Vestibular Physiotherapy Patients May Require Medical Assessment: Results of Vertigo Audit in Hutt Hospital

Introduction: To identify the type of referrals received by vestibular physiotherapists for vertigo and assess whether medical review for these patients would be appropriate. Materials and Methods: We performed a retrospective review of referral forms, vestibular assessment forms, and vertigo clinic letters of patients referred for vertigo or vestibular physiotherapy input between July 1, 2013, to December 31, 2013. Results: We studied 29 patients with a median age of 63 years. A diagnosis was provided in 65.5% of the referrals. Of 14 patients with possible benign paroxysmal positional vertigo (BPPV), Dix-Hallpike had been performed only for 4 patients. Almost half were seen for the medical review in the Vertigo Clinic due to the concerns of possible alternative non-vestibular diagnosis, medication issues, or syncope. Alternative diagnoses identified medically included orthostatic hypotension, stroke, vestibular migraine, medication-induced bradycardia, and phobic postural vertigo. Medication changes in vertigo clinic included treatment for heart failure, migraine, and medication optimization. Conclusion: Medical review is appropriate for some patients referred for vestibular physiotherapy. A medical opinion should be sought by vestibular physiotherapists if there is uncertainty or concerns that the referred patients did not have straightforward vestibular problems, or there were possible alternative diagnoses, concerns with medications, or syncope.

The Design and Development of MOVE-IT: A System for Remote Vestibular and Oculomotor Assessment in People with Concussion

Background: Dizziness is one of the most common symptoms following concussion and requires a thorough vestibular assessment. However, due to limited tools and evidence on remote vestibular assessment and intervention, people unable to attend in-person consults cannot receive effective care. Objective: This study aims to describe the design and development process of MOVE-IT. MOVE-IT is a mobile phone application with an associated head mount device and clinician dashboard which aims to enhance vestibular assessments and intervention via telehealth by enabling clinicians to clearly observe client’s eye movements. Methods: This study used a Living Labs methodology including the use of a scoping review, user engagement, multi stakeholder engagement, real-life settings, and co-creation. MOVE-IT was developed in three phases: Exploration, Experimentation and Evaluation. This paper describes the Exploration and Experimentation process. Exploration included a scoping review, focus group and consultation interviews. Experimentation included the co-creation of a minimum viable product in a real-life setting with regular feedback from multi-stakeholders. Outcome: MOVE-IT includes three components: a mobile phone application, head mount device and clinician dashboard. MOVE-IT aims to enhance the use of telehealth for vestibular assessments by: (1) using the head mount device to enable video recording of client’s eyes during assessment, (2) allowing clinicians to view client’s eye movements via the clinician dashboard whilst (3) a support person assists in the physical aspect of the vestibular assessment by a step-by-step guided video in the mobile application. Conclusion: The Living Lab method was a useful strategy for developing MOVE-IT. MOVE-IT meets all predefined functionality requirements and potentially provides a solution for remote vestibular assessment and intervention in the concussion population. The Evaluation phase will be conducted next to test usability, reliability and validity of MOVE-IT.

Estimated Vestibulogram (EVEST) for Effective Vestibular Assessment

Background. The availability and development of methods testing the vestibuloocular reflex (VOR) brought a broader view into the lateral semicircular canal (L-SCC) function. However, the higher number of evaluated parameters makes more difficult the specialist’s diagnose-making process. Purpose. To provide medical specialists, a new diagnostic-graphic tool, Estimated Vestibulogram- EVEST, enabling a quick and easy-to-read visualization and comparison of the VOR test results within the L-SCC. Methods. The development of EVEST involved 148 participants, including 49 healthy volunteers (28 female and 21 male) and 99 (58 female and 41 male) patients affected by different degrees of peripheral vestibular deficit. The corresponding L-SCC VOR test results, from patients meeting the diagnostic criteria, were used to create the EVEST. Results. Based on the test results, we depicted and calculated the EVEST vestibular function asymmetry (VFA) in all the groups. To assess a feasibility of EVEST to describe a vestibular function deficit, we calculated sensitivity and specificity of VFA using a receiver operating characteristic curve (ROC) and compared it to single tests. In all the tests, we determined the cutoff value as the point with the highest sensitivity and specificity. For discrimination of any vestibular deficit, the VFA with cutoff 6.5% was more sensitive (91%) and specific (98%) than single tests. Results showed that EVEST is a beneficial graphic tool for quick multifrequency comparison and diagnosis of different types of the peripheral vestibular loss. Conclusions. EVEST can help to easily evaluate various types of peripheral vestibular lesion.

