Gentrification drives patterns of alpha and beta diversity in cities.

While there is increasing recognition that social processes in cities like gentrification have ecological consequences, we lack nuanced understanding of the ways gentrification affects urban biodiversity. We analyzed a large camera trap dataset of mammals (>500 g) to evaluate how gentrification impacts species richness and community composition across 23 US cities. After controlling for the negative effect of impervious cover, gentrified parts of cities had the highest mammal species richness. Change in community composition was associated with gentrification in a few cities, which were mostly located along the West Coast. At the species level, roughly half (11 of 21 mammals) had higher occupancy in gentrified parts of a city, especially when impervious cover was low. Our results indicate that the impacts of gentrification extend to nonhuman animals, which provides further evidence that some aspects of nature in cities, such as wildlife, are chronically inaccessible to marginalized human populations.

Treatment of Vestibular Disorders (Inner Ear Balance Problems): How Does Your Physical Therapist Treat Dizziness Related to Inner Ear Balance Problems?

Dizziness is very common, but it is never normal. Dizziness can make performing daily activities, work, and walking difficult. Inner ear balance problems can make people dizzy when they turn their head, which can cause problems during walking and make people more likely to fall. Most of the time dizziness is not from a life-threatening disease. Often, dizziness is related to a problem of the vestibular (or inner ear balance) system. Vestibular disorders can be caused by infections in the ear, problems with the immune system, medications that harm the inner ear, and rarely from diabetes or stroke because of a lack of blood flow to the inner ear. Stress, poor sleep, migraine headaches, overdoing some activities, and feeling anxious or sad can increase symptoms of dizziness. Updated guidelines for the treatment of inner ear disorders are published in this issue of the Journal of Neurologic Physical Therapy. The guideline recommends which exercises are best to treat the dizziness and balance problems commonly seen with an inner ear problem.

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

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

Disruptive Dizziness Among Post-9/11 Veterans With Deployment-Related Traumatic Brain Injury.

OBJECTIVE: To identify disruption due to dizziness symptoms following deployment-related traumatic brain injury (TBI) and factors associated with receiving diagnoses for these symptoms. SETTING: Administrative medical record data from the Department of Veterans Affairs (VA). PARTICIPANTS: Post-9/11 veterans with at least 3 years of VA care who reported at least occasional disruption due to dizziness symptoms on the comprehensive TBI evaluation. DESIGN: A cross-sectional, retrospective, observational study. MAIN MEASURES: International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes of dizziness, vestibular dysfunction, and other postconcussive conditions; neurobehavioral Symptom Inventory. RESULTS: Increased access to or utilization of specialty care at the VA was significant predictors of dizziness and/or vestibular dysfunction diagnoses in the fully adjusted model. Veterans who identified as Black non-Hispanic and those with substance use disorder diagnoses or care were substantially less likely to receive dizziness and vestibular dysfunction diagnoses. CONCLUSIONS: Access to specialty care was the single best predictor of dizziness and vestibular dysfunction diagnoses, underscoring the importance of facilitating referrals to and utilization of specialized, comprehensive clinical facilities or experts for veterans who report disruptive dizziness following deployment-related TBI. There is a clear need for an evidence-based pathway to address disruptive symptoms of dizziness, given the substantial variation in audiovestibular tests utilized by US providers by region and clinical specialty. Further, the dearth of diagnoses among Black veterans and those in more rural areas underscores the potential for enhanced cultural competency among providers, telemedicine, and patient education to bridge existing gaps in the care of dizziness.

Comparison of pharmacists' scoring of fall risk to other fall risk assessments.

