Peer Reviewed
Want to keep up-to-date on current research into the diagnosis and treatment of vestibular disorders? Search the National Institutes of Health Library of Medicine database.
Following are summaries of select research papers.
*VeDA partners with the Journal of Vestibular Research to give a platform to the latest developments in vestibular research.
Individuals with persistent postural-perceptual dizziness (PPPD) exhibit one or more of the following symptoms: unsteadiness, a sensation of floating, or non-rotating dizziness that is present almost every day for more than three months. “PPPD is precipitated by conditions that cause a balance disorder, including vestibular, psychiatric, and traumatic diseases, but the dizziness in PPPD cannot be explained by the conditions.” (Ichijo, et.al.) Dizziness can be made worse by standing stationary, with body movement, and with visual stimulation. In general, individuals feel worse when standing or walking compared to sitting or lying down.
A possible association between PPPD and reliance on visual cues has been suggested. The brain processes information received from the visual (eyes), vestibular (inner ear) and somatosensory (touch) systems to interpret posture and movement. Foam posturography is used to measure an individual’s sway (how he/she moves while trying to balance) in various conditions. Standing on a foam rubber mat decreases the ability to use somatosensory input from the feet. Closing the eyes disrupts the ability to use vision. Measuring sway during these conditions can evaluate whether individuals rely more on visual or somatosensory cues. The aim of this study was to assess postural sway of PPPD patients by comparing them to healthy controls.
PPPD patients included 12 men and 41 women, aged 18-84, recruited from the Balance Disorder Clinic at the University of Tokyo Hospital. Diagnosis was made based on criteria from the Barany Society. The subjects underwent testing to examine the function of the otolith organs (utricle, saccule) in the inner ear. The otolith organs help to sense linear motion and acceleration. Electromyographic (EMG) activity was recorded from a service electrode placed on the upper half of each sternocleidomastoid muscle in the neck (cervical VEMP) and from electrodes placed on the upper and lower eyelids (ocular VEMP).
The video head impulse test (vHIT) was also performed to examine the semicircular canals within the inner ear, which sense angular motion. This test used goggles, which recorded eye movements as the patient’s head was quickly moved side to side and up and down.
For the foam posturography test, experimenters used a force plate that subjects stood on with their feet together to measure velocity (speed) of sway and area of the movement. Subjects were tested under four conditions: Fixed/Open (eyes open standing on a hard surface), Fixed/Closed (eyes closed standing on a hard surface), Foam/Open (eyes open standing on foam mat), and Foam/Closed (eyes closed standing on foam mat). Each trial was timed for 60 seconds, or until the subject needed help to prevent them from falling.
The experimenters used observational study data to find 53 age- and sex-matched healthy subjects. Data from the 53 PPPD patients were compared with data from the 53 healthy subjects.
In comparing posturography findings between healthy subjects and those with PPPD, the velocity (speed) of sway in the PPPD group was significantly higher than in the control group in the Fixed/Open Fixed/Closed, and Foam/Closed conditions. In the Foam/Open condition, the difference was not statistically significant. The area of sway in the PPPD group was significantly higher than that in the control group in the Fixed/Open, Fixed/Closed, Foam/Open, and Foam/Closed conditions.
In assessing Romberg’s ratios (the ratio of velocity or area with the eyes closed to that of the eyes open), the ratios were significantly higher in the PPPD group than in the control group in the Velocity/Fixed, Area/Fixed, Velocity/Foam, and Area/Foam conditions. These results suggest that the PPPD group was more dependent on visual input in a standing posture than the control group. The foam ratios were significantly higher in the control group than in the PPPD group in the Velocity/Open, Area/Open, Velocity/Closed, and Area/Closed conditions. These results suggest that the PPPD group tend to have less dependence on somatosensory cues in a standing posture than the control group.
Within the PPPD group, those that had abnormal VEMP and vHIT tests, falls occurred in all four conditions. In those with VEMP abnormal but vHIT normal, there were falls in all conditions except for the Fixed/Open condition. The VEMP normal and vHIT normal group had the smallest median value of velocity with Foam/Closed and Foam/Open conditions compared to others in the PPPD group.
The results of this study suggest that individuals with PPPD have higher postural instability and depend more on input from their vision while standing compared to healthy subjects. Also, PPPD patients tended to have lower dependence on somatosensory input in standing posture than healthy subjects. This information can be helpful in determining proper rehab protocols to help those recover from PPPD, especially in the physical therapy realm.
Summarized by: Danielle Beatty, DPT
Acknowledgements: Thanks to the Journal of Vestibular Research for granting VeDA access to this article.
Mal de Debarquement syndrome (MdDS) is a rare type of vestibular disorder characterized by a feeling of constant movement in the absence of motion. Movement can be experienced in the form of rocking, swaying, bobbing, or a pulling sensation. Although symptoms get better with passive motion (i.e. when you are a passenger in a car or on a boat), they can return after the passive motion ends. Symptoms may be triggered by motion (MT-MdDS) or occur spontaneously without motion (SO-MdDS). Other aggravating factor are exposure to busy environments (i.e. grocery store, airport), visual stimuli (i.e. computer use, phone use, video games), and fatigue.
The diagnosis criteria described by the International Classification of Vestibular Disorders is as follows: perception of continuous, non-spinning vertigo lasting a day; onset within 48-hours after passive motion is experienced; symptoms resolve temporarily after experiencing passive motion; and symptoms last greater than 48 hours. Undoubtedly, MdDS negatively impacts day to day activities, social interactions, recreational activities, ability to work, and ultimately quality of life. MdDS is not clearly understood, which makes it difficult to treat. In theory it originates in the central nervous system resulting from an abnormal vestibular ocular reflex (VOR). The role of the VOR is to maintain gaze stability during head movements, so when it’s not working properly symptoms of MdDS are experienced.
The purpose of this study was to determine the effectiveness of a treatment protocol directed at the maladaptive VOR. 101 subjects participated in the study, including males and females of various ages, with and without motion triggered MdDS. The basis of the treatment protocol was to apply head movements to the subjects as they simultaneously viewed a moving stripe pattern. The moving stripe pattern signifies an optokinetic stimulus (OKS) used to produce eye movements to aid in gaze stability. The type of stripe pattern was determined by clinical testing. The treatment began as the subject’s head was manually rotated by the clinician at a particular speed. During the manual head rotation, the subject was instructed to view the OKS, which was also set at a certain speed. The subjects received two, 4-minute treatment sessions per day for 2-5 days. Treatment outcomes were measured by subjective and objective data. Patients were required to rate the intensity of symptoms before and after each treatment session. They were also required to complete an MdDS symptom specific questionnaire on the first day before treatment and on the last day after treatment. Objective testing consisted of postural control and balance using a Wii balance board. These measurements were collected before, after, and in between each treatment session.
The results of the treatment protocol indicate 66% improvement. There was no substantial difference between the MT-MdDS group and the SO-MdDS group. Successful outcomes were measured by subjective reports of decreased symptoms, improvement in function, and improvement in quality of life. In addition, subjects demonstrated decreased sway and increased stability. It is important to note that the most improvement occurred during the protocol upon three consecutive treatment days. This study demonstrates that although MdDS is tricky to understand and treat, viable treatment options exist. A key factor is to identify appropriate individuals early in order to decrease the number of healthcare providers they see and treatments they receive.
Article review by Denise Schneider, DPT, FAAOMPT
Mal de débarquement syndrome (MdDS) is an under-recognized and little-understood chronic vestibular disorder primarily characterized with a phantom sensation of oscillatory self-motion or gravitational pull. MdDS typically onsets after prolonged exposure to passive motion of a transport vehicle, and is associated with a failure to readjust to a stable environment after adapting to being in motion. MdDS can be difficult to treat, but the chance of a positive outcome has improved recently with the discovery that a central vestibular function, known as velocity storage, may be ill-adapted in patients with this condition. Velocity storage is a center of multimodal sensory integration that contributes to eye and postural reflexes and spatial perception. As such, a visual-vestibular therapy technique aimed to correct the spatial orientation action of velocity storage is becoming recognized as an effective treatment for MdDS. However, this treatment may not prevent subsequent symptom relapse triggered by re-exposure to prolonged passive motion or provocative visual stimuli.
Presently, it was postulated that decreasing, as opposed to correcting, the ill-adapted velocity storage contribution in the brain pathways could also reduce symptoms of MdDS. Velocity storage may be useful in some contexts when correctly functioning, but having little velocity storage capacity by itself is not a known cause of functional impairment. To decrease the contribution of velocity storage, the investigators applied a visual-vestibular therapy technique modified from one that was originally developed for reducing proneness to motion sickness.
To contrast the effects of the two treatment approaches, 43 patients with MdDS were randomly assigned to two groups and followed for 6 months. Confirming previous studies, most patients (80%) in the group that underwent the spatial readaptation treatment initially experienced a substantial improvement in their symptoms, but the treatment did not prevent a symptom return in the long term. The new therapy technique also demonstrated a significant treatment effect, although with a much smaller initial impact. Just nearly one-half of the patients (43%) in the group that underwent the new treatment reported a substantial improvement in their symptoms. Remarkably, however, most of the responders to this treatment continued to experience reduced symptoms in the long term. Therefore, if initially effective, the treatment also had a long-term preventative effect against symptom relapse.
In summary, the study suggests that decreasing the presumably ill-adapted velocity storage contribution in the brain pathways can reduce symptoms of MdDS in some patients and that the treatment has a lasting effect. This new treatment approach shows promise as a long-term remedy for MdDS that can complement the spatial readaptation approach.
Source:
Maruta J, Cho C, Raphan T, Yakushin SB. Front Rehabil Sci. 2024 Feb 29;5:1331135
Secondary autoimmune inner ear disease (AIED) is often bilateral and asymmetric in patients presenting with audiovestibular symptoms due to a systemic autoimmune disease. This systematic review and meta-analysis are aimed at identifying and highlighting patterns in prevalence of vestibular dysfunction, symptom presentation, and diagnostic methods in literature by combining case reports with quantitative analyses from cohort studies. Secondary AIED does not have a diagnostic algorithm for managing vestibular symptoms. The management of audiovestibular symptoms requires close collaboration between otolaryngologists and rheumatologists to preserve end-organ function of the ear. To improve our ability to understand the impact on the vestibular system, vestibular clinicians need to develop a standardized reporting method. Clinical presentation should frequently be paired with vestibular testing to contextually investigate symptom severity and provide higher quality care.
How the Mongolian Gerbil May Help Solve the Brain Fog Caused by a Rare Inner Ear Problem
Rutgers scientists develop model to enhance understanding of a condition known as “third window syndrome.”
To patients of P. Ashley Wackym, a surgical otologist-neurotologist at Rutgers Robert Wood Johnson Medical School, a diagnosis of superior semicircular canal dehiscence (SSCD) can feel like a death sentence.
SSCD, a type of “third window syndrome,” is caused by an abnormal third mobile window of the inner ear. Normally humans have two of these windows. When a third “window” is present – at birth, after trauma or for reasons that remain unclear – patients can suffer sound-induced dizziness, hearing internal sounds unusually well (one-third can hear their eyes move or blink), and chronic headaches.
Patients can also suffer cognitive dysfunction – such as impaired memory, poor concentration, spatial disorientation, slurred speech, out of body experiences and crippling anxiety. However, many patients refer to this generally as brain fog.
“If you could just blow my head off, I’d let you,” one patient said she told her husband after receiving a diagnosis of SSCD. Vertigo, nausea, confusion and other symptoms of the rare inner ear problem had made everyday tasks – from shopping to listening to music – unbearable. “I cannot live like this,” she said.
Todd Mowery , Wackym, Justin Yao and other colleagues in the Department of Otolaryngology – Head and Neck Surgery are working to speed the recovery of patients like this one, and a Mongolian gerbil with an ear structure like humans could help eventually help researchers better understand the cognitive challenges and facilitate recovery.
Their findings are published in the neuro-otology section of the journal Frontiers in Neurology.
“We don't know what part of the brain is impacted by this disorder,” said Wackym. “That's where the animal model comes in. With this model we might be able to understand the nervous system pathways affected by SSCD and develop interventions to prevent this dysfunction or accelerate recovery.”
As much as two percent of the U.S. population has SSCD, which was first medically identified in 1998. “While surgery can plug the third hole, based upon neuropsychology studies in these patients, full cognitive recovery can take between three and 18 months,” Wackym said.
To develop the cognitive dysfunction animal model, 33 adult Mongolian gerbils were randomly divided into four groups and trained to perform four different decision-making tasks. All then received a semicircular canal fenestration in their inner ear. This procedure created an artificial third window.
The researchers then studied how the SSCD impacted the decision-making. They found that the animals all had significant impairments in their decision-making, like those observed in human patients with SSCD.
They also discovered the impaired decision-making recovers after the bony holes created in the animal’s inner ear healed spontaneously. “This will enable future studies to test SSCD conditions before, during and after recovery, findings that could be applied to human patients,” Wackym said.
“If we knew what was impacted and what was involved with the central neuroplasticity of SSCD, we could develop interventions that might speed up the human-recovery process restoring cognitive function,” he said. “As the first successful animal model for SSCD impaired decision-making, this tool will help neuroscientists better understand the anatomy and pathology of SSCD cognitive dysfunction.”
Authors Benedict Katzenberger, Fiona Brosch, Stéphane Besnard and Eva Grill
Journal of Clinical Medicine, 2023
The vestibular system in the inner ear detects movement of the body. The vestibular nuclei in the brainstem process this movement information as well as input from other senses. This area of the brain is also involved in many important functions including hormone regulation, cognitive function, motion-related emotion, body position, and orientation.
Rocking babies to sleep happens in most cultures, so there seems to be a close tie between sleep and the vestibular system, which is detecting this rocking movement. There is also evidence of a connection between the vestibular system and circadian rhythms, body temperature, rest cycles, and various aspects of sleep.
