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No 454: December 26, 2918

Hunt AW, Paniccia M, Reed N, Keightley M. Concussion-Like Symptoms in Child and Youth Athletes at Baseline: What Is "Typical"? J Athl Train. 2016 Oct;51(10):749-757. doi: 10.4085/1062-6050-51.11.12. Epub 2016 Nov 11.


CONTEXT: After a concussion, guidelines emphasize that an athlete should be asymptomatic before starting a return-to-play protocol. However, many concussion symptoms are nonspecific and may be present in individuals without concussion. Limited evidence exists regarding the presence of "typical" or preinjury (baseline) symptoms in child and youth athletes.

OBJECTIVE: To describe the frequency of symptoms reported at baseline by child and youth athletes and identify how age, sex, history of concussion, and learning factors influence the presence of baseline symptoms.

DESIGN: Cross-sectional cohort study.

SETTING: Baseline testing was conducted at a hospital research laboratory or in a sport or school setting (eg, gym or arena).

PATIENTS OR OTHER PARTICIPANTS: A total of 888 child (9-12 years old, n = 333) and youth (13-17 years old, n = 555) athletes participated (46.4% boys and 53.6% girls, average age = 13.09 ± 1.83 years).

MAIN OUTCOME MEASURE(S): Demographic and symptom data were collected as part of a baseline protocol. Age-appropriate versions of the Post-Concussion Symptom Inventory (a self-report concussion-symptoms measure with strong psychometric properties for pediatric populations) were administered. Demographic data (age, sex, concussion history, learning factors) were also collected.

RESULTS: Common baseline symptoms for children were feeling sleepier than usual (30% boys, 24% girls) and feeling nervous or worried (17% boys, 25% girls). Fatigue was reported by more than half of the youth group (50% boys, 67% girls). Nervousness was reported by 32% of youth girls. Headaches, drowsiness, and difficulty concentrating were each reported by 25% of youth boys and girls. For youths, a higher total symptom score was associated with increasing age and number of previous concussions, although these effects were small (age rs = 0.143, number of concussions rs = .084). No significant relationships were found in the child group.

CONCLUSIONS: Children and youths commonly experienced symptoms at baseline, including fatigue and nervousness. Whether clinicians should expect complete symptom resolution after concussion is not clear.

PMID:  27834505 

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No 453: December 20, 2018

Vander Vegt CB, Register-Mihalik JK, Ford CB, Rodrigo CJ, Guskiewicz KM, Mihalik JP. Baseline Concussion Clinical Measures Are Related to Sensory Organization and Balance. Med Sci Sports Exerc. 2018 Sep 19. doi: 10.1249/MSS.0000000000001789. [Epub ahead of print]


PURPOSE: To examine relationships among baseline demographics, symptom severity, computerized neurocognitive outcomes, and balance performance in collegiate athletes.

METHODS: Collegiate varsity athletes (N=207, age=19.3 ± 1.0 years) participating in an ongoing clinical research program who completed concussion baseline assessments including a demographic questionnaire, graded symptom checklist, neurocognitive assessment, and the Sensory Organization Test (SOT) were included in this study. The SOT composite equilibrium score (COMP) and three sensory ratio scores-vestibular (VEST), visual (VIS), and somatosensory (SOM)-were used to describe athletes' overall sensory organization and ability to utilize input from each sensory system to maintain balance. Separate stepwise multiple linear regression models were performed for each SOT outcome. Total symptom severity level and CNS Vital Signs domain scores served as predictor variables.
RESULTS: Stepwise regression models for COMP (R = 0.18, F4,201 = 11.29, P <0.001), VEST (R = 0.14, F4,201 = 8.16, P<0.001), and VIS (R = 0.10, F4,201 = 5.52, P <0.001) were all significant. Faster reaction times and higher executive function scores were associated with higher COMP and VEST scores in separate models. Those with faster reaction times also had significantly higher VIS scores.
CONCLUSION: Reaction time and executive function demonstrated significant relationships with SOT balance performance. These cognitive processes may influence athletes' ability to organize and process higher order information and generate appropriate responses to changes in their environment, with respect to balance and injury risk. Future investigations should consider these relationships following injury and clinicians should be mindful of this relationship when considering concussion management strategies

PMID:  30239494

No 452: December 12, 2018

Leddy J, Baker JG, Haider MN, Hinds A, Willer B. A Physiological Approach to Prolonged Recovery From Sport-Related Concussion.J Athl Train. 2017 Mar;52(3):299-308. doi: 10.4085/1062-6050-51.11.08.