OBJECTIVES: Given their professional education and participation within the health care system, pharmacists are ideal candidates to assess drug-associated fall risk for patients. The purpose of this investigation was to determine whether pharmacists can quantitatively differentiate individuals who reported falling within the previous year (fallers) from those who do not (nonfallers), and to compare the pharmacists' evaluation with 2 recently published fall risk assessments. DESIGN: Cross-sectional design of pharmacists' assessments of fall risk. SETTING AND PARTICIPANTS: This is a cross-sectional study where 6 licensed pharmacists evaluated patient records from Wave 1 of the National Social Life, Health and Aging Project dataset using generic drug list (drug counts), age, and body mass index to generate a Pharmacist Risk Score (PRS) based on these variables. Pharmacists were allowed to use drug information resources and were provided with a simple 5-point scale to assist them in scoring patients. OUTCOME MEASURES: The main outcome measure of this study was a comparison of the following fall risk assessments (PRS, drug counts, Medication-Based Index of Physical Function, Quantitative Drug Index, and Timed Up and Go [TUG]) capacity to differentiate fallers from nonfallers. RESULTS: Each fall risk assessment was highly correlated (P < 0.001) with the number of reported falls. Drug-associated fall risk assessments were highly correlated (P < 0.001) with each other, but not with TUG. Each fall risk assessment differentiated fallers from nonfallers based on logistic regression (P ≤ 0.001). Receiver operating characteristic (ROC) curve analysis was significant (P ≤ 0.002) for each assessment. The comparison of ROC area under the curve for the fall risk assessments found no significant difference between the PRS and other assessments. CONCLUSION: Fall risk assessment by pharmacists was comparable with other fall risk assessments in distinguishing fallers from nonfallers.

Comparison of two escalated enoxaparin dosing regimens for venous thromboembolism prophylaxis in obese hospitalized patients.

Standard fixed-dose enoxaparin dosing regimens may not provide adequate prophylaxis against venous thromboembolism among obese hospitalized patients. While several escalated doses have been shown to result in more frequent attainment of target anti-factor Xa levels than standard doses, few studies compare escalated doses to each other. In this prospective, multi-center trial, enoxaparin 0.5 mg/kg daily (weight-based dosing) and enoxaparin 40 mg twice daily were compared to determine if either dose resulted in more frequent attainment of anti-factor Xa levels within the goal range of 0.2-0.5 IU/mL. Eighty patients with a BMI ≥ 40 kg/m2 were enrolled. There was no difference in the percent of patients achieving goal anti-factor Xa levels (72.5% vs. 70.0%, respectively; p = 0.72). Patients were more likely to attain anti-factor Xa levels below goal range than above. No bleeding or thrombotic events occurred. Either weight-based or twice-daily escalated enoxaparin dosing regimens appear effective at achieving target anti-factor Xa levels among hospitalized patients, and no safety events were noted. Future studies are needed to determine the clinical significance of this result.

Quantifying hydrologic controls on local- and landscape-scale indicators of coastal wetland loss.

BACKGROUND AND AIMS: Coastal wetlands have evolved to withstand stressful abiotic conditions through the maintenance of hydrologic feedbacks between vegetation production and flooding. However, disruption of these feedbacks can lead to ecosystem collapse, or a regime shift from vegetated wetland to open water. To prevent the loss of critical coastal wetland habitat, we must improve understanding of the abiotic-biotic linkages among flooding and wetland stability. The aim of this research was to identify characteristic landscape patterns and thresholds of wetland degradation that can be used to identify areas of vulnerability, reduce flooding threats and improve habitat quality. METHODS: We measured local- and landscape-scale responses of coastal wetland vegetation to flooding stress in healthy and degrading coastal wetlands. We hypothesized that conversion of Spartina patens wetlands to open water could be defined by a distinct change in landscape configuration pattern, and that this change would occur at a discrete elevation threshold. KEY RESULTS: Despite similarities in total land and water cover, we observed differences in the landscape configuration of vegetated and open water pixels in healthy and degrading wetlands. Healthy wetlands were more aggregated, and degrading wetlands were more fragmented. Generally, greater aggregation was associated with higher wetland elevation and better drainage, compared with fragmented wetlands, which had lower elevation and poor drainage. The relationship between vegetation cover and elevation was non-linear, and the conversion from vegetated wetland to open water occurred beyond an elevation threshold of hydrologic stress. CONCLUSIONS: The elevation threshold defined a transition zone where healthy, aggregated, wetland converted to a degrading, fragmented, wetland beyond an elevation threshold of 0.09 m [1988 North American Vertical Datum (NAVD88)] [0.27 m mean sea level (MSL)], and complete conversion to open water occurred beyond 0.03 m NAVD88 (0.21 m MSL). This work illustrates that changes in landscape configuration can be used as an indicator of wetland loss. Furthermore, in conjunction with specific elevation thresholds, these data can inform restoration and conservation planning to maximize wetland stability in anticipation of flooding threats.