It is hypothesized in this paper that temporary or permanent vestibular hypofunction affects circadian rhythm, sleep, and thermoregulation. It is also hypothesized that chronic vestibular issues result in poorer sleep quality compared to acute vestibular problems.
This was a cross-sectional study using data from the DizzyReg patient registry at the University Hospital Munich, Ludwig-Maximillians University, Germany from the outpatient clinic German Center for Vertigo and Balance Disorders (DSGZ). Included in the study were all new patients 18 years of age or older from April 2022-August 2022. Patients were sorted into peripheral if the vestibular issue came from the inner ear, central if the vestibular issue affected the central nervous system, or functional if their symptoms were primarily psychological. The Pittsburgh Sleep Quality Index (PSQI) was used to assess sleep quality and sleep disturbances for the previous four weeks for each participant. Patients self-reported their sleep difficulties on this 19-question form. The group was also categorized based on two years or less of vestibular issues versus more than two years of vestibular issues. Comorbidities and alcohol consumption were also considered in this study.
The results of this study demonstrate that vertigo significantly affects sleep, and chronic vertigo is associated with decreased sleep quality compared to acute vertigo, independent of other factors such as age, gender, or comorbidities. Having chronic vertigo symptoms is also associated with needing more time to fall asleep and less sleep efficiency, which is the amount of time in bed that you are actually asleep. In this study, 79% of participants reported that it takes 30 minutes or more to fall asleep, and this affected their ability to function during the day. For comparison, a large European study of adults that didn’t focus on vestibular disorders resulted in only 16% of participants needing extra time to fall asleep. A similar difference has been demonstrated in studies comparing people with migraine to those without migraine, showing an almost 10-minute difference in time needed to fall asleep between the two. Since vestibular migraine was represented by participants in the study, this is also relevant to sleep health.
While the exact pathways in the body and cause for the increased sleep disruptions in individuals with vestibular issues has not yet been determined, this study underlines the importance of addressing vestibular issues and providing timely, appropriate treatment to improve sleep and decrease the risk of further chronic health conditions. Vestibular compensation and vestibular rehabilitation are essential components to helping people with vestibular disorders decrease their symptoms and improve their sleep. This also helps stop the cycle of poor sleep and increased vestibular symptoms. Poor sleep leads to worsening symptoms, which perpetuates the poor sleep. This also makes it harder for the brain to compensate for the vestibular disorder and makes vestibular rehabilitation less effective because neuroplasticity is decreased.
In conclusion, the importance of early diagnosis and treatment is crucial for addressing vestibular symptoms and the related sleep deficits. Sleep should be considered with all vestibular assessments, and vestibular function should also be assessed with any sleep problems.
Sleep is a fundamental need for human survival and disrupted sleep can lead to many chronic health conditions. Disrupted sleep makes vestibular symptoms worse, which can increase fall risk and decrease quality of life.
Vestibular issues often don’t get addressed right away, and many patients see several healthcare providers before they get an appropriate diagnosis and treatment for their vestibular symptoms. Addressing vestibular issues as early as possible can help prevent the cycle of poor sleep leading to worsening vestibular symptoms which results in even poorer sleep. It also helps decrease the negative compounding effects of poor sleep on overall health.
Patients with vestibular issues should get proper vestibular treatment for their symptoms as soon as possible to help prevent sleep problems. Thus, clinicians should be screening for sleep problems in their vestibular patients and anyone experiencing sleep issues should also be assessed for vestibular issues. Having awareness of the specialists in one’s area to refer patients for sleep or vestibular assessments saves time and helps patients get treatment faster.
Source: Katzenberger B, Brosch F, Besnard S, Grill E. Chronic Vestibular Hypofunction Is Associated with Impaired Sleep: Results from the DizzyReg Patient Registry. Journal of Clinical Medicine. 2023; 12(18):5903. https://doi.org/10.3390/jcm12185903https://www.mdpi.com/2077-0383/12/18/5903
Bilateral vestibulopathy (BV) is a chronic vestibular disorder, with loss or severely impaired vestibular function in both ears. Symptoms can include unsteadiness and oscillopsia (movement-induced blurred vision) and may result in imbalance while standing and walking, causing an increased risk of falling. Cognitive impairment has also been observed in BV. The combined impact of BV on cognitive and motor functioning could potentially result in “cognitive–motor interference.” In predictable environments, postural control is fairly automatic for healthy persons; however, in unpredictable situations (e.g. in a busy store) and/or with vestibular conditions such as BV, balance can require more attention, resulting in cognitive-motor interference.
Cognitive–motor interference is typically assessed using a dual-task designed experiment, which involves assessing both motor and cognitive functions at the same time. Thus far, only two studies have assessed cognitive–motor interference in persons with BV. This study aimed to study dual-tasking in persons with BV and hypothesized that persons with BV would perform worse on the cognitive and motor tasks in single-task conditions (tests that involve assessing only cognitive or only motor tasks) and disproportionally worse on cognitive and motor dual-task conditions.
For this study, twenty-two persons with BV (based on the Bárány Society criteria) between the ages of 24 and 70 and twenty-two healthy control subjects between the ages of 23 and 69 were included. A series of audiovestibular assessments were completed on both groups. The 2BALANCE protocol, which assesses various cognitive and motor skills, was utilized for dual-task assessment. The 2BALANCE is a cognitive–motor dual-task protocol consisting of two motor tasks and seven cognitive tasks. All tasks were performed in a single-task condition (on its own), in a static dual-task condition (combined motor and cognitive tasks while being stationary) and in a dynamic dual-task condition (combined motor and cognitive tasks while moving):
According to Kahneman’s Capacity Model of Attention, dual-task assessments enable observing the allocation of attention to cognitive and motor tasks. One of the theories proposed to explain the neurophysiological mechanisms behind cognitive–motor interference is the capacity sharing theory, which states that the performance of the motor and/or cognitive task will decrease when the available cognitive capacity is surpassed. This decrease in performance depends on the prioritization of the task. In order to observe the spontaneous allocation of attention, no instructions were given about prioritization in this study. A larger cognitive–motor interference was observed in the BV group, resulting in a decrease in cognitive performance.
Multiple cognitive domains were observed to be affected in the BV group. Adding a walking task impacted the BV group, but not the control group. This might indicate that the walking task required a certain amount of cognitive capacity, causing the remaining capacity to be insufficient to perform the cognitive task in the same manner as while stationary. Specifically, the control group responded significantly faster while walking. These faster response times in the control group might have resulted from a self-imposed time limit to finish the tasks before reaching the end of the walkway. However, the BV group might have been less able to meet this time limit, because of limited cognitive and motor resources.
During the static postural tasks, the BV group used a bigger surface, longer path length, and higher velocity to remain balanced during the static motor task in all test conditions. It could be hypothesized that postural control would be affected by an added cognitive task; however, the opposite was observed. The constrained-action hypothesis could explain this phenomenon, which was observed in both groups. When asked to balance as steadily as possible, one tends to focus more internally on maintaining balance, which can have a negative effect. When a cognitive task is simultaneously performed, the attention might be drawn away from the balancing task and make balance more automatic.
As clinicians, it is important to evaluate balance under dual-task conditions to assess how vestibular disorders can affect cognitive and motor functioning. This ensures a more comprehensive evaluation of functional performance to reduce the risk of falls in those with bilateral vestibulopathy and improve their quality of life.
Summary by Sonia Vovan, PT, BHSc, MScPT
This retrospective case study describes a proposed new way to identify vestibular impairment in patients with post-traumatic brain injury (TBI) using a noise canceling device (NCD).
Patients seen in a specialty vision clinic were diagnosed with vertical heterophoria (VH), or vertical misalignment of the eyes. If they did not respond adequately to microprism lenses and/or if they experienced hyperacusis (noise sensitivity) they were given a NCD and their response evaluated. If there was a significant reduction in TBI symptoms, including dizziness, the patients were referred to a neurotologist for a vestibular diagnostic evaluation. Fourteen patients were identified and found to have abnormalities on vestibular testing consistent with third mobile window disorder (TMWD), which results from a leakage of pressure and/or fluid from the inner ear structures. All were treated with a 6-week medical protocol (diuretics, no straining, low sodium/no caffeine diet). Five responded positively, requiring no further treatment. Nine required surgical intervention and responded positively.
In conclusion, in 14 patients with post-concussive dizziness and VH, a positive response to NCD was associated with abnormal vestibular testing, a diagnosis of TMWD, and symptom reduction/resolution with a medical or or surgical approach. The removal of sound resulting in reduction or resolution of vestibular symptoms represents an inverse Tullio phenomenon.
Summary by Christine Strange, AuD
Motorist Disorientation Syndrome(1) (MDS) also referred to as Motorist’s Vestibular Disorientation Syndrome (2) are terms proposed to describe spatial disorientation (SD) specifically experienced when driving an automobile. Spatial awareness is primarily the result of the integration of proprioception (allows us to perceive the position and movement of our body parts) as well as the visual and vestibular systems. SD can occur due to impairment in one or more of these systems or in the complex processes that synthesize these sensory inputs. The activity of driving or flying introduces elements that exceed natural physical activities, such as increased speed of motion, increased speeds of changing visual environment and alterations of proprioceptive cues and these elements can induce or exacerbate SD in individuals with or without defined vestibular disorder (3,4). SD associated with flying has been extensively studied and the effects on the normal vestibular system and associated misperceptions of motion are well recognized and understood.(4) There are few studies, however, that address similar type symptoms experienced by motorists.
The symptoms associated with MDS have been consistently reported across multiple studies over the last several decades and include veering, the illusion of motion when at rest, tilt or rolling over, and difficulty on steep hills(1,2,3,5).
The perception of the vehicle veering or pulling to one side may be prompted by either a lack of visual references such as trees or buildings while driving a distance on an open road or can occur when large trucks are passing that momentarily limit the visual field. This feeling of veering can be so convincing that the driver may suspect the problem is due a malfunction of the vehicle.(2)
A perception of motion can occur when the vehicle is stationary and the traffic in the adjacent lane begins to move, which, like veering, involves a conflict in visual and vestibular cues. Rounding a corner, particularly at higher speeds, can result in the perception of tilt or vehicle roll over.
Lastly, misperception of angle or difficulty when driving over a hill may be related to the brief loss of visual cues when cresting the hill and/or proprioceptive changes related to postural changes that occur as the result of the incline or decline(2). Symptoms can be triggered by speed and other environmental factors including poor lighting, weather conditions, and familiarity of the road/route.
There are conflicting data regarding the prevalence of abnormal vestibular test results in this patient population. Treatments including medications, vestibular physical therapy, as well as cognitive behavioral therapy have been reported to have success in reducing or resolving symptoms provoked by driving.
There are several visual/vestibular disorders that have overlapping symptoms such as persistent postural perceptual vertigo (PPPD), vestibular migraine, and Mal de Debarquement Syndrome and others. However, MDS has been suggested as a distinct and separate disorder when symptoms are specifically provoked by driving and do not meet the criteria of other established disorders(1,2,3,5). However, further research is needed to explore the symptom and diagnostic profile proposing MDS as a unique disorder versus a subset of other established disorders.
Episodic vertigo can have many different clinical manifestations with one such manifestation being vestibular migraine (VM)1. However, VM is hard to diagnose especially in the absence of an universal definition of what constitutes VM1. This led to the development of the diagnostic criteria by the Bárány Society1. For a diagnosis of VM, the Bárány Society posits that four criteria need to be met:
There is a general consensus that VM is the most frequent clinical entity of episodic vertigo and the second most frequent cause of dizziness1. However, the prevalence highlighted here was based on a previous criteria called the Neuhauser criteria1. Therefore, the study authors set out to investigate the prevalence of VM based on the application of the Bárány criteria1. For this study, Kang et al. conducted a retrospective analysis on patients complaining of dizziness visiting an otolaryngology department in Korea between December 1, 2018 until November 30, 20201. A questionnaire was utilized to determine whether the symptoms met the diagnostic criteria1. The questionnaire was completed through an interview done by an otolaryngologist and was then subsequently captured in electronic medical records1. Additionally, medical records of patients with dizziness or headache-related disease codes were paired and extracted from a hospital database1. Utilizing methods such as Structured Query Language (SQL), demographic and clinical data were collected and responses were stored as comma-separated value (CSV) files for further analysis1. Results showed that out of the 955 patients assessed from the questionnaire, 356 (37.3%) patients had dizziness with a history of headache1. Furthermore, 111 (11.6%) patients had an initial clinical diagnosis of VM1. However, when the Bárány criteria was applied, the prevalence of VM dropped to 2.9% which is much lower than the reported prevalence of VM reported in the literature1. The study authors note that the lower-than-expected prevalence in the study could be due to a variety of factors such as racial and/or regional difference in the study population1. Furthermore, the study authors postulate that prevalence might have been higher if the less stringent Neuhauser criteria was applied1. The study authors suggest that since literature has shown the effects that migraine has on vertigo, it is important to further refine and modify the diagnostic criteria in future iterations as needed1. This can lead to quicker and more accurate diagnosis, a reduction in any possible misdiagnosis, as well as improved patient outcomes.
Summary by Saishravan Shyamsundar
Reference:
Mal de débarquement syndrome (MdDS) is a vestibular disorder involving a subjective sensation of rocking, swaying, or bobbing. Diagnostic criteria for MdDS are: (1) non-spinning vertigo with a majority oscillatory (back and forth movement) component, (2) onset within 48 hours of the end of passive motion (i.e. car travel), (3) transient symptom relief with re-exposure to passive movement, (4) symptoms lasting more than 48 hours and (5) not otherwise explained by another condition. Symptoms are usually triggered by sea, air, and car travel. Symptoms may also develop spontaneously in the absence of motion stimulus.