Management of the athlete with postconcussion syndrome (PCS) is challenging because of the nonspecificity of PCS symptoms. Ongoing symptoms reflect prolonged concussion pathophysiology or conditions such as migraine headaches, depression or anxiety, chronic pain, cervical injury, visual dysfunction, vestibular dysfunction, or some combination of these. In this paper, we focus on the physiological signs of concussion to help narrow the differential diagnosis of PCS in athletes. The physiological effects of exercise on concussion are especially important for athletes. Some athletes with PCS have exercise intolerance that may result from altered control of cerebral blood flow. Systematic evaluation of exercise tolerance combined with a physical examination of the neurologic, visual, cervical, and vestibular systems can in many cases identify one or more treatable postconcussion disorders.

PMID: 28387557 

No 451: December 7, 2018

Mucha A, Fedor S, DeMarco D. Vestibular dysfunction and concussion. Handb Clin Neurol. 2018;158:135-144. doi: 10.1016/B978-0-444-63954-7.00014-8.


The assessment and treatment of sport-related concussion (SRC) often requires a multifaceted approach. Vestibular dysfunction represents an important profile of symptoms and pathology following SRC, with high prevalence and association with prolonged recovery. Signs and symptoms of vestibular dysfunction may include dizziness, vertigo, disequilibrium, nausea, and visual impairment. Identifying the central and peripheral vestibular mechanisms responsible for pathology can aid in management of SRC. The most common vestibular disturbances after SRC include benign paroxysmal positional vertigo, vestibulo-ocular reflex impairment, visual motion sensitivity, and balance impairment. A variety of evidence-based screening and assessment tools can help to identify the various types of vestibular pathology in SRC. When vestibular dysfunction is identified, there is emerging support for applying targeted vestibular rehabilitation to manage this condition

PMID: 30482341 

No 450: November 28, 2018

McCaslin DL1, Jacobson GP, Bennett ML, Gruenwald JM, Green AP. Predictive properties of the video head impulse test: measures of caloric symmetry and self-report dizziness handicap. Ear Hear. 2014 Sep-Oct;35(5):e185-91


OBJECTIVES: The purpose of this investigation was to determine whether a predictable relationship existed between self-reported dizziness handicap and video Head Impulse Test (vHIT) results in a large sample of patients reporting to a dizziness clinic. Secondary objectives included describing the characteristics of the vHIT ipsilesional and contralesional vestibulo-ocular reflex slow-phase velocity in patients with varying levels of canal paresis. Finally, the authors calculated the sensitivity and specificity of the vHIT for detecting horizontal semicircular canal impairment using the caloric test as the "gold standard."

DESIGN: Participants were 115 adults presenting to a tertiary medical care center with symptoms of dizziness. Participants were administered a measure of self-report dizziness handicap (i.e., Dizziness Handicap Inventory) and underwent caloric testing and vHIT at the same appointment.

RESULTS: Results showed that (1) there were no significant group differences (i.e., vHIT normal versus vHIT abnormal) in the Dizziness Handicap Inventory total score, (2) both ipsilesional and contralateral velocity gain decreased with increases in caloric paresis, and (3) a caloric asymmetry of 39.5% was determined to be the cutoff that maximized discrimination of vHIT outcome.

CONCLUSIONS: The level of self-reported dizziness handicap is not predicted by the outcome of the vHIT, which is consistent with the majority of published reports describing the poor relationship between quantitative tests of vestibular function and dizziness handicap. Further, the study findings have demonstrated that vHIT and caloric data are not redundant, and each test provides unique information regarding the functional integrity of the horizontal semicircular canal at different points on the frequency spectrum. The vHIT does offer some advantages over caloric testing, but at the expense of sensitivity. The vHIT can be completed in less time, is not noxious to the patient, and requires very little laboratory space. However, the study data show that a caloric asymmetry of 39.5% is required to optimize discrimination between an abnormal and normal vHIT. It is the authors' contention that the vHIT is a complementary test to the balance function examination and should viewed as such rather than as a replacement for caloric testing.