Relationship Between Corrective Saccades and Measures of Physical Function in Unilateral and Bilateral Vestibular Loss.

OBJECTIVES: Following the loss of vestibular function, some patients functionally improve and are minimally bothered by their loss of peripheral function while others remain more symptomatic and are unable to return to their activities of daily living. To date, the mechanisms for functional improvement remain poorly understood. The purpose of the present study was to examine the association between corrective saccades and measures of handicap, dynamic visual acuity, gait, and falls. DESIGN: A retrospective chart review was performed to identify patients who were diagnosed with unilateral or bilateral vestibular hypofunction and who also completed a baseline vestibular rehabilitation evaluation. A total of 82 patients with unilateral vestibular hypofunction and 17 patients with bilateral vestibular hypofunction were identified. The video head impulse test results for each patient were grouped based on the type of presenting saccades. Specifically, the saccade grouping included the following: (1) covert, (2) overt, or (3) a combination of both types of saccades. RESULTS: The results show that covert saccades are associated with better performance on measures of dynamic visual acuity, gait, and balance in patients with unilateral vestibular hypofunction. Patients exhibiting overt saccades or combination of both covert and overt saccades were more often found to have an abnormal gait speed and be characterized as being at risk for falls using the Dynamic Gait Index. We observed no differences in physical function for those patients with bilateral vestibular hypofunction as a function of saccade grouping. CONCLUSIONS: When comparing saccade groups (covert, overt, or combination of both), patients with unilateral vestibular hypofunction and covert saccades demonstrated better performance on standard baseline physical therapy measures of dynamic visual acuity and gait and balance. We did not observe any significant associations between saccade group and physical function in patients with bilateral vestibular hypofunction; however, additional studies are needed with adequate sample sizes. Our findings may suggest that corrective saccade latency in patients with unilateral vestibular hypofunction is related to measures of physical function. The extent to which saccade latency has the potential to be a useful target for vestibular rehabilitation is still to be determined and may be promising target to improve functional outcomes.

Association of Traumatic Brain Injury With Vestibular Dysfunction and Dizziness in Post-9/11 Veterans.

OBJECTIVE: To describe the prevalence and impact of vestibular dysfunction and nonspecific dizziness diagnoses and explore their associations with traumatic brain injury (TBI) severity, mechanism, and postconcussive comorbidities among post-9/11 veterans. SETTING: Administrative medical record data from the US Departments of Defense and Veterans Affairs (VA). PARTICIPANTS: Post-9/11 veterans with at least 3 years of VA care. DESIGN: Cross-sectional, retrospective, observational study. MAIN MEASURES: International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for TBI, vestibular dysfunction, dizziness, and other commonly associated postconcussive conditions; Neurobehavioral Symptom Inventory. RESULTS: Of the 570 248 post-9/11 veterans in this sample, 0.45% had a diagnosis of vestibular dysfunction and 2.57% had nonspecific dizziness. Those with either condition were more likely to have evidence of TBI (57.11% vs 28.51%) and reported more disruption from neurobehavioral symptoms. Blast and nonblast injuries were associated with greater symptom disruption, particularly in combination. CONCLUSIONS: There was a consistent, significant association between TBI and vestibular dysfunction or nonspecific dizziness, after controlling for sociodemographic factors, injury mechanism, and comorbid conditions. Given that most deployed post-9/11 veterans report blast and/or nonblast injuries, the need for prompt identification and management of these conditions and symptoms is clear.

Impact of Interdisciplinary Team Care for Children With 22q11.2 Deletion Syndrome.

