateral SSCD compared with those with unilateral SSCD (odds ratio, 3.81; P = 0.0659), and less improvement in dizziness (odds ratio, 0.186; P = 0.0627). No other significant differences were found between the symptoms or clinical outcomes and improvements between the bilateral and unilateral cohorts. CONCLUSION: Bilateral SSCD might result in different clinical symptoms that are more prevalent compared with unilateral SSCD. The findings from the present series of patients with bilateral SSCD suggest that patient symptoms and history are important in the diagnosis of bilateral SSCD and deciding whether 1 or both dehiscences requires surgical intervention.


Assuntos
Doenças do Labirinto/cirurgia , Procedimentos Cirúrgicos Otológicos/métodos , Canais Semicirculares/anormalidades , Canais Semicirculares/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Tontura/etiologia , Tontura/terapia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Zumbido/etiologia , Zumbido/terapia , Resultado do Tratamento , Adulto Jovem
15.
Adv Otorhinolaryngol ; 82: 170-179, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30947209

RESUMO

Research over the last 4 decades has revealed a great deal of information about psychiatric and functional causes, consequences, and comorbidity of vestibular syndromes. Primary care clinicians, neurologists, and otologists who are willing to set aside the 20th century notion of "psychogenic dizziness" and incorporate 21st century concepts about 5 behavioral entities into their practices will be rewarded for their efforts with a marked improvement in diagnostic acumen and therapeutic effectiveness. Panic attacks may cause or contribute to acute or episodic vestibular symptoms. Generalized anxiety and depression do the same for chronic vestibular symptoms. Fear of falling causes considerable functional impairment, particularly in the elderly. Persistent postural-perceptual dizziness, a newly defined functional vestibular disorder that was 145 years in the making, is the most common cause of chronic dizziness in neurotologic practice. These 5 disorders are the primary diagnoses in 8-10% of patients who consult neurologists or otologists for vestibular symptoms and may be present in up to 50% of patients with structural vestibular disorders. They affect the clinical course of other illnesses and outcomes of medical and surgical interventions. Fortunately, when recognized properly, they are among the most treatment responsive of all conditions that cause vestibular symptoms.


Assuntos
Tontura/etiologia , Tontura/psicologia , Tontura/terapia , Ansiedade/psicologia , Comorbidade , Depressão/psicologia , Medo/psicologia , Humanos , Transtornos Psicofisiológicos/psicologia
16.
Adv Otorhinolaryngol ; 82: 150-163, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30947210

RESUMO

Patients with symptoms of dizziness may present to a wide range of medical services. Awareness of the full breadth of possible diagnoses is thus helpful in managing dizzy patients. This chapter provides a comprehensive review of systemic diseases that may contribute to the complex symptom of dizziness and provide a review of recent advances in each field.


Assuntos
Gerenciamento Clínico , Tontura/diagnóstico , Tontura/etiologia , Tontura/terapia , Diagnóstico Diferencial , Humanos , Medição de Risco , Fatores de Risco
17.
Adv Otorhinolaryngol ; 82: 143-149, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30947233

RESUMO

Aging in vestibular structures with loss of hair cells in the inner ear starts early in life, but vestibular function usually remains relatively unimpaired up to advanced ages. However, dizziness and imbalance are common in the elderly and have substantial impact on the quality of life. Dizziness interferes with the everyday activities of 30% of persons over age 70. As causes can be multiple, including vestibular and non-vestibular components, it is crucial to detect the factors leading to dizziness and imbalance to maintain mobility and avoid secondary complications like falls and anxiety. The more common causes of dizziness and imbalance in old age are sensory deficits, such as bilateral vestibular hypofunction, polyneuropathy, and impaired visual acuity; benign paroxysmal positional vertigo; and central disorders such as cerebellar ataxia and normal-pressure hydrocephalus. Further relevant factors include sedative or antihypertensive medication, loss of muscle mass (sarcopenia), and the fear of falling. Many elderly persons have multiple risk factors at the same time. Treatable components include benign paroxysmal positional vertigo that can be effectively treated with specific physical maneuvers, sedating drugs that can be reduced in many cases, and sarcopenia that can be treated with physical training. If a specific cause for dizziness and imbalance can be identified, treatment is often successful even in advanced age. The common causes can be revealed by systematic clinical examination and selective laboratory testing.


Assuntos
Tontura , Avaliação Geriátrica/métodos , Equilíbrio Postural , Idoso , Diagnóstico Diferencial , Tontura/diagnóstico , Tontura/etiologia , Tontura/fisiopatologia , Tontura/terapia , Humanos , Exame Físico , Qualidade de Vida , Testes de Função Vestibular
18.
Subcell Biochem ; 91: 195-225, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30888654

RESUMO

The world's population is ageing due to increased hygiene and improved medical care. Dizziness and imbalance frequently affect the elderly and is most common among individuals over the age of 60. In this age group approximately 30% of the population experience these debilitating symptoms at some point. They contribute to falls and frailty, which often result in hospitalization causing tremendous cost for the health care systems, and increased mortality. To make the matters worse balance disorders are often complex. Physicians face the difficulty of diagnosing the patient with the exact disorder especially since each disorder may manifest differently in each patient. In addition, several treatment options exist, however, with a low level of evidence. This chapter summarizes the underlying degenerative processes of the peripheral as well as the central vestibular system, diagnostic tools, the most common balance disorders in the elderly, and possible treatment options of these disorders.