The underlying mechanism of MdDS is unclear. Several hypotheses have been proposed, including maladaptation of the vestibular system and changes in the activity of specific brain regions. MdDS usually affects middle-aged women; however, given the rarity of MdDS and its propensity to affect middle-aged adults, it is unsurprising that more information is needed regarding this condition in pediatric populations.
This article describes three cases of pediatric persistent MdDS, subsequent treatment, and their responses. MdDS in children is similar to adults, although migraine, migraine equivalents, and mood disorders appear more frequently. All three of the patients experienced migraine headaches or migraine equivalents at some point following the diagnosis of MdDS, which is higher than the prevalence of migraine reported in this age group. Though MdDS and chronic vestibular migraine share similar clinical characteristics, a hallmark feature of MdDS involves symptom alleviation with passive motion, with the return of symptoms when stationary. The comorbidity of mood disorders with MdDS is less commonly reported, even in adults. Two of the patients were diagnosed with generalized anxiety disorder, although only one was diagnosed before MdDS symptom onset. The third patient also reported significant anxiety surrounding the persistent MdDS symptoms. All patients included in this report received treatment with selective serotonin reuptake inhibitors (SSRI)/serotonin and norepinephrine reuptake inhibitors (SNRI) and/or benzodiazepines for anxiety, and experienced a moderate improvement in MdDS symptoms.
Although the investigation of mood disorders should remain a focus among pediatric MdDS patients, equal emphasis should be placed on diagnosing and treating MdDS or alternative causes of abnormal motion perception.
This article highlights the long delay in diagnosis that can occur in children with MdDS. The patients waited one month to 10 years before receiving a formal diagnosis and treatment. This delay can be largely attributed to the need for more awareness of the condition in this patient population. Pediatricians or general practitioners who encounter pediatric patients with MdDS symptoms should refer patients to neurologists or otologists to confirm the diagnosis and to vestibular therapists for treatment.
Summary by Sonia Vovan, PT, BHSc, MScPT
Source: Ramesh S, Ben-Dov T, April MM, Cho C, Mal de Débarquement Syndrome in Children: A Case Series, The Journal of Pediatrics (2023), doi: https://doi.org/10.1016/j.jpeds.2023.113435.
This third Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-3) from the Society for Academic Emergency Medicine is on the topic adult patients with acute dizziness and vertigo in the emergency department (ED). A multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding five questions for adult ED patients with acute dizziness of less than 2 weeks' duration. The intended population is adults presenting to the ED with acute dizziness or vertigo. The panel derived 15 evidence-based recommendations based on the timing and triggers of the dizziness but recognizes that alternative diagnostic approaches exist, such as the STANDING protocol and nystagmus examination in combination with gait unsteadiness or the presence of vascular risk factors. As an overarching recommendation, (1) emergency clinicians should receive training in bedside physical examination techniques for patients with the acute vestibular syndrome (AVS; HINTS) and the diagnostic and therapeutic maneuvers for benign paroxysmal positional vertigo (BPPV; Dix–Hallpike test and Epley maneuver). To help distinguish central from peripheral causes in patients with the AVS, we recommend: (2) use HINTS (for clinicians trained in its use) in patients with nystagmus, (3) use finger rub to further aid in excluding stroke in patients with nystagmus, (4) use severity of gait unsteadiness in patients without nystagmus, (5) do not use brain computed tomography (CT), (6) do not use routine magnetic resonance Imaging (MRI) as a first-line test if a clinician trained in HINTS is available, and (7) use MRI as a confirmatory test in patients with central or equivocal HINTS examinations. In patients with the spontaneous episodic vestibular syndrome: (8) search for symptoms or signs of cerebral ischemia, (9) do not use CT, and (10) use CT angiography or MRI angiography if there is concern for transient ischemic attack. In patients with the triggered (positional) episodic vestibular syndrome, (11) use the Dix–Hallpike test to diagnose posterior canal BPPV (pc-BPPV), (12) do not use CT, and (13) do not use MRI routinely, unless atypical clinical features are present. In patients diagnosed with vestibular neuritis, (14) consider short-term steroids as a treatment option. In patients diagnosed with pc-BPPV, (15) treat with the Epley maneuver. As of 2023, when applied in routine practice by emergency clinicians without special training, HINTS testing is inaccurate, partly due to use in the wrong patients and partly due to issues with its interpretation. Most emergency physicians have not received training in use of HINTS. As such, it is not standard of care, either in the legal sense of that term (“what the average physician would do in similar circumstances”) or in the common parlance sense (“the standard action typically used by physicians in routine practice”).
Source: Edlow, JA, Carpenter, C, Akhter, M, et al. Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE-3): Acute dizziness and vertigo in the emergency department. Acad Emerg Med. 2023; 30: 442- 486. doi:10.1111/acem.14728
Depersonalization and Derealization (DPDR) is a psychiatric disorder characterized by a sense of unreality and detachment from one’s surroundings, body, emotions, and self. The physical processes vary and include problems with sensory function that alter one’s perception of reality. Vestibular (inner ear) sensory dysfunction contributes to DPDR symptoms, as it interferes with a person’s perception of their posture and surroundings, and movement of themselves in relation to their surroundings.
The inner ear contains two divisions: 1) the peripheral vestibular system, which consists of the hearing and vestibular organs in the ear, and 2) the central vestibular system, which consists of the brain and brainstem, and is involved in processing and integrating information from the peripheral vestibular system. Peripheral vestibular dysfunction may bring about DPDR disorder. However, there is a lack of information on DPDR symptoms in disorders that include central (nervous system) vestibular dysfunction. This paper investigates whether DPDR may develop due to central vestibular hypofunction, such as in Machado Joseph Disease (MJD), and how vestibular dysfunction may develop into DPDR disorder.
The paper creates a concept of the “Three-Stage Model of DPDR”:
The vestibular system consists of two main components: the semi-circular canals and the otolith organs. The semi-circular canals are a series of tubes that sense rotational movement. The otolith organs consist of sacs that sense gravity and change in linear (backwards and forwards) motion. Patients with chronic (ongoing) peripheral vestibulopathy demonstrated reduced function of all six semi-circular canals (SCCs) of the inner ear, as well as spatial disorientation, anxiety, and other DPDR symptoms. Spatial disorientation and anxiety together can lead vestibulopathy to develop into DPDR symptoms. On the other hand, although patients with MJD demonstrated impaired function of all 6 SCCs and spatial disorientation, they showed normal otolith function and no anxiety or DPDR symptoms. These findings indicate that spatial disorientation and anxiety are prerequisites (required) for developing DPDR symptoms. Therefore, in the absence of panic anxiety, MJD central vestibulopathy is not necessarily converted into DPDR symptoms.
Studies of DPDR in vestibular patients have typically focused on SCCs functioning. This study tested both the SSCs and otoliths to evaluate their relative contribution to the beginning of DPDR symptoms, and their findings suggest that otolith dysfunction can generate DPDR symptoms. Otolith dysfunction creates spatial disorientation and anxiety by unsettling the activity of the hippocampus and TPJ. As the otoliths are the primary direct sensors of gravitational forces (gravity) and contribute to a person’s perception of being upright, dysfunction distorts this perception, causing anxiety and contributing to DPDR symptoms.
In conclusion, peripheral (inner ear), but not central (nervous system), vestibulopathy leads to DPDR symptoms. Specifically, otolith dysfunction, either with or without SSCs dysfunction, promotes DPDR symptoms. Finally, this paper proposes a three-step model for the development of DPDR in peripheral vestibulopathy:
Summary by Sonia Vovan, PT, BHSc, MScPT
Based on published literature, the Bárány Society takes the view that the evidence supporting a mechanistic link between an illusory sensation of self-motion (i.e., vertigo – spinning or otherwise) and neck pathology and/or symptoms of neck pain - either by affecting the cervical vertebrae, soft tissue structures or cervical nerve roots - is lacking. When a combined head and neck movement triggers an illusory sensation of spinning, there is either an underlying common vestibular condition such as migraine or BPPV, or less commonly a central vestibular condition. The Committee notes that migraine, including vestibular migraine, is by far the commonest cause for the combination of neck pain and vestibular symptoms. The committee also notes that since head movement aggravates symptoms in almost any vestibular condition, the common finding of increased neck muscle tension in vestibular patients may be linked as both cause and effect to reduced head movements. Additionally, there are theoretical mechanisms which have not been explored. The committee accepts that further research is required to answer the question as to whether those rare cases in which neck muscle spasm is associated with a vague sense of spatial disorientation and/or imbalance is indeed linked to impaired neck proprioception.
Background:
Dizziness is a common problem which can significantly burden the healthcare system and affect one’s ability to work. Vestibular rehabilitation is one of the treatments for dizziness which involves movement of the head and body to help patients habituate to their symptoms. Despite the strong evidence for vestibular rehabilitation, more than half of the patients with acute symptoms continue to have chronic dizziness. One theory is that patients are avoiding movements that make them dizzy, which is counterproductive to resolving their symptoms. The Vestibular Activities Avoidance Instrument (VAAI) was developed to detect motion-based fear-avoidance behaviors, especially since there are few instruments that exist to measure these behavioral and psychological factors. The initial instrument had 81 items, but this was not as useful clinically, so a modified version was created with 9 items.
Methods:
A prospective cohort study was conducted with 151 healthy participants over the age of 20 who were recruited by students and staff of the Rehabilitation Sciences and Physical Therapy Department of the University of Antwerp, Belgium and 106 people with dizziness over the age of 20 who were recruited by the ENT departments of two hospitals: one in Antwerp, Belgium and one in Rotterdam, the Netherlands.
All participants completed the 81-item VAAI and were asked to complete it again at least one day later as a re-test. VAAI scores completed initially and as a re-test from each participant that were within 7 days of each other were included in this study. 102 healthy participants and 43 people with dizziness met these criteria.
Discussion:
Both the 9-item and 81-item VAAI instruments demonstrated excellent test-retest reliability and internal consistency for both participant groups. Results showed that the participants with dizziness had significantly higher fear avoidance beliefs compared to the healthy controls. The VAAI can help predict individuals who will have activity and participation limitations at 3 months and help categorize patients into groups of lower versus higher risk for chronic dizziness. The Dutch version of the VAAI scored slightly lower in internal consistency compared to the English version, but overall is a useful outcome measure for detecting patients who may be at high risk for chronic dizziness secondary to fear-avoidance behavior.
What is it important/how does it impact patients/clinical relevance?
Identifying patients early in the rehabilitation process that present with fear avoidance behaviors is beneficial for treatment planning. Connecting them with the appropriate team including cognitive behavioral therapy and vestibular rehabilitation that addresses fear avoidance behaviors can improve overall outcomes. Using the 9-item VAAI is better for clinical application due to time constraints, while the 81-item VAAI is useful for research settings.
Source
Summary by Megan Daly, PT, DPT, CHC
MdDS is a condition where patients feel like they are always on a boat. It is typically triggered by passive motion-events (cruises, flights, etc.), but can develop after non-motion events. People with MdDS can experience symptoms like those with certain visual disorders, therefore we wanted to see if there were overlaps between these conditions. This study surveyed people with MdDS and individuals from the general population about visual health and found that the MdDS group reported a higher frequency of visual dysfunction symptoms. Compared with motion-triggered patients, non-motion patients reported unique visual symptoms. This demonstrates that visual disorders may coexist in MdDS.
By Divya Chari, MD & Jeffrey Sharon, MD
Brain fog is a common complaint for those with vestibular disorders. Forgetfulness, inattention, trouble concentrating, and errors in navigation all occur, leading to lost keys, forgotten names, and wrong turns. But why do vestibular problems cause brain fog.
The traditional view of the vestibular system focuses on two primary functions: 1) keeping eyes steady as we move; and 2) keeping bodies steady as we move. If the vestibular system is there for clear vision and coordinated movement, why do so many experience trouble thinking? A number of research studies published in the last 20 years show that the vestibular system is far more complicated than we originally thought. These studies give us insight into connections between the vestibular system and the brain. They turn the traditional view of the vestibular system on its head (pun intended!).
The aim of our research was to collect and organize the evidence that vestibular problems can cause brain fog. In the paper, we summarize both animal and human data. Animals are easier to study because researchers can surgically remove or chemically destroy the peripheral vestibular system. Or the part of the inner ear that contains the gravity sensors and movement sensors that tell our brain where we are in space. With human research, we study those with already damaged vestibular systems. While this does make the data messier, there are advantages as well, because humans are much more articulate than laboratory mice!
Numerous animal studies have shown that when the vestibular system is removed the animal doesn’t just have problems with keeping their eyes and bodies steady as they move, they also show specific patterns of brain dysfunction. They can’t form the mental maps necessary to navigate, and therefore they get lost and disoriented. They try and try but can’t find food or home without their vestibular system.
In humans, a number of different cognitive problems can be seen with vestibular disease. Studies have shown errors in navigation, short term memory, mental rotation (turning a picture of an object in your head), and attention. In most studies, people with one damaged vestibular system (keep in mind, we have two inner ears!) perform somewhat worse than healthy volunteers, and those without any vestibular system perform the worst.
When you study how the vestibular system is connected to different parts of the brain, the brain fog phenomenon makes sense. The vestibular system is directly plugged into the hippocampus, a brain area important for memory and navigation. One study showed that humans with vestibular damage had smaller hippocampi because of atrophy. Of note, we see brain fog with many different vestibular diseases, including vestibular hypofunction, vestibular migraine, and superior canal dehiscence syndrome.
Everyone agrees that more research is needed. We need to better understand brain fog and whether different diseases have different patterns of brain dysfunction. We also need better research to understand the most important question: with proper treatment, can we cure brain fog?