PMID: 24801960

No 449: November 21, 2018

Khater AM, Afifi PO. Int J Pediatr Otorhinolaryngol. Video head-impulse test (vHIT) in dizzy children with normal caloric responses.  2016 Aug;87:172-7.


OBJECTIVE: The caloric test and the video head-impulse test are diagnostic tools to examine dizzy patients through assessing the function of the semicircular canals. There are major differences between the two tests as regards stimulus characteristics, methodology, and function examined. The aim of this study is to evaluate the results of vHIT in children and adolescents with normal caloric test.

MATERIALS AND METHODS: This work was performed on 63 patients, but 14 were excluded because of technical problems in the caloric test. So, this is a prospective work in 49 patients (27 females and 22 males) with different types of vestibular disease seen because of vertigo in which both procedures were performed the same day. The caloric test was performed with air at two different temperatures in which both ears were irrigated alternately. Then, the video head-impulse test was carried out. Main outcome measures were the gain of vestibulo-ocularreflex, gain asymmetry, and refixation saccades in the vHIT.

RESULTS: in all studied cases, caloric test was normal. The mean age of patients was 16 years. By vHIT, in 8 patients (16%) no abnormality was detected, while abnormal findings were found in 41 patients. Single canal affection was seen in 29 patients whereas 12 patients had combined canal affection. The right side was affected in 27 and left side in 22 patients. In single canal affection, isolated horizontal canals were affected in 4, anterior canals in 5 and posterior canals in 20 patients. While in combined canal affection, the affection is seen in the same ear. Moreover the most common pattern seen is affection of left anterior and left posterior canals.

CONCLUSION: The caloric and vHIT is very important tests in diagnosis of dizzy patients. The information from both methods is redundant in some cases but complementary in most. vHIT is a "child friendly," relatively easy-to-use, and simple tool to evaluate each of the 6 semicircular canals.

PMID: 27368467

No 448: November 14, 2018

Alhabib SF, Saliba I. Video head impulse test: a review of the literature. Eur Arch Otorhinolaryngol. 2017 Mar;274(3):1215-1222.


Video head impulse test (vHIT) is a new testing which able to identify the overt and covert saccades and study the gain of vestibulo-ocularreflex (VOR) of each semicircular canal. The aim of this study is to review the clinical use of vHIT in patients with vestibular disorders in different diseases. PubMed and Cochrane databases were searched for all articles that defined vHIT, compared vHIT with another clinical test, and studied the efficacy of vHIT as diagnostic tools with vestibular disease. 37 articles about vHIT were reviewed. All articles studied the vHIT in English and French languages up to May 2015 were included in the review. Editorial articles or short comments, conference abstracts, animal studies, and language restriction were excluded from the review. Four systems were used in the literature to do the vHIT. vHIT is physiological quick test, which studied the VOR at high frequency of each semicircular canal by calculating the duration ratio between the head impulse and gaze deviation. vHIT is more sensitive than clinical head impulse test (cHIT), especially in patient with isolated covert saccades. vHIT test is diagnostic of vestibular weakness by gain reduction and the appearance of overt and covert saccades. If the vHIT is normal, then caloric test is mandatory to rule out a peripheral origin of vertigo. It is recommended to test each semicircular canal, as isolated vertical canal weakness was identified in the literature. More investigation would be required to determine the evolution of the VOR gain with the progression of the vestibular disease.

PMID: 27328962

No 447: October 31, 2018

Keshavarz B, Riecke BE, Hettinger LJ, Campos JL. Vection and visually induced motion sickness: how are they related? Front Psychol. 2015 Apr 20;6:472. doi: 10.3389/fpsyg.2015.00472. eCollection 2015


The occurrence of visually induced motion sickness has been frequently linked to the sensation of illusory self-motion (vection), however, the precise nature of this relationship is still not fully understood. To date, it is still a matter of debate as to whether vection is a necessary prerequisite for visually induced motion sickness (VIMS). That is, can there be VIMS without any sensation of self-motion? In this paper, we will describe the possible nature of this relationship, review the literature that addresses this relationship (including theoretical accounts of vection and VIMS), and offer suggestions with respect to operationally defining and reporting these phenomena in future.