OBJECTIVE: To evaluate disease-specific guideline adherence among children with 22q11.2 deletion syndrome receiving multidisciplinary team care through a 22q specialty clinic compared to children not receiving team care. DESIGN: Retrospective chart review; quality improvement project. SETTING: Tertiary care pediatric hospital. PATIENTS: One hundred eighty-nine patients with 22q11.2 deletion syndrome were categorized into those receiving team care and those not receiving team care. Guideline adherence was compared between the 2 groups. MAIN OUTCOME MEASURE(S): Percent adherence across 8 disease-specific guidelines. RESULTS: A Welch t test revealed mean adherence among patients receiving team care was significantly higher (83% vs 42%, P < .001) compared those not receiving team care. Among team patients with a single 22q Center visit, a paired samples t test showed that mean adherence increased from 63% before the clinic encounter to 86% six months after the encounter (P < .001). Some guidelines were more likely to be associated with provider nonadherence, whereas others were more likely to be associated with patient nonadherence. CONCLUSIONS: Multidisciplinary team care is associated with significantly higher guideline adherence in children with 22q11DS. Additional research is needed to investigate the effect of team care on long-term health outcomes in children with 22q11DS.

A Quality Improvement Initiative to Improve Feeding and Growth of Infants With Cleft Lip and/or Palate.

OBJECTIVE: The purpose of this quality improvement initiative was to improve feeding and growth outcomes in infants with cleft lip and/or palate (CL/P). DESIGN: Institute for Healthcare Improvement quality improvement model. SETTING: Large pediatric academic medical center in the Midwestern United States. PARTICIPANTS: One hundred forty-five infants with nonsyndromic CL/P ages 0 to 12 months. INTERVENTIONS: Key drivers included (1) caregiver education and resources, (2) care coordination and flow, and (3) provider education and training. Interventions were designed around these themes and included targeting improved team communication, increased social work consultations, patient tracking, staff education, improved access to feeding equipment, and the launch of a new cleft palate feeding team. MAIN OUTCOME MEASURE(S): The primary outcome measure was the percentage of new patients with CL/P who met criteria for failure to thrive (FTT) per month. The secondary outcome measure was the frequency of hospitalization for infants with CL/P with a primary reason for admission of feeding difficulties or FTT. RESULTS: The institutional FTT rate for infants with CL/P decreased from 17% to 7% ( P < .003). The frequency of hospitalization for FTT improved from once every 30 days to once every 118 days. CONCLUSIONS: Targeted interventions aimed at improving feeding efficiency and effectiveness, as well as changes in care delivery models, can reliably promote improvements in feeding and growth outcomes for infants with CL/P, even with psychosocial risk factors present.

Mangrove expansion and contraction at a poleward range limit: climate extremes and land-ocean temperature gradients.

Within the context of climate change, there is a pressing need to better understand the ecological implications of changes in the frequency and intensity of climate extremes. Along subtropical coasts, less frequent and warmer freeze events are expected to permit freeze-sensitive mangrove forests to expand poleward and displace freeze-tolerant salt marshes. Here, our aim was to better understand the drivers of poleward mangrove migration by quantifying spatiotemporal patterns in mangrove range expansion and contraction across land-ocean temperature gradients. Our work was conducted in a freeze-sensitive mangrove-marsh transition zone that spans a land-ocean temperature gradient in one of the world's most wetland-rich regions (Mississippi River Deltaic Plain; Louisiana, USA). We used historical air temperature data (1893-2014), alternative future climate scenarios, and coastal wetland coverage data (1978-2011) to investigate spatiotemporal fluctuations and climate-wetland linkages. Our analyses indicate that changes in mangrove coverage have been controlled primarily by extreme freeze events (i.e., air temperatures below a threshold zone of -6.3 to -7.6°C). We expect that in the past 121 yr, mangrove range expansion and contraction has occurred across land-ocean temperature gradients. Mangrove resistance, resilience, and dominance were all highest in areas closer to the ocean where temperature extremes were buffered by large expanses of water and saturated soil. Under climate change, these areas will likely serve as local hotspots for mangrove dispersal, growth, range expansion, and displacement of salt marsh. Collectively, our results show that the frequency and intensity of freeze events across land-ocean temperature gradients greatly influences spatiotemporal patterns of range expansion and contraction of freeze-sensitive mangroves. We expect that, along subtropical coasts, similar processes govern the distribution and abundance of other freeze-sensitive organisms. In broad terms, our findings can be used to better understand and anticipate the ecological effects of changing winter climate extremes, especially within the transition zone between tropical and temperate climates.

Development and evaluation of the medication-based index of physical function (MedIP).