Introduction: Psoriatic skin lesions are often seen in the auricle and external auditory canal, but middle ear and inner ear manifestations are not easily identified. Several studies have indicated hearing loss and vestibular dysfunction with psoriasis, but the extent of association has not been well defined.
Conclusion: This study shows that psoriasis is associated with hearing loss and vestibular dysfunction, but clinical significance remains undefined. The trends noted in the study require more investigation, and the pathophysiologic mechanisms need to be defined.
Summary written by Sonia Vovan, PT, BHSc, MScPT, Cynthia Ryan, MBA, and John King III, MEd, PhD
During a vestibular exam, it is common to test the VOR (vestibular-ocular reflex,) which is an automatic eye movement that keeps images stable when the head moves. However, motion perception, which helps us sense the speed of items moving in our visual field, is not always tested.
The aims of this study were to:
Investigate whether patients with Meniere’s disease (MD) can accurately sense their own motion.
Compare VOR to asymmetric (opposite side) and symmetric (same side) rotation.
Patients sat on a computer-controlled chair fixed on a platform in a sound-proof room. Before testing, patients were asked to look at a target on the wall and memorize its location, which they had to imagine during the trial (as the trial was performed in the dark with eyes closed). During the trial the chair was moved at different velocities, fast to one side (called a fast half cycle, or FHC), then returning slowly to the original position (slow half cycle, SHC). Patients were asked to track the memorized target by maintaining a hand-held pointer directed at that spot. Tracking position error (TPE) is a measurement used to represent when a patient did not track the imagined target correctly.
The study tested patients with unilateral (one-sided) Meniere’s disease and unaffected (control) individuals. In unaffected subjects the TPE was similar, whether the fast half cycle was directed to one side or the other. However, in patients with Meniere’s disease, the TPE was different depending on the direction of the fast half cycle, specifically, FHC to the healthy (non-affected) side caused a greater TPE than to the side damaged by Meniere’s disease. Individuals with more frequent Meniere’s attacks were more affected. This difference in TPE was termed the Perceptual Asymmetric Index.
Subjects were also evaluated with the same task (pointing at an imaginary target) while being rotated back and forth in a symmetric pattern at different frequencies (speeds).* The TPE was measured after four cycles and again found to be different between the patients and controls.
Eye movements were recorded to enable direct measurement of the VOR, from which slow phase eye position (SPEP) was calculated. The difference in SPEP for this task was called the VOR Asymmetric Index, and was found to be higher in Meniere’s patients compared to controls.
The Perceptual Asymmetric Index was found to be correlated with the Dizziness Handicap Inventory (DHI) score. Interestingly, the VOR Asymmetric Index did not appear to demonstrate correlation with the DHI.
The study shows that the Asymmetric index may be helpful in determining which side is affected in Meniere’s patients when this is not clear, as well as in individuals with a normal VOR.
As perceived self-motion may be at the core of the discomfort experienced by Meniere’s patients, rehabilitation focused on motion perception may significantly improve the quality of life of these patients. Evaluation of vestibular perceptual asymmetry can guide rehabilitation programs to restore balance by providing valuable information to initiate rehabilitation techniques that enhance motion perception towards the side where it is less responsive or reduce motion perception towards the side where it is excessive.
*This symmetric type of rotation is what is typically done clinically with a rotational chair. The asymmetric (fast half-cycle) rotation is not the clinic norm. Thus, the use of the non-symmetric rotation may be helpful when testing patients with Meniere’s Disease.
Insights from the Vestibular Disorders Association Registry
Authors: Colin R Grove, Wagner Henrique Souza, Patricia L Gerend, Cynthia A Ryan, Michael Schubert
Introduction: Benign paroxysmal positional vertigo (BPPV) is the most frequently occurring peripheral vestibular disorder. Clinical practice guidelines (CPG) for BPPV exist; however, little is known about how affected patients perceive their condition is being managed.
The purpose of this study was to leverage data from VeDA’s patient registry to examine patients’ perceptions regarding: 1) how the management of adults who report being diagnosed with BPPV compares with the BPPV CPG, 2) whether those who report being diagnosed with BPPV are managed differently than those who report being diagnosed with other causes of vertigo or dizziness, and 3) whether the outcomes of common interventions differ between those who do and do not report being diagnosed with BPPV. We hypothesized that compared to those who report being diagnosed with other causes of vertigo or dizziness, adults who report being diagnosed with BPPV would endorse symptoms characteristic of BPPV more frequently, report falls less frequently, undergo advanced diagnostic testing less often, be offered CRMs more frequently, and achieve superior outcomes with CRMs.
Material and Methods: Researchers retrospectively analyzed data from 1,262 adults who were enrolled in the Vestibular Disorders Association Registry from 2014 to 2020. The responses were analyzed for those who did and did not report BPPV based on the following: symptoms experienced, falls reported, diagnostics undertaken, interventions received (eg, canalith repositioning maneuvers [CRMs], medications), and responses to interventions.
Results: Of the 1,262 adults included, 26% reported being diagnosed with BPPV. Many adults who reported BPPV (83%) also reported additional vestibular diagnoses, or may have had atypical BPPV.
The symptom profile for those with BPPV differed from those without BPPV. A significantly greater proportion of those with BPPV said that specific movements or positions triggered their dizziness. Additionally, a significantly lower proportion of those with BPPV experienced room-spinning or head-spinning vertigo, and/or felt woozy while watching things move in the environment and/or being surrounded by people in a busy environment.
Participants with BPPV indicated having more diagnostics than those without BPPV. Those with BPPV underwent magnetic resonance imaging and were prescribed medications more frequently than those without BPPV. Falls were experienced by similar proportions of adults with and without BPPV. As expected, adults with BPPV received CRMs more often than those without BPPV, and more registrants with BPPV endorsed the benefit from CRMs compared to those without BPPV.
Discussion: In this registry, BPPV was often reported concurrently with other vestibular disorders. Those with BPPV underwent an array of resource-intensive diagnostic tests more frequently than did those without BPPV. The most frequently reported symptom of people with BPPV was a falling sensation, even while sitting or lying down. The rates of falls in those with and without BPPV are higher than previously reported. Adults with BPPV reported significant differences in how their care is managed and their overall outcomes compared to those without BPPV.
BPPV is under-diagnosed, possibly because dizziness may be attributed to the primary diagnosis alone and further exploration and testing is not pursued. As a result, persons with BPPV who present with atypical dizziness are not exposed to diagnostic positioning maneuvers. Conversely, persons with dizziness may receive an initial diagnosis of BPPV and further work-up is not undertaken that could uncover a secondary and concurrent diagnosis. Therefore, diagnostic positioning maneuvers should be conducted in patients who report dizziness during position changes, even if the symptom profile is not typical for BPPV.
Conclusion: Patient-reported outcomes provide useful information regarding the lived experience of adults with BPPV which can improve their clinical care.
https://doi.org/10.2147/PROM.S370287
Fibromyalgia (FM) is a poorly understood central pain processing disorder. People with FM experience a broad range of symptoms, such as chronic pain, sleep disruption, chronic fatigue, and psychosomatic symptoms. Recent studies have shown that FM patients also experience dizziness. This study aimed to establish the prevalence of vestibular symptoms in FM patients through a series of questionnaires. The study found that FM participants were significantly affected by vestibular symptoms, which correlated with FM-associated pain and non-pain symptoms. The dizziness reported by FM participants showed unusual features, suggesting an FM-intrinsic mechanism of vestibular dysfunction, possibly linked to migraine and dysautonomia conditions. Correlations between dizziness and depressive mood revealed an impact of dizziness on psychological status, leading to depressive reactions and interpersonal difficulties, and possibly involving a noxious, self-sustained stress condition. Researchers suggest that dizziness plays an inherent role in FM and should be considered by healthcare providers when treating FM patients.
Our position in a three dimensional world could be described by three spatially fixed axes: X, Y and Z. The head and eye orientations can each also be described by three axes. To see clearly when the head moves, the vestibulo-ocular reflex (VOR) counter-rotates the eyes to stabilize the gaze in space. For slow movements, there is a central vestibular mechanism that receives input from the peripheral vestibular system, the visual system, and somatosensory information and “integrates” this information to code the orientation of the eyes with respect to gravity while the head and body are in motion. This mechanism is called velocity storage. The orientation of the three axes of velocity storage is defined by roll, pitch, and yaw “eigenvectors.” In a stationary upright position of the head and body, the eigenvectors must be aligned with the head coordinate axes to stabilize our orientation perceptions. If any of the three eigenvectors of velocity storage becomes misaligned with respect to the head coordinates, it is as if the head were tilted and is perceived as a pulling sensation by patients with Mal de Débarquement Syndrome (MdDS). Dai et al. (2014) suggested that the deviation of the roll (X-) axis eigenvector induces the rocking in MdDS patients. Some MdDS patients, however, do not suffer from rocking but rather a pulling sensation in a particular direction. The treatment for this is explained in the present study. The authors of this paper hypothesized that pulling sensations in any direction could be generated by maladaptation of the yaw eigenvector of velocity storage with respect to the Z-axis. This idea suggested that the proper treatment for pulling was to re-adapt the yaw eigenvector to better align with the head Z-axis. They showed how an optokinetic stimulus (OKS), a purely visual stimulus, could be used to re-adapt the eigenvector. This idea was consistent with the data, which demonstrated that the gravitational pull to the right, left, back and forth, down, and up could be corrected. This new treatment complements the original treatment of perceptions of rocking developed by Dai et al. (2014).
Persistent postural perceptual dizziness (PPPD), is a “functional” disorder, which means that it impairs normal functioning of bodily processes, though its underlying mechanism is difficult or impossible to identify.
Specific criteria for PPPD include dizziness, unsteadiness, non-spinning vertigo exacerbated by upright posture, active or passive motion, moving visual stimuli, and complex visual stimuli, which persists for three months or more. It is usually precipitated by a vestibular condition such as neuritis, but can also be triggered by other medical/psychological events, and in some cases has no identifiable trigger.
In this article, Azzie et al. collected responses through several questionnaires presented to 100 people attending a multi-disciplinary balance clinic. People were asked to rate the severity of their symptoms such as dizziness, anxiety, and depression. Respondents were primarily female and middle-aged. For 55% of participants a trigger could be tied to their PPPD, while 45% did not have a precipitating event.
The results indicated that 58% of respondents were severely impacted by their condition. On average, patients had symptoms for 35 months and had to take 9 months off from work. Visual vertigo scores were higher than the control group, indicating that PPPD patients are significantly more affected by disorienting environments and complex visual stimuli. The majority of patients in this study were evenly distributed among mildly, moderately, and moderately severe depression classifications, and reported mild anxiety. Most (71%) patients had a secondary diagnosis contributing to their dizziness; the most common (28%) was vestibular migraine.
There were some limitations of this study. Results may not be generalizable to PPPD patients seen at non-specialist clinics. Patient reported symptoms are a potential bias and rely heavily on recall, which may result in over or under estimation. Secondary diagnoses may make it difficult to distinguish between factors caused by the patient’s PPPD and other conditions.
This information can help healthcare providers have a better understanding of the impact PPPD has on peoples’ lives, leading to more successful treatment.
Summary author: Jennifer Robbins, MPT
The Bárány Society considers Vestibular Medicine Curriculum as a major initiative to improve the care for vestibular patients worldwide by improving training of health professionals.
The Bárány Society acknowledges that Vestibular Medicine is a concept that embraces all types of disorders which may lead to vestibular symptoms, ranging from disorders of the inner ear to the brain, and beyond these structures. Therefore, the diagnosis and treatment of vestibular disorders transcends traditional physician and allied health professional disciplinary boundaries, with many diverse groups practicing Vestibular Medicine.
In Vestibular Medicine, each of these specialties and professions have their own characteristic role and profile, while having some overlap between their activities, which can be substantial. Vestibular Medicine is truly multidisciplinary. It is important for those practicing to cooperate with each other and to understand and recognize their own, and each other’s, expertise and limitations.
The Bárány Society Vestibular Medicine Curriculum provides a framework that defines the knowledge, skills, and attitudes needed to become proficient in Vestibular Medicine. Each specialty and profession has its own minimum requirements regarding knowledge and skills, ranging from anatomy and physiology to vestibular symptoms, history taking, bedside examination, ancillary testing, vestibular disorders, their treatment, professional attitudes, and research.
Basic research topics are specifically included in this framework, because according to the Barany Society you can only become an expert in Vestibular Medicine if you are aware of the ongoing basic and translational research in the field. On the other hand, vestibular scientists can use this curriculum as an inspiration for their research projects.
This curriculum defines requirements for Broad, Focused and Expert Level proficiency. This enables everybody involved in the care for vestibular patients to reach the level of proficiency needed for their own clinical practice. We encourage all physician specialties and health professions dealing with vestibular patients to use this curriculum.
The Barany Society Vestibular Medicine Curriculum defines Vestibular Medicine as a multidisciplinary concept and provides guidance for future teaching and training initiatives. We strongly encourage everybody involved in Vestibular Medicine to adopt this curriculum as an inspiration and benchmark for clinical practice and training. To facilitate its implementation, the Bárány Society has established an educational committee to promote high quality vestibular training worldwide, using this curriculum as the foundation.
Summary author: Raymond van de Berg, MD, PhD
Source:
Introduction
Migraine is a prevalent neurological disorder that can affect multiple areas of the brain. The brain is “hyperexcitable” or “hypersensitive.” Previous studies have demonstrated that the brains of those with migraines respond differently with electrophysiological testing because it is perceived as a stressful trigger.
Motion sickness (MS) occurs due to a sensory conflict or sensory mismatch between actual vs. expected inputs of the vestibular, visual, and somatosensory (touch) systems. Nausea and vomiting may be accompanied by other symptoms including headache, drowsiness, sweating, facial pallor, cold sweating, increased salivation, sensations of bodily warmth, dizziness, loss of appetite, and increased sensitivity to odors. Many of these features of motion sickness resemble symptoms of acute vestibular disease.