Assuntos
Envelhecimento/patologia , Doenças Vestibulares/fisiopatologia , Acidentes por Quedas , Tontura/fisiopatologia , Tontura/terapia , Humanos , Equilíbrio Postural , Doenças Vestibulares/patologia , Doenças Vestibulares/terapia
19.
J Otolaryngol Head Neck Surg ; 48(1): 11, 2019 Mar 11.
Artigo em Inglês | MEDLINE | ID: mdl-30857559

RESUMO

BACKGROUND: Vertigo remains a diagnostic challenge for primary care, emergency, and specialist physicians. Multidisciplinary clinics are increasingly being employed to diagnose and manage patients with dizziness. We describe, for the first time in Canada, the clinical characteristics of patients presenting with chronic and acute dizziness to both a multidisciplinary chronic dizziness clinic (MDC) and a rapid access dizziness (RAD) clinic at The Ottawa Hospital (TOH). METHODS: We performed a retrospective review of all patients presenting to the MDC and RAD clinics at TOH from July 2015 to August 2017. RESULTS: Overall, 211 patients (median age: 61 years old) presented to the RAD clinic and 292 patients (median age: 55 years old) presented to the MDC. In the RAD clinic, 63% of patients had peripheral dizziness, of which 55% had BPPV, and only one patient had functional dizziness. Interestingly, only 25% of RAD diagnoses were concordant with emergency department diagnoses; moreover, only 33% of RAD patients had HiNTS completed, while 44% had CT scans, of which only one scan had an abnormal finding. Prior to assessment, all patients in the MDC had an unclear cause of dizziness. 28% of patients had vestibular dizziness and 21% had functional dizziness, of which 43% had persistent postural perceptual dizziness. Moreover, 12% of patients with functional dizziness also suffered from comorbid severe anxiety and depression. CONCLUSIONS: Dizziness is a heterogeneous disorder that necessitates multidisciplinary care, and clinics targeting both the acute and chronic setting can improve diagnostic accuracy, ensure appropriate diagnostic testing, and facilitate effective care plans for patients with dizziness.


Assuntos
Tontura/diagnóstico , Tontura/epidemiologia , Atenção Terciária à Saúde , Doença Aguda , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Canadá , Doença Crônica , Tontura/terapia , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto Jovem
20.
J Neurol ; 266(5): 1236-1249, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30809703

RESUMO

Over the past years galvanic vestibular stimulation (GVS) has been increasingly applied to stimulate the vestibular system in health and disease, but not in patients with persistent postural-perceptual dizziness (PPPD) yet. We functionally tested motion perception thresholds and postural responses to imperceptible noisy (nGVS) and perceptible bimastoidal GVS intensities in patients with PPPD with normal vestibulo-ocular reflexes. We hypothesized that GVS destabilizes PPPD patients under simple postural conditions stronger compared to healthy controls. They were compared to healthy subjects under several conditions each with the eyes open and closed: baseline with firm platform support, standing on foam and cognitive demand (count backward). Low and high GVS intensities (range 0.8-2.8 mA) were applied according to the individual thresholds and compared with no GVS. PPPD patients showed a reduced perception threshold to GVS compared to healthy control subjects. Median postural sway speed increased with stimulus intensity and on eye closure, but there was no group difference, irrespective of the experimental condition. Romberg's ratio was consistently lower during nGVS than in all other conditions. Group-related dissociable effects were found with the eyes closed in (i) the baseline condition in which high GVS elicited higher postural sway of PPPD patients and (ii) in the foam condition, with better postural stability of PPPD patients during perceptible GVS. Group and condition differences of postural control were neither related to anxiety nor depression scores. GVS may be helpful to identify thresholds of vestibular perception and to modulate vestibulo-spinal reflexes in PPPD, with dissociable effects with respect to perceptible and imperceptible stimuli. The sway increase in the baseline of PPPD may be related to an earlier transition from open- to closed-loop mode of postural control. In contrast, the smaller sway of PPPD in the foam condition under visual deprivation is in line with the known balance improvement under more demanding postural challenges in PPPD. It is associated with a prolonged transition from open- to closed-loop postural feedback control. It could also reflect a shift of intersensory weighting with a smaller dependence on proprioceptive feedback control in PPPD patients under complex tasks. In summary, GVS discloses differences between simple and complex balance tasks in PPPD.


Assuntos
Tontura/complicações , Tontura/terapia , Estimulação Elétrica/métodos , Equilíbrio Postural/fisiologia , Transtornos das Sensações/complicações , Vestíbulo do Labirinto/fisiologia , Estimulação Acústica , Adulto , Idoso , Análise de Variância , Depressão/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Postura/fisiologia , Psicofísica , Adulto Jovem
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