Background: the development of an objective and comprehensive drug-based index of physical function for older adults has the potential to more accurately predict fall risk. Design: the index was developed using 862 adults (ages 57-85) from the National Social Life, Health, and Aging Project (NSHAP) Wave 1 study. The index was evaluated in 70 adults (ages 51-88) from a rehabilitation study of dizziness and balance. Methods: the prevalence among 601 drugs for 1,694 side effects was used with fall history to determine the magnitude of each side effect's contribution towards physical function. This information was used to calculate a Medication-based Index of Physical function (MedIP) score for each individual based on his or her medication profile. The MedIP was compared to the timed up and go (TUG) test as well as drug counts using receiver operating characteristic (ROC) analysis. The associations between various indices of physical function and MedIP were calculated. Results: within the NSHAP data set, the MedIP was better than drug counts or TUG at predicting falls based on ROC analysis. Using scores above and below the cutpoint, the MedIP was a significant predictor of falls (OR = 2.61 [95% CI 1.83, 3.64]; P < 0.001). Using an external data set, it was shown that the MedIP was significantly correlated with fall number (P = 0.044), composite physical function (P = 0.026) and preferred gait speed (P = 0.043). Conclusion: the MedIP has the potential to become a useful tool in the healthcare and fall prevention of older individuals.

Vestibular consequences of mild traumatic brain injury and blast exposure: a review.

The purpose of this article is to review relevant literature on the effect of mild traumatic brain injury (mTBI) and blast injury on the vestibular system. Dizziness and imbalance are common sequelae associated with mTBI, and in some individuals, these symptoms may last for six months or longer. In war-related injuries, mTBI is often associated with blast exposure. The causes of dizziness or imbalance following mTBI and blast injuries have been linked to white matter abnormalities, diffuse axonal injury in the brain, and central and peripheral vestibular system damage. There is some evidence that the otolith organs may be more vulnerable to damage from blast exposure or mTBI than the horizontal semicircular canals. In addition, benign paroxysmal positional vertigo (BPPV) is a common vestibular disorder following head injury that is treated effectively with canalith repositioning therapy. Treatment for (non-BPPV) mTBI-related vestibular dysfunction has focused on the use of vestibular rehabilitation (VR) augmented with additional rehabilitation methods and medication. New treatment approaches may be necessary for effective otolith organ pathway recovery in addition to traditional VR for horizontal semicircular canal (vestibulo-ocular reflex) recovery.

Graphical Models for Quasi-experimental Designs.

Randomized controlled trials (RCTs) and quasi-experimental designs like regression discontinuity (RD) designs, instrumental variable (IV) designs, and matching and propensity score (PS) designs are frequently used for inferring causal effects. It is well known that the features of these designs facilitate the identification of a causal estimand and, thus, warrant a causal interpretation of the estimated effect. In this article, we discuss and compare the identifying assumptions of quasi-experiments using causal graphs. The increasing complexity of the causal graphs as one switches from an RCT to RD, IV, or PS designs reveals that the assumptions become stronger as the researcher's control over treatment selection diminishes. We introduce limiting graphs for the RD design and conditional graphs for the latent subgroups of com-pliers, always takers, and never takers of the IV design, and argue that the PS is a collider that offsets confounding bias via collider bias.

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

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

Vestibular, balance, microvascular and white matter neuroimaging characteristics of blast injuries and mild traumatic brain injury: Four case reports.

BACKGROUND: Case reports are presented on four Veterans, aged 29-46 years, who complained of chronic dizziness and/or postural instability following blast exposures. Two of the four individuals were diagnosed with mild traumatic brain injury and three of the four were exposed to multiple blasts. Comprehensive vestibular, balance, gait, audiometry and neuroimaging procedures were used to characterize their injuries. CASE REPORT: Vestibular assessment included videonystagmography, rotary chair and cervical and ocular vestibular evoked myogenic potentials. Balance and gait testing included the sensory organization test, preferred gait speed and the dynamic gait index. Audiometric studies included pure tone audiometry and middle-ear measurements. Neuroimaging procedures included high resolution structural magnetic resonance imaging, susceptibility-weighted imaging and diffusion-tensor imaging. FINDINGS: Based on the neuroimaging and vestibular and balance test results, it was found that all individuals had diffuse axonal injuries and all had one or more micro-hemorrhages or vascular anomalies. Three of the four individuals had abnormal vestibular function, all had abnormally slow walking speeds and two had abnormal gait and balance dysfunction. CONCLUSION: The use of contemporary neuroimaging studies in conjunction with comprehensive vestibular and balance assessment provided a better understanding of the pathophysiology and pathoanatomy of dizziness following blast exposures than standard vestibular and balance testing alone.