The caloric vestibular test (CVT) is used to compare the sensitivity and function of the right vs. left inner ear (peripheral vestibular system). This test can evoke nausea, vomiting, or imbalance. It has been shown that the ability to habituate (adjust) to vestibular stimulation relates to one’s susceptibility to motion sickness. Since those who suffer from migraines have a higher incidence of motion sickness, hypersensitivity of vestibular sensory processing is more likely to occur. The researchers therefore hypothesized that CVT-related side effects might be more robust and disturbing in patients with migraine and/or motion sickness because of their maladaptive or hypersensitive brains.
Materials and methods
Researchers analyzed records of 554 adult patients who underwent water based CVT with a complaint of dizziness. Water or air is irrigated in the ear to compare responses generated by each inner ear through measurement of nystagmus or eye movement. This test is used to determine if there is a vestibular weakness or hypofunction of the inner ear. For this experiment, only those with normal caloric responses were included. Patients were between the ages of 18 and 60. The Dizziness Handicap Inventory (DHI) is a questionnaire that evaluates self-perceived handicaps imposed by dizziness. The researchers included patients whose DHI score was between 36-52 points. Patients were divided into four groups: those with only migraines (MG), those with only MS (MSG), those with migraine and MS (MMSG), and those without migraine and MS (non-MMSG). Researchers monitored headaches, nausea, vomiting, and imbalance for 30 minutes after testing. Participants performed tandem (heel to toe) walking before and after testing to assess for imbalance.
Results
In analyzing results, researchers compared the symptoms of the groups separately for each gender. The severity of nausea and headache for each gender was significantly higher in the MG, MSG, and MMSG than the non- MMSG. For males, the MSMG had a significantly higher occurrence of vomiting than the other groups. As for imbalance in females, a significantly higher occurrence was found in the MSMG than in the other groups.
The provoked symptoms from the caloric test disappeared within a couple hours in the majority of patients. However, three patients (two females and one male) required hospitalization for optimal medical management of their severe headache or nausea/vomiting. The median DHI scores were significantly different between the non-MMSG and other groups. The median DHI scores did not differ though between the MS and migraine groups.
Discussion
The results of this study revealed that the MG, MSG, and MMSG had a higher intensity of headaches and higher frequency of vestibular symptoms compared to the non-MMSG after caloric vestibular testing. Nausea was the most commonly provoked symptom in all groups, including the non-MMSG. Studies show that migraine and motion sickness patients may have abnormal autonomic function compared to healthy subjects. Therefore, the autonomic nervous system might be responsible for the higher severity of CVT-evoked symptoms in cases of migraine and motion sickness. Imbalance was mostly seen in females in the MMSG and in males in the MG and MMSG. Being female and greater age were significant factors for CVT-evoked imbalance.
As for migraine sufferers, there are structural and functional changes across cortical and brainstem networks that likely contribute to the initiation of headaches. Patients with moderate or severe headaches may have a lower threshold for a trigger like CVT because of reduced intracortical inhibition or increased cortical excitability.
Researchers concluded that clinicians should reconsider the necessity of CVT and should be more cautious when performing caloric testing on a patient who has migraines or motion sickness.
Source: Gedik-Soyuyuce, Ozlem, Yalinay-Dikmen, Pinar, and Korkut, Nazim. ‘The Effect of Migraine and
Motion Sickness on Symptoms Evoked by the Caloric Vestibular Test’. 1 Mar. 2022 : 135 – 144.
Summarized by Danielle Beatty, DPT
Geographical location is known to affect health outcomes; however, evidence regarding whether place affects healthcare for persons suspected to have vestibular dysfunction is lacking. The objective of this paper was to investigate whether place affects healthcare seeking and outcomes for adults with symptoms of vestibular pathology. The authors assessed for regional disparities associated with demographics, diagnosis, chronological factors, and financial expenditures from Americans who participated in the Vestibular Disorders Association registry. Respondents were grouped per geographical regions
defined by the United States Census Bureau. Results indicated that there was no significant between-region differences for age, sex, or ethnicity. There were more Asian respondents in the West versus the Midwest and more Black respondents in the South versus the West. The time to first seek care was shorter in the Northeast versus the South. The time from the first healthcare visit to receiving a final diagnosis was shorter in the Northeast versus the South. Compared to the Midwest, fewer respondents in the Northeast reported “no” out-of-pocket financial impact.
CONCLUSIONS: Geographical location affects healthcare seeking and outcomes for persons suspected to have vestibular dysfunction.
Persistent Postural-Perceptual Dizziness (PPPD) is a chronic functional disorder leading to persistent dizziness or unsteadiness which occurs for at least three months. Symptoms typically occur when in an upright position, when in motion, or when exposed to a busy visual environment. Most cases occur amongst middle aged females.
While largely precipitated by a vestibular event such as Benign Paroxysmal Positional Vertigo (BPPV), there are reported cases of PPPD not caused by an acute event. PPPD can negatively impact how individuals experience their personal, social, and work lives. Current treatment approaches begin with open communication and education regarding PPPD diagnosis, with further management via vestibular rehabilitation, cognitive behavioral therapy, and pharmaceutical management with Selective Serotonin Reuptake Inhibitors (SSRI).
The aim of this study was to understand how disease duration impacts the quality of life, perceived dizziness handicap, and mental health in patients with a diagnosis of PPPD. Methodology of this study looked at changes across three validated subjective questionnaires: EuroQol-5D (EQ-5D), Dizziness Handicap Inventory (DHI), and the Depression Anxiety and Stress Scale (DASS-21). Collectively, the three questionnaires indicated generic quality of life, self-perceived severity of dizziness, and degree of stress, anxiety, and depression.
Two trends were apparent upon collection of the three validated questionnaires. Firstly, there was an inverse relationship between the severity of dizziness on the DHI and the health related quality of life measured by the EQ-5D, as well as between the level of stress, anxiety, and depression measured on the DASS-21 and the health related quality of life measured by the EQ-5D. Secondly, there was a direct relationship between the severity of dizziness as measured by the DHI and the level of depression, stress, and anxiety measured by the DASS-21. The inverse relationships above simply indicate that as dizziness severity and impaired mental health increase, quality of life decreases; while the positive relationship indicates as dizziness severity increases, so does depression, anxiety, and stress.
The relationship between dizziness and mood disorders is well established in the research. It is not uncommon for comorbid psychiatric disorders to arise during or after a vestibular event in the form of anxiety and depression, avoidance behaviors, and catastrophizing. These psychiatric symptoms can often worsen perception of dizziness and increase perceived handicap. The perceived worsening of dizziness can also worsen mental health and increase handicap. Therefore, the relationship is bi-directional and can lead to a vicious feed-forward cycle where anticipatory anxiety about onset of dizziness promotes sustained functional impairment through avoidance or compensation.
In summary, increased disease duration of PPPD can cause worsened dizziness, mental health, and perceived handicap. Commonly, much of the stress and anxiety caused by PPPD is due to absence of a clear diagnosis. Thus, it is important for clinicians to build constructive and stable rapport with their patients to promote diagnosis acceptance early on to avoid any self-stigmatization and begin the path to recovery.
By John Patrick Dorangricchia PT, DPT
History taking is one of the most important diagnostic tools in vestibular medicine. Therefore, the clinician should pay good attention to this step of the diagnostic process. However, history taking is a challenge, since many pitfalls are encountered, especially when performing it in patients with non-acute vestibular symptoms. For example, to focus on the quality of the symptoms (e.g. vertigo, light-headedness, non-specific dizziness) has proved unreliable, in contrast to focusing on the time course and triggers of symptoms. Furthermore, multiple vestibular disorders can co-occur within the same patient, and for these patients it might be difficult to distinguish all these type of disorders from each other. Therefore, in order to systematically guide the clinician and patient through the process of history taking, a 4-step approach is proposed, in which specific attention is paid to the time course and triggers of symptoms. This 4-step approach involves the following four steps: 1) describing any attack(s) of vertigo and/or dizziness, 2) describing any chronic vestibular symptoms, 3) screening for functional, psychological and psychiatric co-morbidity, and 4) establishing a comprehensive diagnosis, which included all the possible co-occuring (vestibular) disorders. It is important that “one aspect at a time” is addressed. After all, by addressing them separately, it is easier to separate symptoms from attacks (e.g. attacks of Meniere’s disease), from symptoms of vestibular hypofunction (e.g. vestibulopathy due to Meniere’s disease), and from symptoms of functional origin (e.g. Persistent Postural Perceptual Dizziness due to Meniere’s disease). By including all these disorders in the final diagnosis, treatment can also be focused on all of them. The aim of this 4-step approach is to improve history taking in vestibular patients, and to raise the awareness of the co-occurrence of vestibular disorders.
By Raymond van de Berg
Source:
van de Berg R, Kingma H. History Taking in Non-Acute Vestibular Symptoms: A 4-Step Approach. Journal of Clinical Medicine. 2021; 10(24):5726. https://doi.org/10.3390/jcm10245726
Motion Sickness Disorder (MSD) and Visually Induced Motion Sickness (VIMS) are normal responses to physical or visual motion, but can be considered a disorder in individuals that are especially susceptible or significantly impacted. The Bárány Society has developed criteria to help diagnose individuals with these disorders.
Generalized motion sickness is differentiated from what would be considered a “disorder” as follows:
Generalized motion sickness and visually induced motion sickness (VIMS)
Motion sickness disorder (MSD) and visually induced motion sickness disorder (VIMSD)
Susceptibility to motion sickness in normal individuals is not a strong predictor of susceptibility to VIMS. Nausea and vomiting are less common in VIMS than in motion sickness, whereas ocular issues (e.g., eyestrain, blurred vision) and headache are more common. Older adults are more susceptible to VIMS but not to motion sickness than younger adults. Motion sickness frequency and severity can be reduced by avoiding or limiting exposure to sickness-inducing stimuli, by modifying behavior during exposure (e.g., limiting head movements), by taking medications prior to exposure, by utilizing earth-referenced cues (e.g., viewing the outside world), or through gradual exposure to offending motion via habituation.
Common treatments include prescription of habituation exercises, prophylactic medications (anti-muscarines, anti-histamines, anticholinergics), alternative treatments (music, smells), and behavioral strategies (breathing exercises, meditation). The use of ginger or acupressure for motion sickness is common, but the empirical evidence for these interventions is mixed. The methods with the greatest benefits appear to be through adaptation, medications, and modifying behavior during exposure. Habituation is often stimulus-specific and may not generalize across all motion situations.
Motion sickness in childhood has been estimated at 35–43% prior to puberty and 25% in young adults; it is a frequent problem in 14% of adults younger than 30 years old and 7% of adults 61 years old or older. VIMS ranges widely depending on stimulus type and visual content, with rates varying from 1% to 60% to 80–95%.
Age
Infants are resistant to motion sickness until about age 2, after which susceptibility rises, peaking between the ages of 7–12 years and declining through adulthood. VIMS increases with age, with older adults reporting more VIMS than younger adults.
Sex
The literature has not yet demonstrated a consensus on sex differences in motion sickness susceptibility. Sex differences in VIMS have been observed in some studies, but again the overall case is weak for biological male/female differences.
Race and ethnicity and Genetics
A partial heritable component to motion sickness was observed, with heightened susceptibility in people of Asian descent compared to European or African descent, though further studies are needed.
Migraine
Motion sickness is self-reported in at least 50% of migraine sufferers with childhood motion sickness correlating with the development of migraines later in life. Research suggests that neural pathways for nausea and emesis are particularly sensitive in individuals with migraine. Migraine headache sufferers experience both motion sickness and VIMS to a higher degree than those without migraine, but the correlation is weak.
Structural vestibular disorders
Patients with chronic stable vestibular loss (unilateral and bilateral) report less motion sickness than healthy controls. In comparison, patients with benign paroxysmal positional vertigo fail to show a significant difference in motion sickness susceptibility. Vestibular neuritis can result in either an increase or a decrease in motion sickness susceptibility after its onset, with increased susceptibility in uncompensated cases. Two studies have shown that those with Ménière’s disease are more susceptible to motion sickness but are not as susceptible as those with migraine. No difference was noted between the degree of caloric asymmetry in vestibular patients and motion sickness ratings. In contrast, patients with vestibular disorders without vestibular loss report higher degrees of motion sickness than controls.
Motion sickness is a normal physiological reaction and should only be considered a disorder when it affects an individual’s ability to perform activities of daily life. This includes a reduction in school or work productivity, activity avoidance, the use of pharmacological remedies, or mental health changes. Disability can be determined and quantified by pairing formal disability scales (e.g. Sheehan Disability Scale) with an existing motion sickness or VIMS scale. As a basic assessment, The Social Life and Work Impact of Dizziness short form can be easily adapted for motion sickness.
For most individuals, education, exposure minimization, avoidance of aggravating behaviors, short-term use of anti-motion sickness medications, or simple habituation exercises may be used to reduce disability. In cases where VIMS or motion sickness does not rise to the level of a disability, it should still be recognized as a condition that may benefit from intervention.
Written by Joon Nah BScBiol, BScPT
Source
Cha, Yoon-Hee, et al. “Motion Sickness Diagnostic Criteria: Consensus Document of the Classification Committee of the Bárány Society.” Journal of Vestibular Research, IOS Press, 4 Oct. 2021, https://content.iospress.com/articles/journal-of-vestibular-research/ves200005.