PMID: 25941509

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No 446: October 24, 2018

Kim CH, Hong SM. Is the modified cupulolith repositioning maneuver effective for treatment of persistent geotropic direction-changing positional nystagmus? Eur Arch Otorhinolaryngol. 2018 Jul;275(7):1731-1736. doi: 10.1007/s00405-018-5006-4. Epub 2018 May 26.


OBJECTIVE: Clinicians sometimes see patients with relatively persistent geotropic direction-changing positional nystagmus (DCPN) as a variant of lateral semicircular canal-benign paroxysmal positional vertigo (LSCC-BPPV). Recently, the concept of a "light cupula" in the lateral semicircular canal, exhibiting persistent geotropic DCPN, has been introduced. However, the underlying pathogenesis of light cupula is not known. We investigated the efficacy of a modified cupulopathy repositioning maneuver (mCuRM), designed to reduce light debris attached to the cupula in patients with persistent geotropic DCPN.

STUDY DESIGN: Retrospective cohort study.

METHODS: Participants included 65 patients with a persistent geotropic DCPN: 35 underwent treatment (mCuRM group), and 30 were followed-up but received no treatment (No CuRM group). We compared the therapeutic and survival rate of persistent geotropic DCPN between two groups.

RESULTS: On Day 1, the persistent geotropic DCPN did not resolve in either group. On the first and second follow-up days, persistent geotropic DCPN was observed in 28 (80%) and 21 (60%) of patients, respectively, in the mCuRM group, and in 28 (93.3%) and 24 (80%) patients, respectively, in the no mCuRM group. The differences between groups were not statistically significant. Furthermore, no between-group differences were found in the time from diagnosis to resolution of nystagmus, or the time from symptom onset to resolution of nystagmus. Kaplan-Meier analysis of the time course of persistent geotropic DCPN resolution from the day of diagnosis and day of symptom onset revealed no significant differences between the groups.

CONCLUSION: Our findings indicate that mCuRM had no therapeutic benefit for a persistent geotropic DCPN and suggest that the pathophysiology of persistent geotropic DCPN is less likely to be a light debris attached to the cupula.

PMID: 29804128

No 445: October 17, 2018

Hoppes CW, Sparto PJ, Whitney SL, Furman JM, Huppert TJ. Changes in cerebral activation in individuals with and without visual vertigo during optic flow: A functional near-infrared spectroscopy study. Neuroimage Clin. 2018 Sep 5;20:655-663. doi: 10.1016/j.nicl.2018.08.034. eCollection 2018.


BACKGROUND AND PURPOSE: Individuals with visual vertigo (VV) describe symptoms of dizziness, disorientation, and/or impaired balance in environments with conflicting visual and vestibular information or complex visual stimuli. Physical therapists often prescribe habituation exercises using optic flow to treat these symptoms, but it is not known how individuals with VV process the visual stimuli. The primary purpose of this study was to use functional near-infrared spectroscopy (fNIRS) to determine if individuals with VV have different cerebral activation during optic flow compared with control subjects.

METHODS: Fifteen individuals (5 males and 10 females in each group) with VV seeking care for dizziness and 15 healthy controls (CON) stood in a virtual reality environment and viewed anterior-posterior optic flow. The support surface was either fixed or sway-referenced. Changes in cerebral activation were recorded using fNIRS during periods of optic flow relative to a stationary visual environment. Postural sway of the head and center of mass was recorded using an electromagnetic tracker.

RESULTS: Compared with CON, the VV group displayed decreased activation in the bilateral middle frontal regions when viewing optic flow while standing on a fixed platform. Despite both groups having significantly increased activation in most regions while viewing optic flow on a sway-referenced surface, the VV group did not have as much of an increase in the right middle frontal region when viewing unpredictable optic flow in comparison with the CON group.