Benign Positional Paroxysmal Vertigo in Children

The aim of this study was to assess the prevalence and analyze clinical parameters of benign positional paroxysmal vertigo (BPPV) in a pediatric age. A cohort of 423 children under the age of 15 (median age 11. interquartile range 9–13) was submitted to vestibular assessment for balance disorders. Dix-Hallpike and Roll-Supine tests were performed to look for positioning nystagmus using video-infrared goggles. BPPV was found in 43 of 423 children evaluated for balance disorders (10.2%). There were 28 females (65.1%) and 15 (34.9%) males. The posterior canal was involved in 79% of cases and the horizontal canal in 21% of cases. No apogeotropic bilateral or anterior canal form were seen. Thus, BPPV is not an infrequent type of vertigo in children and must be evaluated as soon as possible in order to plan the most appropriate maneuver and restore daily activities as soon as possible, avoiding anxiety and fear.

The effect of external trigeminal nerve stimulation on the vestibular component correction in patients with vestibular migraine

Aim: to study the possibilities of vestibular component correction in patients with vestibular migraine using external trigeminal nerve stimulation. Patients and Methods: the study included 42 patients (32 of them women) aged 18 to 50 y.o., with established vestibular migraine. All patients underwent external trigeminal nerve stimulation. The duration of each therapeutic course was 20 minutes, the frequency was 3 times a week for 3 months. The assessment of the condition dynamics was conducted using the Dizziness Handicap Inventory (DHI), Subjective Vestibular Assessment on a 5-point scale and Vestibular Rehabilitation Benefit Questionnaire. Results: at the first visit, the majority (77%) of patients suffered from severe dizziness, 23% of patients experienced moderate symptoms. After treatment, most patients experienced only mild symptoms of dizziness, while 31% of patients had no symptoms of dizziness. The total score for DHI before treatment was 58 (95% CI 54–63), after treatment — 19 (95% CI 16–24) (p<0,05). The median indicator of life quality deficiency according to the Vestibular Rehabilitation Benefit Questionnaire before correction of vestibular dysfunction was 57 (95% CI 51.3–64.8), after external stimulation course — 38 (95% CI 32.7–44.6) (p<0.05). Conclusion: external trigeminal nerve stimulation can be considered as an actual non-pharmacological method of vestibular dysfunction correction in patients with vestibular migraine. KEYWORDS: vestibular dysfunction, dizziness, vestibular migraine, external trigeminal nerve stimulation, life quality. FOR CITATION: Illarionova E.M., Gribova N.P. The effect of external trigeminal nerve stimulation on the vestibular component correction in patients with vestibular migraine. Russian Medical Inquiry. 2021;5(10):683–686 (in Russ.). DOI: 10.32364/2587-6821-2021-5-10-683-686.

Video head impulse test saccades and loss of cervical vestibular evoked myogenic potentials are late vestibular footprints of cochlear implantation