During the early stage of the COVID-19 pandemic (2020), medical consultations for vestibular disorders plummeted by 50% (Ueda, 2021). Fear of infection was reported as the most frequent cause of appointment cancellations. Telemedicine, which was still in a rudimentary state, emerged as a partial solution to assist these patients in a virtual format. The new paradigm of medical attention demanded a new guide for the appropriate use of technical resources and an algorithm for virtual management of vestibular disorders. They were initially used to triage patients to urgent versus expedited care. However, as the pandemic dragged on, the telemedicine format was progressively adapted, for specific diagnoses (e.g. BPPV), and for vestibular telerehabilitation. Our published work (Barreto, 2021) summarizes the results and recommendations of a working group formed "ad hoc" for the management of non-face-to-face vestibular patients during this unique pandemic situation. The creation of a digital vestibular management algorithm for the identification, counseling, initial intervention, monitoring and targeting of people with possible chronic vestibular hypofunction, Meniere’s disease or positional vertigo seems to be feasible, and it will provide a reasonable alternative to in-person evaluations during the COVID-19 pandemic and beyond. On the other hand, patients with the acute vestibular syndrome (AVS) with rapid-onset vertigo and/or unsteadiness often accompanied by nausea, vomiting, and motion intolerance could be unable to cooperate for the tele-examination because of visual intolerance, nausea, vomiting, and discomfort, as well as technical and practical issues from poor lighting, slow Wi-Fi connections, and limited experience with technology. We proposed a strategy to provide this kind of care through the following steps:
The last is prioritized according to:
Although it would need to be validated, it is probable that a “Tele-Vertigo” approach performed by the dizzy specialist has better results in terms of correct diagnosis and treatment than an in-person non-specialist approach at the emergency department. Although at first glance telemedicine in dizzy patients may be associated with considerable limits, a great deal can be learned from the virtual visit practice if properly handled.
By Darío A. Yacovino, Marcello Cherchi, and Renato Gonzaga Barreto
Reference:
This study examined the risk of dementia in older people diagnosed with Benign Paroxysmal Peripheral Vertigo (BPPV). The research team examined data collected by The National Insurance Service of Korea, which included patients with and without diagnoses of dementia and those with and without a BPPV diagnosis. Patients in the study group (those with dementia) were matched 1:4 with members of a control group resulting in 11,432 patients diagnosed with dementia and 45,728 in the control group. The additional study parameters accounted for gender, income, region of residence, and medical history (including history of BPPV).
Since the vestibular system is known to affect cognitive functions, such as visuospatial ability, memory and attention, the authors believe it is reasonable to conclude that vestibular disorders may be associated with dementia. The authors also explain that BPPV is the most common cause of dizziness in those over 70 years old and BPPV may have a higher recurrence rate than in younger patients. Taking into consideration these factors, the authors of this study hypothesized that BPPV could increase the risk of dementia.
Following analysis of the study and control groups, the authors found that a history of BPPV was present in 5.3% of the individuals with dementia compared to 2.6% of the individuals in the control group. After adjusting for various factors, the risk of dementia was higher in the group with BPPV than the control group. As stated by the authors, “BPPV was related with an increased risk of dementia in patients ≥60 years of age.” Other factors related to gender, income, location of residence, and past medical history (high blood pressure, diabetes, high cholesterol) were also associated with an increased risk of dementia.
Despite these findings of a link between BPPV and dementia, the picture is certainly not a clear, straight-forward one. The authors suggest many possible factors related to the association between BPPV and dementia. Several direct factors such as increased risk of falls (possibly leading to head trauma) and physical inactivity may increase the risk of dementia. Additionally, BPPV frequently causes patients to become socially isolated and less physically active, which can contribute to the development of dementia. BPPV and dementia also share some common physiological causes, such as ischemic heart disease (lack of oxygen to the heart), high blood pressure, diabetes mellitus, and dyslipidemia (high cholesterol). Additionally, some research has indicated that medications, such as benzodiazepines administered to reduce vertigo or anxiety in patients with BPPV may affect the development of dementia. This study also found an increased risk of dementia in men with BPPV. Sex-based differences may be correlated with education and income levels, social activities, and alcohol consumption. Living in a rural area and access to healthcare may also play a role. Finally, BPPV may be a more-obvious symptom of neurological degeneration than symptoms associated with the cognitive impairment of dementia.
As with any study, there are limitations noted in this study. One limitation that was acknowledged by the study author is that the diagnosis of BPPV is not always accurate and may be confused with other vestibular or neurological diagnoses.
The conclusion of this study is that the risk of dementia is higher in people who have been diagnosed with BPPV, although, as pointed out above, this may be a complicated picture with many other health risk factors playing a role in the development of dementia. The findings related to complex risk factors of dementia found in this study further support that it is important to have vestibular conditions diagnosed quickly and accurately so they can be treated effectively, and secondary conditions can be mitigated.
By Jennifer Robbins, MPT & Jordan Tucker, DPT, EdD
Source: Kim SY, Yoo DM, Min C, Choi HG. Increased Risk of Neurodegenerative Dementia after Benign Paroxysmal Positional Vertigo. International Journal of Environmental Research and Public Health. 2021; 18(19):10553. https://doi.org/10.3390/ijerph181910553
Introduction
Endolymphatic hydrops is a disorder of the inner ear and can affect the endolymphatic fluid of the cochlea, the vestibular apparatus, or both. Many questions remain about the role of hydrops in the generation of Meniere Disease (MD) symptoms and their evolution over time.
The Journal of Vestibular Research devoted an issue to the proceedings of the 2019 GDR Vertige Annual Conference dedicated to endolymphatic hydrops, at the initiative of Drs. C. Chabbert and A. Charpiot, which included twelve articles.
This special issue displays an overview of the current understanding and clinical knowledge of the membranous labyrinth, a liquid compartment with highly regulated homeostasis and dynamic physical properties.
Imaging
Fine imaging of the inner ear is one of the major recent insights of the neuro-otology domain. However, it still remains a photographic snapshot of a sensory organ that is constantly deforming. In-vivo observations of the dynamics of a pressure wave in the inner ear illustrates the importance of the time parameter in the study of vestibular phenomena.
Over the last decade, application of MRI techniques provided the first in vivo images of endolymphatic hydrops. The use of contrast solutions allowing clear distinction between perilymph and endolymph is the latest step allowing identification of areas preferentially exposed to swelling in the endolymphatic compartment. This technological advance also makes it possible to correlate more precisely the different symptoms of MD to structural damages affecting the different inner ear compartments. It also raises new questions related to the existence of endolymphatic hydrops in non-symptomatic subjects.
Biochemical, Genetic and Other Factors
The factors capable of modifying the dynamic behavior of the vestibule are as varied as biochemical and endocrine messengers, pressure phenomena, and genetic factors, among others.
There is a lack of knowledge about the molecular effectors involved in the ion exchange and fluid flows between perilymph and endolymph. Research by Dr. I. Djennaoui from the Strasbourg University Hospital raises the interesting question of whether MD’s acute episodes are driven by pressure or volume events.
MD probably arises from the interplay of genetic and environmental factors. The maintenance of a proper fluid and ionic composition is determined by water channels, ionic transporters and bio humoral factors. Pr. R. Teggi from the San Raffaele Scientific Institute in Milano debates the role of ionic exchangers and regulating factors in the pathophysiology of MD, and instead focuses on genetic factors.
Dr. Redon and colleagues from the Marseille University Hospital review literature related to the presence of endolymphatic hydrops in some neurological disorders.
Dr. S. Hegemann from Zurich University suggests a close connection between MD and migraine, the coexistence of endolymphatic hydrops and Menière attacks, as well as the detected signs of inflammation in the inner ears of MD patients.
Dr. Simon from the Necker-Sick Children’s Hospital and INCC University discusses the parallels between MD and congenital diseases.
Dr. A. Weckel of the Purpan University Hospital of Toulouse illustrates the difficulties encountered by clinicians in establishing a correct diagnosis of MD on the basis of only clinical criteria, and evokes the uncertainties of the therapeutic approach mainly based on conservative therapies.
These articles touch on the complexity of peripheral vertigo, hydrops perhaps being the final transiently observable element common to multiple situations ranging from physiological extremes to pathology. The articles of this issue demonstrate that the labyrinth, with its endolymph and volume regulation, is much more than a passive instrument for measuring acceleration.
The mission of GDR Vertige is to stimulate exchanges and collaborations between the different components of the French neuro-otology community. Learn more at https://gdrvertige.com/en/.
Diagnostic criteria for vestibular migraine (VM) have been defined by the Barany Society. However, many patients have symptoms that can be suggestive of VM, but do not fit the criteria. Due to the lack of definitive diagnosis, clinicians have difficulties with properly diagnosing patients and determining the most appropriate treatment. The aim of this study is to quantify and describe the characteristics of patients suffering from episodic vestibular syndrome (EVS), in which all known potential causes for their vestibular symptoms have been ruled out, in order to determine if they could be associated with VM.
VM, like other neurotologic diseases, is diagnosed using criteria that constitute a diagnostic gold standard. The criteria are the only diagnostic tool available and should be specific enough to allow clinicians to rely on them and sensitive enough to allow patients that could respond to medication to be treated. Therefore, the study found that patients that present with EVS with symptoms that are in some way suggestive of VM, and in which other causes of EVS have been ruled out, cannot be diagnosed with any other known neurotologic disease, in order to be diagnosed with VM.
There was a group of patients forming the “borderline group” that did not meet the criteria for VM. One of the study’s objectives was to describe what type of patients form this group and how they respond to treatment. For those in the borderline group who followed the course of treatment, only their vestibular symptoms improved significantly, whereas their headache intensity and number of attacks did not. As the VM criteria of the Barany Society state that “(…) a favorable response to anti-migraine drugs may support the suspicion of an underlying migraine mechanism. However, the apparent efficacy of a drug may be influenced by confounding factors (…)”, even if the symptoms in the patients of the borderline group improved, it could not be proven that the positive response was due to the treatment or due to other factors. Thus, response to treatment cannot be considered a criterion for VM.
If the VM criteria are not met, it is recommended to rule out other causes when dealing with patients suffering from EVS and the clinician must determine whether the intensity of the symptoms significantly affect the patient’s daily life in such a way as to warrant treatment. In these cases, migraine prophylaxis could be tried, even though there are no currently established therapeutic protocols for those patients.
Based on the study’s results, some considerations for future research include:
To conclude, a substantial percentage of patients suffering from EVS cannot be diagnosed, although some of them present with symptoms that are suggestive of VM. Although the relationship between a prophylactic migraine treatment and the improvement of symptoms has not been determined in those patients, a subgroup of patients seemed to benefit from migraine treatment, suggesting that their vestibular symptoms belong to the migraine spectrum. However, there was another subgroup of patients who did not benefit from migraine treatment. Therefore, future research needs to determine distinctive features that can further define those subgroups in order to improve diagnosis and provide those patients with timely and appropriate treatment.
Written by Sonia Vovan, MPT
Source: Domínguez-Durán, Emilio et al. ‘Exploring the Frontiers of Vestibular Migraine: A Case Series’. Journal of Vestibular Research 31 (2) : 91 – 99.
Introduction
Acute symptoms of vestibular (inner ear) disorders typically include vertigo (sensation of spinning). There are also central nervous system conditions such as migraine, cerebrovascular disorders, or neurodegenerative conditions that may cause vertiginous attacks. When vertigo occurs, the metabolic system is active, releasing and inhibiting different neurotransmitters in the brain. Medication is usually prescribed to help manage vertigo symptoms, with a sedative effect. These medications include antihistamines, anticholinergics, benzodiazepines, and antidopaminergic drugs. Considering vertigo syndromes affect elderly patients who often experience side effects with medications, another lower dose alternative would be helpful. This study aims to assess the possible role that melatonin, a harmless hormone, could play in regulating the acute phase of vertigo.
Melatonin and the Vestibular Pathway
Neurotransmitters relay their messages in the brain by traveling between cells and attaching to specific receptors on target cells. There are melatonin receptors found within the inner ear. Also, these receptors are found throughout the vestibular pathway in various structures within the brain. The cerebellum, which is responsible for interpreting signals from the vestibular system and giving appropriate output to the body, also contains melatonin receptors. Melatonin aids in sleep-wake cycles. Individuals with vestibular disorders often have disruption of these circadian rhythms.
Role of Melatonin as an Anti-Inflammatory and Antioxidant Vestibular Agent
Vertigo patients show higher levels of reactive oxygen species (highly reactive chemicals formed by oxygen) and superoxide metabolites than healthy subjects. Oxidative stress (an imbalance between free radicals and antioxidants in the body) may be due to the physiological stress that vertigo induces. Melatonin has an antioxidant effect, as it acts to detoxify both reactive oxygen and reactive nitrogen species. Vestibular syndromes create inflammation during acute attacks, and subjects with chronic vertigo have higher basal levels of inflammatory mediators. Melatonin theoretically then would be able to regulate not only attacks but also recurrences of vertigo.
Melatonin as a Modulator in the Vestibular Neurotransmission
Gamma-aminobutyric acid (GABA) is the predominant inhibitory neurotransmitter in the vestibular pathway. Melatonin’s sedative effect is mainly enabled by binding to the GABA-A receptor, as it occurs with benzodiazepines.
Several findings support a possible involvement of dopamine as a modulator of excitatory vestibular neurotransmission in the afferent terminals (signals traveling from the inner ear to the brain). The responses of these receptors not only modulate glutamate receptors but may also have a protective function on vestibular dendrites (extensions of nerve cells designed to receive communication from other cells).
The existence of dopamine D2 receptors has been reported in the vestibular nuclei in the brain. The use of antidopaminergic drugs helps modulate the vestibular neurons and controls vomit. Although there is no report directly involving melatonin in this effect in vestibular structures, it has been demonstrated that this hormone modulates dopamine and can inhibit its release in specific areas within the brain of mammals.
