Drug–Drug Interactions in Vestibular Diseases, Clinical Problems, and Medico-Legal Implications

Peripheral vestibular disease can be treated with several approaches (e.g., maneuvers, surgery, or medical approach). Comorbidity is common in elderly patients, so polytherapy is used, but it can generate the development of drug–drug interactions (DDIs) that play a role in both adverse drug reactions and reduced adherence. For this reason, they need a complex kind of approach, considering all their individual characteristics. Physicians must be able to prescribe and deprescribe drugs based on a solid knowledge of pharmacokinetics, pharmacodynamics, and clinical indications. Moreover, full information is required to reach a real therapeutic alliance, to improve the safety of care and reduce possible malpractice claims related to drug–drug interactions. In this review, using PubMed, Embase, and Cochrane library, we searched articles published until 30 August 2021, and described both pharmacokinetic and pharmacodynamic DDIs in patients with vestibular disorders, focusing the interest on their clinical implications and on risk management strategies.

Teleneurorehabilitation program (virtual reality) for patients with balance disorders: descriptive study

Background Balance disorders are common in patients with neurological or vestibular diseases. Telerehabilitation program is a treatment to be as safe as conventional treatment. One of the most used methods to perform telerehabilitation is the incorporation of Virtual Reality. In general, rehabilitation programs train predictive postural control, so the patient does not always acquire the necessary autonomy to react to situations of instability. On the other hand, the objective and systematic supervision and measurement of these programs is limited, making it necessary to create clinical protocols with precise and measurable rehabilitation objectives. This study present the training selection methodology and clinical protocol for patients with balance disorders inserted in a Telerehabilitation Program based on Virtual Reality. Methods Descriptive study where physiotherapists were trained to use RehaMetrics®. To evaluate their level of agreement in the selection of the exercise clusters developed, the Interobserver Reliability was measured through the kappa statistic. Subsequently, the exercises were applied to a group of patients recruited with sedentary trunk control (Berg Balance Scale = 3 points in item 3), mild or normal cognitive level (Montreal Cognitive Assessment> 21 points), and prescribed for tele-rehabilitation by a doctor. Results The agreement among the expert physiotherapists irrespective of the cluster exceeds 80%, which indicates a very good strength of agreement, while the novices reached a level of agreement of 45%, which suggests a moderate strength of agreement. All clinical outcomes showed statistically significant differences between the median times, as did the Maximum Width Left Side (MWLS) (cm). The average number of minutes of training was 485.81 (SD 246.49 min), and the number of sessions performed during the 4 weeks of intervention was 17 (SD 7.15 sessions). Conclusions This analysis what had excellent interobserver reliability with trained physiotherapists. Regarding the second phase of the study, the results show a statistically significant difference between the initial and final evaluation of the clinical tests, which could result in better performance in aspects such as: balance, gait functionality, meter walked and cognition. Telerehabilitation Program based on Virtual Reality is an excellent alternative to provide continuity of treatment to patients with balance disorders.

The relationship between functional head impulse test and age in healthy individuals

BACKGROUND: fHIT is an easily applicable test battery that indirectly evaluates the vestibulo-ocular reflex (VOR) from a functional perspective. AIMS/OBJECTIVES: The aim of this study was to Individuals determine the correlation between age and the percentage of correct answers (% CA) obtained in the functional head impulse test (fHIT) in healthy individuals. MATERIAL AND METHODS: A total of 105 volunteers, 50 males and 55 females, between the ages of 18 and 70 years, participated in the study. A Beon Solution fHIT system (Zero Branco (TV), Italy) was used in the study. RESULTS: In our study, a decrease in the mean % CA was observed in all semicircular canals (SCCs) with increasing age. Between age and mean % CA, a significant negative moderate (–0.311) correlation was observed in lateral SCCs, and a significant negative low (–0.257) correlation was observed in posterior SCCs (p < 0.05). In anterior SCCs, there was no statistically significant relationship between age and mean % CA (p > 0.05). CONCLUSIONS: The present study performed in a healthy population will be helpful in terms of making comparisons in studies to be conducted in various vestibular diseases. It will also be a guide for identifying pathological consequences in vestibular diseases.