BACKGROUND: Cochlear implantation may be complicated by concurrent injury to the vestibular apparatus, potentially resulting in disabling vertigo and balance problems. Information on vestibular function before implantation as measured by the video head impulse test (VHIT) and cervical vestibular evoked myogenic potentials (cVEMPs) is scarce and literature on long-term effects is non-existing. OBJECTIVE: We aimed to evaluate how vestibular function was affected by cochlear implantation (CI), as measured by VHIT and cVEMPs in the late phase after implantation. METHODS: Retrospective repeated measurement study. Patients: Among the 436 patients elected for CI surgery during 2013 to 2018, 45 patients met the inclusion criteria (CI recipients with a vestibular assessment prior to the first CI and a repeated vestibular assessment after the CI operation). Intervention: VHIT and cVEMPs before and after cochlear implantation. Main outcome measures were vestibular function as evaluated by VHIT gain, saccades and cVEMPs. RESULTS: The mean time between first and second vestibular screening was 19 months. The mean VHIT gain on implanted ears was 0.79 before the operation and showed no change at follow-up (p = 0.65). Likewise, the number of abnormal VHIT gain values was equal before and after the operation (p = 0.31). Preoperatively, saccades were present on 12 ears (14% ) compared with 25 ears (29% ) postoperatively (p = 0.013) and were associated with significantly lower VHIT gain values. Preoperatively, positive cVEMPs were found in 20 CI ears (49% ) and 24 contralateral ears (62% ). 10 CI ears lost cVEMP postoperatively compared with 2 ears on the contralateral side (p = 0.0047). CONCLUSIONS: Even though VHIT gain has been reported to be affected in the immediate post-implantation period, the findings in this study show that VHIT gain is normalized in the long-term. However, cochlear implantation is associated with the occurrence of VHIT saccades in the long-term and these are associated with lower VHIT gain values. In addition, cVEMP responses are significantly reduced long-term on implanted ears, which agrees with other studies with shorter follow-up.

Vestibular rehabilitation in Europe: a survey of clinical and research practice

Vestibular rehabilitation (VR) is practiced across Europe but little in this area has been quantified. The aim of this study was to investigate current VR assessment, treatment, education, and research practices. This was an online, cross-sectional survey with 39 VR specific questions and four sections: demographics, current practice, education, and research. The survey was disseminated through the Dizzynet network to individual therapists through country-specific VR special interest groups. Results were analysed descriptively. A thematic approach was taken to analyse open questions. A total of 471 individuals (median age 41, range 23 − 68 years, 73.4% women), predominately physiotherapists (89.4%) from 20 European countries responded to the survey. They had worked for a median of 4 years (range < 1 − 35) in VR. The majority (58.7%) worked in hospital in-patient or out-patient settings and 21.4% in dedicated VR services. Most respondents specialized in neurology, care of the elderly (geriatrics), or otorhinolaryngology. VR was reported as hard/very hard to access by 48%, with the main barriers to access identified as lack of knowledge of health care professionals (particularly family physicians), lack of trained therapists, and lack of local services. Most respondents reported to know and treat benign paroxysmal positional vertigo (BPPV 87.5%), unilateral vestibular hypofunction (75.6%), and cervicogenic dizziness (63%). The use of vestibular assessment equipment varied widely. Over 70% used high-density foam and objective gait speed testing. Over 50% used dynamic visual acuity equipment. Infrared systems, Frenzel lenses, and dynamic posturography were not commonly employed (< 20%). The most frequently used physical outcome measures were the Clinical Test of the Sensory Interaction of Balance, Functional Gait Assessment/Dynamic Gait Index, and Romberg/Tandem Romberg. The Dizziness Handicap Inventory, Visual Analogue Scale, Falls Efficacy Scale, and the Vertigo Symptom Scale were the most commonly used patient reported outcome measures. Adaptation, balance, and habituation exercises were most frequently used (> 80%), with virtual reality used by 15.6%. Over 70% reported knowledge/use of Semont, Epley and Barbeque-Roll manoeuvres for the treatment of BPPV. Most education regarding VR was obtained at post-registration level (89.5%) with only 19% reporting pre-registration education. There was strong (78%) agreement that therapists should have professionally accredited postgraduate certification in VR, with blended learning the most popular mode. Three major research questions were identified for priority: management of specific conditions, effectiveness of VR, and mechanisms/factors influencing vestibular compensation and VR. In summary, the survey quantified current clinical practice in VR across Europe. Knowledge and treatment of common vestibular diseases was high, but use of published subjective and objective outcome measures as well as vestibular assessment varied widely. The results stress the need of improving both training of therapists and standards of care. A European approach, taking advantage of best practices in some countries, seems a reasonable approach.