Other compounds involved in vestibular neurochemistry, such as substance P or calcitonin gene-related peptide (CGRP), both associated with migraine and potentially vestibular migraine (VM), are also inhibited by melatonin.
Regulation of Melatonin in the Vestibular Sympathetic Activity
The autonomic nervous system consists of the sympathetic nervous system (SNS) and parasympathetic nervous system (PNS). The SNS is activated when our fight or flight response is triggered. The PNS is the recovery from fight or flight, and triggers digestion. Patients diagnosed with vertigo show less parasympathetic activity. Melatonin causes a reduction in epinephrine flow and induces relaxation of the smooth muscle of the arterial walls by increasing the availability of nitric oxide, thereby encouraging PNS activation. Furthermore, melatonin is capable of lowering blood pressure, specifically binding to receptors in blood vessels, thus blocking the catecholaminergic (fight or flight) response.
Conclusions
The use of melatonin in the acute phase of vertigo can be highly effective, although more studies and clinical trials are needed. The adjuvant use of melatonin with other drugs could not only improve the symptoms of acute vertigo but also prevent the use of larger doses of commonly used drugs. Some reports showed transient dizziness as a side effect. This symptom may be only a subjective report or it may be associated with its sedative function. In conclusion, melatonin administration in vertigo could be a new therapeutic effect of melatonin, among the many already described that this hormone exerts within the human body.
Summary by Danielle Beatty, DPT
Superior semicircular canal dehiscence syndrome (SSCD) is an inner ear disorder where people have an extra opening or ‘dehiscence’ into the inner ear. This extra opening can disturb the way that pressure is transmitted in the inner ear. The extra opening is usually only a few millimeters in size but can cause a variety of troublesome symptoms, such as hearing internal noises, like your heartbeat, loudly in your ears, a fullness sensation in the ear, or experiencing dizziness in response to loud sounds or when straining when you cough. These symptoms can be debilitating.
New diagnostic criteria for SSCD have been developed by the international classification of vestibular disorders and were recently published in the Journal of Vestibular Research. The diagnosis requires:
Fortunately, there are several tests of the vestibular system that can be used to help diagnose superior semicircular canal dehiscence syndrome.
Patients often have enhanced responses on ocular or cervical vestibular-evoked myogenic potential (VEMP) testing. This enhanced response could be an elevated amplitude on cervical or ocular VEMPS or a normal response at a lower-than-normal intensity stimulus. Patients often can hear sound that is transmitted through the bone abnormally well in that ear; this can be seen on pure tone audiometry. Finally, the first patients were diagnosed when loud sounds played in the affected ear caused eye movements (nystagmus). Loud, low-pitch sounds can stimulate the superior semicircular canal and is the reason patients experience dizziness when they hear a loud noise like a truck passing or people clapping.
Establishing a diagnosis using consistent criteria is important for patients and physicians alike. Although there are no medical treatments for SSCD, there are surgical treatments that have been shown to improve symptoms. These new criteria will contribute to improved research and allow physicians to communicate better with patients when discussing how likely a treatment is to make them feel better.
Written by Bryan Ward, MD
Diagnostic criteria consensus document of the Classification Committee of Vestibular Disorders of the Bárány Society and the International Headache Society
“Benign Paroxysmal Vertigo of Childhood” and Vestibular Migraine (VM) are believed to be the most frequent causes of vertigo and dizziness in children. “Benign Paroxysmal Vertigo of Childhood” is defined as “recurrent spontaneous attacks of vertigo which may be associated with vomiting, pallor, fearfulness, postural imbalance, ataxia, and/or nystagmus in otherwise healthy children.” VM is defined as at least five episodes with vestibular symptoms of moderate/severe intensity, lasting between five minutes and 72 hours, with migraine headaches or symptoms during most of the attacks. Pediatric patients may likely fit both of these criteria.
This consensus document aims to classify “Vestibular Migraine of Childhood” (VMC) and “probable Vestibular Migraine of Childhood.” Also, this article strives to introduce a new term and classification of recurrent vertigo in children, named “Recurrent Vertigo of Childhood” (RVC) which should replace the term “Benign Paroxysmal Vertigo of Childhood.” This is part of an ongoing project to develop an International Classification of Vestibular Disorders (ICVD), being overseen by the Classification Committee of the Bárány Society and the International Headache Society. The Diagnostic Criteria are listed in the chart below:
Diagnostic Criteria
| Vestibular Migraine of Childhood (VMC) | Probable Vestibular Migraine of Childhood (probable VMC) | Recurrent Vertigo of Childhood (RVC) |
| At least 5 episodes with vestibular symptoms moderate/severe intensity, lasting 5 min to 72 hrs | At least 3 episodes with vestibular symptoms moderate/severe intensity, lasting 5 min to 72 hrs | At least 3 episodes with vestibular symptoms moderate/severe intensity, lasting 1 min to 72 hrs |
| Current or past history of migraine with or without aura** | Only one of the criteria listed under VMC** | None of the criteria listed under VMC** |
| At least ½ episodes associated with: headache on one side, pulsating quality, moderate/severe pain intensity; or aggravated by physical activity; or light/sound sensitivity; or visual aura** | ||
| Age < 18 years | Age < 18 years | Age < 18 years |
| Not better accounted for by another headache/vestibular disorder or other condition | Not better accounted for by another headache/vestibular disorder or other condition | Not better accounted for by another headache/vestibular disorder or other condition |
Children typically have a more difficult time describing their vestibular symptoms compared to adults. Vestibular symptoms can include spontaneous vertigo, positional vertigo, visually-induced vertigo, head motion-induced vertigo, or head motion-induced dizziness with nausea. Vestibular symptoms of moderate intensity interfere with, but do not prevent daily activities. Vestibular symptoms of severe intensity prevent continuation of daily activities.
There are many other conditions to consider in children experiencing vestibular symptoms, including psychiatric causes, benign paroxysmal positional vertigo, vestibular paroxysmia, Ménière’s disease, vestibular epilepsy/epileptic vertigo/nystagmus, episodic ataxias, tumors, orthostatic (blood pressure related) dizziness, and recurrent ear infections. Consult your child’s doctor to determine what additional testing and consultations may be required to arrive at an appropriate diagnosis and to move forward with suitable treatment strategies.
Written by Danielle Beatty, DPT
Source: van de Berg, Raymond et al. Vestibular Migraine and Recurrent Vertigo of Childhood: Diagnostic Criteria Consensus Document of the Classification Committee of Vestibular Disorders of the Bárány Society and the International Headache Society. Journal of Vestibular Research, 31 (1) : 1–9.
The Barany Society and the Classification Committee of the Barany Society (CCBS) have created diagnostic criteria for Mal de Débarquement Syndrome (MdDS) with the goal of creating common terminology for diagnosis and research. These criteria will be included in the International Classification of Vestibular Disorders (ICVD).
Vestibular disorders can be due to functional alterations within the central nervous system without a concurrent structural injury, so it is important to determine the differences between MdDS and other similar functional vestibular disorders. MdDS has appeared in the medical literature for over 300 years with individuals describing symptoms as non-spinning vertigo, dizziness, and imbalance after sea voyages.
In March 2017, the CCBS introduced a format for developing criteria for MdDS. In June 2018, a committee of international specialists was formed and drafted criteria. The draft was presented to CCBS members in June 2019, and then the completed criteria were presented to the Barany Society membership in January 2020.
In terms of diagnostic criteria, there are differences between short-term land sickness lasting less than 48 hours and the syndrome lasting beyond 48 hours. Therefore, the criteria created constitute the disorder of MdDS:
MdDS is frequently misdiagnosed as other disorders in the general medical community. It is significantly represented in women with onset peak between 40–49 years. More than one lifetime episode of MdDS can occur with subsequent episodes usually lasting longer than previous episodes and a decreased chance of a spontaneous recovery. Symptom severity can fluctuate due to multiple factors, including stress, sleep deprivation, and hormonal factors. The vertigo of MdDS persists in different body positions. Common additional symptoms include sensations of spatial disorientation, fatigue, visual motion intolerance, headaches, and anxiety. Diagnosis is based on clinical history alone. There are no findings on physical examination, laboratory testing, or imaging that are indicative of MdDS. Differential diagnoses include vestibular migraine, motion sickness, and persistent postural perceptual dizziness.
Future research investigations are required to bring into line foundations of MdDS with ICVD nomenclature and to more clearly identify its differences from similar disorders.
Creating a uniform set of diagnostic criteria for MdDS would improve accuracy of diagnosis in order to apply the appropriate treatment strategies in a timely manner.
Written by Sonia Vovan, MPT
Source: Cha, Y., Baloh, R. W., Cho, C., Magnusson, M., Song, J., Strupp, M., Wuytsg, F., Staab, J. P. (2020). Mal de débarquement syndrome diagnostic criteria: Consensus document of the Classification Committee of the Bárány Society. Journal of Vestibular Research, 30(5), 285-293. doi:10.3233/ves-200714
Background: The period immediately following a concussion generally receives the most attention and scrutiny, as many symptoms resolve within 7-10 days. However, recent studies have shown that concussion symptoms can persist for months after the initial injury.
The Vestibular System: The vestibular and visual systems work together to calibrate eye and head movements. A disruption in the normal functioning of the vestibular system, the visual system, or the pathway that integrates these systems can result in slippage of the visual image on the retina, which can affect gaze stability.
A normally functioning vestibular system helps maintain gaze stability while the head is in motion through the vestibulo-ocular reflex (VOR), which produces commensurate eye movements in a direction opposite to head movements. Blurred vision results when there is a dysfunction in the VOR and images are not held steady on the retina.
Purpose: To study the long-term impact of concussion on gaze stability and sleep.
Methods: Dynamic Visual Acuity (DVA, the ability to see clearly during head movement) was measured using a computerized test that detects peripheral vestibular impairment. All participants completed two questionnaires to assess sleep quality and daytime sleepiness. For those with a history of concussion, the Post-Concussion Symptom Scale (PCSS) was used to measure 22 self-reported symptoms, such as dizziness and headache. Time since injury and number of concussions were also recorded.
Results: Mean DVA was significantly lower in chronic concussion patients compared to healthy young adults. The concussion group also reported lower sleep quality.
Summary: This paper showed a significant difference in dynamic visual acuity in young adults with a history of concussion. Loss of DVA is associated with lower sleep quality and increased sleepiness. Further studies are needed to evaluate the benefit of vestibular rehabilitation and early sleep education on this population.
Written by Mona Fazzina, PT, DPT, Certificate in Vestibular Rehabilitation, 2020, Board Certified Clinical Specialist in Geriatric Physical Therapy (GCS), Certified Exercise Expert for Aging Adults (CEEAA)
BPPV is a common condition in which the inner ear crystals (otoconia) become displaced and land in an area where they are not supposed to be. This confuses the brain and causes vertigo whenever the head moves to a certain position.
Although most of the time vertigo symptoms in BPPV occur immediately following head movements, many patients complain of imbalance throughout the day. That is most likely related to the fact that we have to constantly monitor our orientation by integrating information from our vestibular system – our eyes, muscles and joints. If the vestibular system does not provide accurate information about our orientation we may develop an altered sensation of balance with respect to the surrounding environment. In particular, the mismatch between the vestibular and visual information may lead to visually-induced imbalance.
In this study, 30 patients with a history of BPPV were assessed BEFORE canalith repositioning maneuvers. The diagnosis of BPPV was confirmed by positioning tests and by excluding other vestibular and central abnormalities. Two other groups, one consisting of 30 healthy individuals ages 20 to 25 years and another consisting of 30 healthy individuals ages greater than 60 years, were included in the study.
The test involved the subjects standing on a plate that measured body movements in the front-to-back and side-to-side directions. The test was conducted under three different conditions of eyes open without goggles while watching a static image displayed in head-mounted goggles and while watching a moving image with the same goggles. Each test condition lasted 30 seconds.
The study demonstrated that both BPPV patients and older healthy subjects had more body movements compared to the younger group. Increased movements in the front-to-back direction occurred for all visual conditions, whereas increased movements in the side-side directions occurred only during the first 20 seconds of the test. In addition, body movements in the front-to-back direction were influenced by the static and moving images.
Previous studies have shown that the vestibular system deteriorates with aging. Furthermore, older individuals become more dependent on vision for maintaining balance. This study demonstrates that BPPV patients behave similarly to the older individuals. Increased body sway in patients with BPPV may increase the risk of fall in these patients. Therefore, balance training exercises may help these patients use more effective postural control strategies.
It should be noted that the value of this paper is diminished because it did not repeat the test after repositioning maneuvers. Therefore, it is not clear if these findings are related to misplaced particles that can be resolved by repositioning maneuvers or if they reflect a long-term deterioration of the vestibular structures.
Written by Jennifer Robbins, MPT, with contributions from Kamran Barin, PhD
Source: Journal of Vestibular Research 30 (2020) 267–274 267 DOI:10.3233/VES-200709
Balance performance when responding to visual stimuli in patients with Benign Paroxysmal Positional Vertigo (BPPV) Sang-I Lin, Yi-Ju Tsai and Pei-Yun Lee∗
Department of Physical Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
Patients with vestibular symptoms such as vertigo, dizziness, and imbalance often seek treatment from their primary care physicians, who may order various testing and treatment. Having vestibular symptoms can also affect one’s ability to work. Therefore, the overall cost in managing vestibular conditions can be quite high. The treatment of choice according to guidelines in the US, UK, and the Netherlands is vestibular rehabilitation (VR). This is an exercise-based program administered by a healthcare professional, which is designed to reduce vestibular symptoms, improve balance, and restore the ability to perform daily activities.