DISCUSSION AND CONCLUSIONS: Individuals with VV produced a pattern of reduced middle frontal cerebral activation when viewing optic flow compared with CON. Decreased activation in the middle frontal regions of the cerebral cortex may represent an alteration in control over the normal reciprocal inhibitory visual-vestibular interaction in visually dependent individuals. Although preliminary, these findings add to a growing body of literature using functional brain imaging to explore changes in cerebral activation in individuals with complaints of dizziness, disorientation, and unsteadiness. Future studies in larger samples should explore if this decreased activation is modified following a rehabilitation regimen consisting of visual habituation exercises.

PMID: 30211002

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No 444: October 10, 2018

Geraghty AWA, Essery R, Kirby S, Stuart B, Turner D, Little P, Bronstein A, Andersson G, Carlbring P, Yardley L. Internet-Based Vestibular Rehabilitation for Older Adults With Chronic Dizziness: A Randomized Controlled Trial in Primary Care. Ann Fam Med. 2017 May;15(3):209-216. doi: 10.1370/afm.2070.


PURPOSE: Vestibular rehabilitation is an effective intervention for dizziness due to vestibular dysfunction, but is seldom provided. We aimed to determine the effectiveness of an Internet-based vestibular rehabilitation program for older adults experiencing dizziness in primary care.

METHODS: We undertook a single-center, single-blind randomized controlled trial comparing an Internet-based vestibular rehabilitation intervention (Balance Retraining, freely available from with usual primary care in patients from 54 primary care practices in southern England. Patients aged 50 years and older with current dizziness exacerbated by head movements were enrolled. Those in the intervention group accessed an automated Internet-based program that taught vestibular rehabilitation exercises and suggested cognitive behavioral management strategies. Dizziness was measured by the Vertigo Symptom Scale-Short Form (VSS-SF) at baseline, 3 months, and 6 months. The primary outcome was VSS-SF score at 6 months.

RESULTS: A total of 296 patients were randomized in the trial; 66% were female, and the median age was 67 years. The VSS-SF was completed by 250 patients (84%) at 3 months and 230 patients (78%) at 6 months. Compared with the usual care group, the Internet-based vestibular rehabilitation group had less dizziness on the VSS-SF at 3 months (difference, 2.75 points; 95% CI, 1.39-4.12; P <.001) and at 6 months (difference, 2.26 points; 95% CI, 0.39-4.12; P = .02, respectively). Dizziness-related disability was also lower in the Internet-based vestibular rehabilitation group at 3 months (difference, 6.15 points; 95% CI, 2.81-9.49; P <.001) and 6 months (difference, 5.58 points; 95% CI, 1.19-10.0; P = .01).

CONCLUSIONS: Internet-based vestibular rehabilitation reduces dizziness and dizziness-related disability in older primary care patients without requiring clinical support. This intervention has potential for wide application in community settings.

PMID: 28483885

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No 443: October 3, 2018

Popkirov S, Staab JP, Stone J. Persistent postural-perceptual dizziness (PPPD): a common, characteristic and treatable cause of chronic dizziness. Pract Neurol. 2018 Feb;18(1):5-13. doi: 10.1136/practneurol-2017-001809. Epub 2017 Dec 5.


Persistent postural-perceptual dizziness (PPPD) is a newly defined diagnostic syndrome that unifies key features of chronic subjective dizziness, phobic postural vertigo and related disorders. It describes a common chronic dysfunction of the vestibular system and brain that produces persistent dizziness, non-spinning vertigo and/or unsteadiness. The disorder constitutes a long-term maladaptation to a neuro-otological, medical or psychological event that triggered vestibular symptoms, and is usefully considered within the spectrum of other functional neurological disorders. While diagnostic tests and conventional imaging usually remain negative, patients with PPPD present in a characteristic way that maps on to positive diagnostic criteria. Patients often develop secondary functional gait disorder, anxiety, avoidance behaviour and severe disability. Once recognised, PPPD can be managed with effective communication and tailored treatment strategies, including specialised physical therapy (vestibular rehabilitation), serotonergic medications and cognitive-behavioural therapy.

PMID: 29208729

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