The bucket test reinterpreted: a study on benign paroxysmal positional vertigo and Ménière’s disease patients

Background The bucket test is a simple and practical instrument to evaluate vestibular diseases; additionally, it could be a useful tool in the evaluation of the vertigo patient. Unfortunately, the bucket test still lacks standardization. The objective of this study was to evaluate and to interpret the subjective visual vertical (SVV) using the bucket test in benign paroxysmal positional vertigo (BPPV) and Ménière’s disease patients. We performed a cross-sectional study in a secondary care center. All patients with diagnosis of unilateral posterior canal BPPV or Ménière’s disease underwent complete neuro-otological physical examination and the bucket test. Normal bucket test was 0° to 3° according to previous study. Results We included seventy-eight subjects. Benign paroxysmal positional vertigo cases (n = 51) showed a mean 2.62° of SVV prior to the Epley maneuver and 1.7° of SVV after the maneuver (p = < 0.001), 57% of patients with BPPV were categorized as abnormal. Inactive Ménière’s disease patients (n = 22) had mean SVV of 2.74° and Ménière’s disease with active crisis (n = 5) had 5.06° of SVV (p = 0.002). Conclusion The bucket test is a simple and useful test for the evaluation of SVV, and it has a role in the evaluation of patients with active vestibular diseases such as Ménière’s disease and BPPV.

Exploring the biomechanical responses of human cupula by numerical analysis of temperature experiments

The vestibular receptor of cupula acts an important role in maintaining body balance. However, the cupula buried in the semicircular canals (SCCs) will be destroyed if it is detached from the relevant environment. The mechanical properties of human cupula still remain ambiguous. In this paper, we explored the cupula responses changing with temperature by experiments and numerical simulation of SCCs model. We obtained 3 volunteers’ nystagmus induced by constant angular acceleration when the temperature of volunteers’ SCCs was 36 °C and 37 °C respectively. The slow-phase velocity of 3 volunteers decreased by approximately 3°/s when the temperature of SCCs reduced by 1 °C, which corresponded to the reduction of cupula deformation by 0.3–0.8 μm in the numerical model. Furthermore, we investigated the effects of the variation of endolymphatic properties induced by temperature reduction on cupula deformation through numerical simulation. We found that the decrease of cupula deformation was not caused by the change of endolymphatic properties, but probably by the increase of cupula’s elastic modulus. With the temperature reducing by 1 °C, the cupula’s elastic modulus may increase by 6–20%, suggesting that the stiffness of cupula is enhanced. This exploration of temperature characteristic of human cupula promotes the research of alleviating vestibular diseases.

Exploring the Mechanical Properties of Human Cupula by Numerical Analysis of Temperature Experiments

The vestibular receptor of cupula acts an important role in maintaining body balance. However, the cupula buried in the semicircular canals (SCCs) will be destroyed if it is detached from the relevant environment. The mechanical properties of human cupula still remain ambiguous. In this paper, we explored the cupula’s elastic modulus changing with temperature by experiments and numerical simulation of SCCs model. We obtained 3 volunteers’ nystagmus induced by constant angular acceleration when the temperature of volunteers’ SCCs was 36℃ and 37℃ respectively. The slow-phase velocity of 3 volunteers decreased by approximately 3°/s when the temperature of SCCs reduced by 1℃, which corresponded to the reduction of cupula deformation by 0.3–0.8 µm in the numerical model. Furthermore, we investigated the effects of the variation of endolymphatic properties induced by temperature reduction on cupula deformation through numerical simulation. We found that the decrease of cupula deformation was not caused by the change of endolymphatic properties, but probably by the increase of cupula’s elastic modulus. With the temperature reducing by 1℃, the cupula’s elastic modulus may increase by 6%-20%, suggesting that the stiffness of cupula is enhanced. This exploration of temperature characteristic of human cupula promotes the research of alleviating vestibular diseases.

Studies across subspecialties of neurology (SON) report noninferiority of telemedicine (TM) compared with face-to-face intervention (FTF-I)