Feasibility of a Low-Cost, Interactive Gaming System to Assess Balance in Older Women.

The use of low-cost interactive game technology for balance rehabilitation has become more popular recently, with generally good outcomes. Very little research has been undertaken to determine whether this technology is appropriate for balance assessment. The Wii balance board has good reliability and is comparable to a research-grade force plate; however, recent studies examining the relationship between Wii Fit games and measures of balance and mobility demonstrate conflicting findings. This study found that the Wii Fit was feasible for community-dwelling older women to safely use the balance board and quickly learn the Wii Fit games. The Ski Slalom game scores were strongly correlated with several balance and mobility measures, whereas Table Tilt game scores were not. Based on these findings, the Ski Slalom game may have utility in the evaluation of balance problems in community-dwelling older adults.

Multimodal Exercise Benefits Mobility in Older Adults With Visual Impairment: A Preliminary Study.

Evidence-based recommendations for interventions to reduce fall risk in older adults with visual impairment are lacking. Adapted tango dance (Tango) and a balance and mobility program (FallProof) have improved mobility, balance, and quality of life (QOL) in individuals with movement impairment. This study compared the efficacy of Tango and FallProof for 32 individuals with visual impairment (age: M = 79.3, SD =11 [51-95 years]). Participants were assigned to Tango or FallProof to complete twenty, 90-min lessons within 12 weeks. Participants underwent assessment of balance, dual-tasking, endurance, gait, and vision-related QOL. The balance reactions of participants in both groups improved (p < .001). Endurance, cognitive dual-tasking, and vision-related QOL may have improved more for Tango than FallProof. Group differences and gains were maintained across time. Both programs could be effective options for motor rehabilitation for older adults with visual impairment because they may improve mobility and QOL while reducing fall risk.

Remote assessment and management of patients with dizziness: development, validation, and feasibility of a gamified vestibular rehabilitation therapy platform.

Introduction: Dizziness is a growing public health concern with as many as 95 million adults in Europe and the United States experiencing vestibular hypofunction, which is associated with reduced quality of life, poorer health, and falls. Vestibular rehabilitation therapy (VRT) is effective in reducing symptoms and improving balance; however, limited access to qualified clinicians and poor patient adherence impedes optimal delivery. The goal of this study was to develop and evaluate the feasibility of a remote therapeutic monitoring VRT Platform application (APP) for the assessment and treatment of vestibular dysfunction. Methods: User-centered iterative design process was used to gather and integrate the needs of users (clinicians and patients) into the design at each stage of development. Commonly used vestibular patient-reported outcome measures (PROs) were integrated into the APP and adults with chronic dizziness were enrolled to evaluate validity and reliability of the APP compared to standard clinical measures (CLIN). Gaze stabilization exercises were gamified to provide an engaging experience and an off-the-shelf sensor captured eye and head movement to provide feedback on accuracy of performance. A prospective, pilot study design with pre-and post-treatment assessment assessed feasibility of the APP compared to standard VRT (CLIN). Results: Participants with dizziness wanted a summary rehabilitation report shared with their clinicians, felt that an app could help with accountability, and believed that a gaming format might help with exercise adherence. Clinicians felt that the app should include features to record and track eye and head movement, monitor symptoms, score accuracy of task performance, and measure adherence. Validity and reliability of the digital PROs (APP) were compared to scores from CLIN across two sessions and found to have good validity, good to excellent test-retest reliability, and excellent usability (≥88%ile). The pilot study demonstrated feasibility for use of the APP compared to CLIN for treatment of vestibular hypofunction. The mean standard system usability score of the APP was 82.5 indicating excellent usability. Discussion: Both adult patients with chronic dizziness and VRT clinicians were receptive to the use of technology for VRT. The HiM-V APP is a feasible alternative to clinical management of adults with chronic peripheral vestibular hypofunction.