Individuals have used internet-based programs to facilitate vestibular rehabilitation. These programs are often inexpensive, easily accessible, and can be personalized according to the needs of each patient. Combining an internet-based intervention with face-to-face support by a healthcare professional is called blended care. Stand-alone internet-based programs are generally less expensive than blended internet-based programs, but the risk of non-adherence is also higher. This study aimed to evaluate the cost-effectiveness of stand-alone and blended internet-based VR versus usual care for general practice patients with a chronic vestibular syndrome.
Participants were selected from 59 general practices in the Netherlands, for a total of 322 participants, aged 50 years and older, having symptoms for at least one month that were exacerbated or triggered by head movements. Subjects were placed into one of three groups. The internet-based VR group had treatment which lasted for 6 weeks, with weekly online sessions with daily VR exercises. The patients logged the intensity of their symptoms, and the program was modified for the next week depending on patients’ report. Participants in the blended VR group received the same internet-based VR treatment, however they were also visited twice at home by a trained physiotherapist (physical therapist). Participants in the usual care group received standard care by their general practitioners. Researchers looked at patients’ quality of life, vestibular symptoms, and medical and productivity costs. Costs included healthcare costs, costs related to help from family/friends, reduced efficiency at work due to symptoms, and missing work/housework due to symptoms.
Researchers found that there were significant improvements in vestibular symptoms for the stand-alone and blended VR groups at 6 months follow-up compared with usual care participants. In using the Dizziness Handicap Inventory (DHI), which quantifies the impact of symptoms on daily life, there was not a significant difference in score improvement when comparing the three groups. Total societal costs for both the VR groups were higher than the costs of usual care, however this was not a significant difference based on calculations. The researchers included all healthcare costs into their calculation, so some of these expenses may have been from care that was not due to vestibular symptoms. The researchers conducted further analysis attempting to exclude costs that were likely unrelated to vestibular symptoms, and the stand-alone VR group became less expensive when compared to usual care. Researchers also assessed quality of life through a questionnaire and used this to calculate quality-adjusted life years (QALYs). One QALY is equivalent to one life-year of perfect health. A gain in QALYs was then considered an improvement in the quantity and/or quality of life. Both VR groups did demonstrate a gain in QALYs compared to usual care, however this change was not significant.
This study followed participants for a period of only 6 months, so it is hard to determine the long-term cost effectiveness between the three groups and whether one would be superior. Also, adherence to any exercise program can be quite a challenge, and it is unclear whether the researchers verified patients’ consistency with performing their VR program. Healthcare costs will also vary from country to country.
In conclusion, stand-alone and blended internet based vestibular rehabilitation both led to gains in QALYs compared to usual care (however not significant). Both VR groups demonstrated a significant reduction in vestibular symptoms compared to usual care. Usual care was determined to be lower cost compared to both VR groups; however, this was not a significant difference. Vestibular rehabilitation, whether internet based, in person, or a combination, is an important treatment regimen for those with vestibular symptoms. The researchers concluded, “Internet-based VR is an easily accessible, effective form of treatment that could potentially improve care for a largely undertreated group of patients with a chronic vestibular syndrome in general practice.”
Written by Danielle Beatty, DPT
Sources:
van Vugt VA, Bosmans JE, Finch AP, et al
Cost-effectiveness of internet-based vestibular rehabilitation with and without physiotherapy support for adults aged 50 and older with a chronic vestibular syndrome in general practice
BMJ Open 2020;10:e035583. doi: 10.1136/bmjopen-2019-035583
The paper reviewed proposes criteria for determining which patients with bilateral vestibulopathy (BVP) might be good candidates to participate in research studying the efficacy of vestibular implants (VI).
BVP is a condition characterized by significantly reduced vestibular function in both ears. Symptoms include dizziness, imbalance, and oscillopsia (a visual blurring that occurs during head movements). BVP negatively affects the patient’s quality of life and increases their risk of falls. BVP can be caused by a number of secondary conditions, including ototoxicity and autoimmune disorders, or occur for unknown reasons. Current treatments include vestibular rehabilitation therapy to improve balance and visual acuity during head movements. Unfortunately, most BVP patients do not regain full function.
The vestibular implant (VI) has been proposed to facilitate restoration of vestibular function for BVP patients who meet stringent criteria. The VI is a prosthetic device that provides continuous, long-term, motion-modulated stimulation via electrodes to the three semi-circular canals in the inner ear . VI surgery is irreversible. Therefore, a comprehensive risk-benefit analysis is critical for determining which patients might benefit from this procedure, despite the potential risks.
This paper sought to provide a basis for determining criteria for VI as a foundation for future research.
VI implantation criteria are not the same as diagnostic criteria for BVP. The major difference between VI-implantation criteria and the approved diagnostic criteria for BVP is that all included vestibular tests of semicircular canal function (head impulse test, caloric test, and rotatory chair test) need to show significant impairments of vestibular function in the implantation criteria.
The provisional VI criteria recommended include (but are not limited to):
1. Chronic vestibular syndrome with unsteadiness when walking or standing, especially in darkness or on uneven ground, and movement-induced blurred vision.
2. Symptoms are greatest during head movement.
3. Bilaterally (on both sides) reduced VOR (vestibular ocular reflex – reflexive eye movements used for stabilizing your vision).
4. Symptoms are not accounted for by another disease.
5. Test results to demonstrate deficiencies in all three tests of semicircular function: the head impulse test, the caloric test and the rotatory chair test.
The authors state that the VI is not a treatment technique for decreased function of the vestibular nerve or the central vestibular system.
VI surgery can adversely affect residual vestibular function irreversibly. Other potential and serious complications from VI surgery include hearing loss and facial nerve paralysis.
For appropriate patients, the success in benefitting from the VI depends in part on the patient’s understanding and ability to use it, tolerate it, and participate actively and effectively in the post-implantation rehabilitation phase. A six-month waiting period following onset of symptoms is strongly recommended to determine the course and prognosis of BVP before considering VI. The entire vestibular team must agree on the operability of the patient. Psychological and psychiatric disorders complicate the process of evaluating a patient for the VI.
There are two versions of the VI. One to restore just vestibular function and another that includes a cochlear implant, which could also help restore hearing.
Written by Mona Fazzina, PT, DPT
Coordination of the body involves the prioritizing of sensory systems depending on the movement the person is doing. The brain needs vision, touch, joint movement, inner ear (vestibular) information, sound (and sometimes smell) to control the body smoothly. When someone has a vestibular disorder, the brain’s ability to prioritize the senses is affected, and it is not able to use the inner ear/vestibular input effectively. The purpose of vestibular rehabilitation is to help the brain to re-learn how to prioritize the sensory systems, and compensate for any loses. This study indicated that vibration stimulation on the lower back may enhance traditional vestibular rehabilitation, encouraging the body to reorganize which sensory systems it uses at what time. This study included a group of eight people with vestibular disorders on one side of the body (unilateral). A neurologist evaluated and diagnosed them. They all performed vestibular rehabilitation balance training for six weeks. The treatment for one group (the experimental group) also included sensory stimulation involving a customized, vibrating device attached to their lower back with a belt. The sensors in the device detected when the person was shifting his/her torso and provided the vibration then. A physical therapist who did not know which participants received the sensory stimulation performed several tests to determine whether the vibrational sensory stimulation was making a difference. The results were measured with body sway, standing dynamic gait tests, and surveys specific to vestibular disorders. They were tested one month and six months after the treatment had ended as well. All participant improved, but the group with the sensory stimulation performed better. Furthermore, they maintained their abilities six months after the treatment had ended. This study is encouraging because it may enable people suffering from unilateral vestibular disorders to make further and or more complete recovery. There are other types of sensory stimulation that may be used to improve vestibular rehabilitation, namely auditory, visual, and electro-tactile combinations. They will need to be tested in future studies.
Written by Jennifer A. Robbins, MPT
This paper attempted to determine the effect of dizziness on cognitive function. The paper made the assumption that cognitive decline correlates to the increased perception of dizziness. The result was that cognitive decline could exist without dizziness, but the presence of dizziness increased the cognitive impairment if they coexisted in the same person. The study also confirmed that postural instability is an important determinant of dizziness. This is not a new thought, as patients will often use the word “dizzy” when referring to postural stability.
Written by Dr. Dennis Fitzgerald
This article explains the results of a study performed in a physiotherapy clinic in Australia intended to explore the incidence of BPPV and its varied forms of presentation, evaluation and treatment. The observational study included 314 patients with BPPV, specifically involving the posterior semicircular canal (PC) or horizontal semicircular canal (HC). The diagnostic maneuvers used were the Dix-Hallpike (DHP) and the Supine roll test (SRT) respectively.
In a significant majority of the patients it took one or two canalith repositioning maneuvers (CRMs) to effectively treat PC BPPV (91%), and HC BPPV (88%). More than two CRMs were required to effectively treat patients with bilateral PC BPPV, multiple canal involvement, or canal conversions.
Patients who had nystagmus and vertiginous symptoms during the Epley Maneuver (EM) and those who did not have nystagmus and vertiginous symptoms during the EM had similar treatment outcomes. Of note, 19% of patients experienced down-beating nystagmus (DBN) and vertigo after the first or even the second EM.
As a result of this observational study of 314 patients, three arguments were put forth:
Other protocols followed during this observational study include the adherence to the clinical practice guidelines for BPPV. Therefore, patients were not given post-treatment precautions.
The financial and personal time benefits to the patient and the public are considerable with the implementation of repeated CRMs within the same session. An additional benefit of this practice is that the efficacy of the treatment is known within the same session. The benefits and advantages of repeated CRMs over consecutive sessions is greater than supposed risks.
Written by Mona Fazzina, PT, DPT
Historically, the caloric test has been the most common clinical method for evaluating vestibular function. The caloric test has a number of limitations and sometimes causes unpleasant symptoms for patients suffering from dizziness.
In the past 10 years or so the video head impulse test (vHIT) has gained popularity for evaluating vestibular abnormalities. vHIT can test parts of the vestibular system, namely the vertical semicircular canals, that are not tested in the caloric test. So far, vHIT is not considered a replacement for the caloric test, and in most clinics the two tests are used in conjunction with each other for a broader evaluation of the vestibular pathway. In a somewhat oversimplified analogy with the hearing evaluation, one can describe the caloric test and vHIT as testing two different sound frequencies in the audiogram.
Unlike with the caloric test, the extent of semicircular canal dysfunction was not readily available from vHIT. This paper uses a computer simulation of the vestibular pathways to determine a simple formula that can relate the loss of canal function to the measured parameters of vHIT. This can also help in clarifying the relationship between vHIT and other vestibular tests, including the caloric test.
Ninety years ago, Tullio described the physiologic outcomes of creating a third mobile window in the semicircular canals of pigeons. Since that time, many locations of third mobile windows have been described; however, the sound-induced dizziness and/or nystagmus has been memorialized by the eponym ‘Tullio phenomenon.’ Clinically, the most thoroughly characterized third mobile window is superior semicircular canal dehiscence (SSCD). Over the years, many other sites of a mobile third window have been reported (15 to date). They all produce, to varying degrees, the spectrum of symptoms and findings seen in third window syndrome (TWS).
This communication is the first assessment of outcomes after surgical repair of cochlea-facial nerve dehiscence (CFD) in a series of patients. Pre- and postoperative quantitative measurement of validated survey instruments, symptoms, diagnostic findings and anonymous video descriptions of symptoms in a cohort of 16 patients with CFD and TWS symptoms were systematically studied.
Overall there was a marked and clinically significant improvement in Dizziness Handicap Inventory (DHI), Headache Impact Test (HIT-6) and TWS symptoms postoperatively for the CFD cohort who had round window reinforcement (RWR) surgery. A statistically significant reduction in cVEMP thresholds was observed in patients with radiographic evidence of CFD. Surgical management with RWR in patients with CFD was associated with improved symptoms and outcomes measures. There was no statistically significant change of hearing in the patients with CFD who underwent RWR. It was emphasized that radiographic CFD is not in itself an indication for surgery and that the most important factor in decision-making should be in the context of clinical symptoms and other diagnostic findings. There are 3 important presenting symptoms and physical findings that are critical when identifying a TWS, including CFD: 1) sound-induced dizziness; 2) hearing internal sounds; and 3) hearing or feeling low frequency tuning forks in an involved ear when applied to a patient’s knee or elbow. Another important observation in the study was that multiple sites of dehiscence in temporal bones with TWS occur and this finding is important to consider when faced with recurrent or incompletely resolved TWS symptoms after plugging a SSCD.
Source: Wackym, P. Ashley, et. al. Front. Neurol., 13 December 2019
When the vestibule in our inner ear is damaged, information about the position or movement of our body in space is altered or missing. This situation is serious since our brain can no longer provide the motor responses necessary to maintain our balance. The major risk is of course the fall. To prevent this, our brain has an extraordinary ability to adapt called “vestibular compensation”. This fascinating neurobiological process allows our brain to use information from other sensory sensors, such as those of vision or posture, to detect the movements of our body in its environment. To achieve this, it is necessary to reshape our brain connectivity, a bit like old telephone terminals. This is a complex process that involves a mosaic of structural rearrangements, among which the birth of new neurons plays a central role. In the review published in Progress in Neurobiology, we describe how the adult brain produces new neurons to restore balance after vestibular loss. This discovery can be considered as the best example so far of causal reparative role of adult neurogenesis.
Written by Christian Chabbert and Brahim Tighilet
Source: Progress in Neurobiology, 2019
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Vestibular Research Studies Below are clinical studies that are currently recruiting research study participants. You can find more studies recruiting patients at ClinicalTrials.gov. *If you are a VeDA professional member and would like to recruit
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The NIDCD National Temporal Bone, Hearing and Balance Pathology Resource Registry (the Registry) is a non-profit organization established in 1992 by the National Institute on Deafness and Other Communication Disorders (NIDCD) of the National Institutes of Health. The Registry serves as a resource for the public and scientific communities about research on the pathology of the human auditory and vestibular systems.
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