Background: Studies across subspecialties of neurology (SON) report noninferiority of telemedicine (TM) compared with face-to-face intervention (FTF-I). Clinical scales (CS) are important tools for outcome measures in clinical care. However, which CS in FTF-I can be used in teleneurology is unclear. Objectives: Define the most used CS in studies comparing TM with FTF-I in different SON. Design and Setting/Methods: We searched PubMed and Embase for randomized controlled trials, published from 2011 to April 2021, with Key words ‘’telemedicine’’ cross-referenced with ‘’neurology’’ or neurological diseases, considering the synonyms. Results: 43 eligible studies in 400 records, from 12 countries, with 5600 patients and 8 SON: stroke (10), headache (4), epilepsy (6), cognitive disorders (7), demyelinating diseases (8), movement disorders (3), neuromuscular diseases (3), and vestibular diseases (2). The most used CS: National Institute of Health Stroke Scale (NIHSS) and Modified Rankin Scale (MRS) for stroke impairment and limitation; Headache Impact Test (HIT-6) and Migraine Disability Assessment Scale (MIDAS) for headache disability; Quality Of Life in Epilepsy Inventory (QOL-31) for seizure burden; Mini-Mental State Exam (MMSE) and Zarit Burden Interview (ZBI) for cognitive function and caregiver burden in dementia care; Expanded Disability Status Scale (EDSS) and Fatigue Impact Scale (FIS) for disability and fatigue in Multiple Sclerosis; Parkinson’s disease Questionnaire (PDQ-39) and Unified Parkinson’s Disease Rating Scale (UPDRS) for QOL and disability in PD; Amyotrophic Lateral Sclerosis Functional Rating Scale Revised (ALSFRS-R) for severity in ALS; and Vertigo Symptom Scale Short form (VSS-SF) for vertigo. Conclusions: We present feasible CS usually applied in teleneurology that can be used as important tools for future findings in TM research and practice.

Association between vestibular dysfunction and findings of horizontal head-shaking and vibration-induced nystagmus

BACKGROUND: The association between vestibular function and findings of horizontal head-shaking nystagmus (HHSN) and vibration-induced nystagmus (VIN) tests is not well understood. OBJECTIVE: To investigate the association between function in the five distinct vestibular end organs and findings of these nystagmus tests. METHODS: We retrospectively reviewed the medical records of 50 patients with vestibular diseases who underwent HHSN testing, VIN testing, video head impulse testing (vHIT), cervical vestibular evoked myogenic potential testing to air-conducted sound (ACS cVEMP) and ocular VEMP testing to ACS (ACS oVEMP). We performed mixed-effects logistic regression analyses to see whether age, sex or the presence of nystagmus in HHSN or VIN have an association with the presence of peripheral vestibular dysfunction on the opposite side to the direction of nystagmus. RESULTS: The presence of HHSN had a significant association with abnormal vHIT in the lateral semicircular canal (LSCC) on the opposite side to the direction of nystagmus. The presence of VIN had a significant association with abnormal vHIT in all the SCCs and abnormal ACS oVEMP on the opposite side to the direction of nystagmus. CONCLUSIONS: HHSN had an association with LSCC dysfunction alone. VIN had an association with dysfunction in all the SCCs and the utricle.

Os 100 artigos mais citados em reabilitação vestibular

Introdução: A reabilitação vestibular é caracterizada como o conjunto de ações que tem como objetivo restabelecer o equilíbrio corporal. A publicação de artigos científicos sobre reabilitação vestibular vem crescendo nos últimos anos. A análise de citações tem por função rever os artigos mais citados a fim de identificar publicações que apresentam maior reconhecimento e impacto em uma determinada área. Apesar do grande número de publicações, é necessário que seja feita uma reflexão sobre os avanços das pesquisas nessa área, além de avaliar a contribuição individual de cada publicação, especialmente na área da fonoaudiologia. Objetivo: Identificar os 100 artigos mais citados sobre reabilitação vestibular e realizar análise bibliométrica. Método: Em junho de 2020 foi realizada pesquisa específica por título na base de dados “Scopus”, sendo utilizada estratégia de pesquisa ("vestibular diseases" OR "vestibular rehabilitation") AND ("balance rehabilitation" OR "exercise rehabilitation" OR rehabilitation). Os 100 artigos mais citados foram selecionados e analisados, independente do ano, país ou periódico em que foi realizada a publicação. Resultados: O artigo mais citado recebeu média de 36,5 citações por ano. A data de publicação foi de 1989 a 2017. A maioria dos artigos foram publicados no período de 2000 a 2009, com 52 artigos publicados no período. O periódico Otolaryngology – Head and Neck Surgery publicou o maior número de artigos (12 de 100). O tema mais citado foi Distúrbios Vestibulares (68 de 100). A maioria dos artigos teve como país de publicação os Estados Unidos (68 de 100 publicações). Conclusão: Foram identificados os 100 artigos mais citados em Reabilitação Vestibular, que podem ser considerados relevantes, e que os achados impactam as pesquisas na área. Além disso, pode ser observado recorrência de temas, os países com maior número de publicações e os periódicos mais utilizados para publicação sobre a reabilitação vestibular. O impacto do estudo da reabilitação vestibular na Fonoaudiologia ainda é pequeno, se comparado ao número de publicações de outras áreas.