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No. 386: August 9, 2017 

Jáuregui-Renaud K, Villanueva Padrón LA, Cruz Gómez NS. The effect of vestibular rehabilitation supplemented by training of the breathing rhythm or proprioception exercises, in patients with chronic peripheral vestibular disease. J Vestib Res. 2007;17(1):63-72.

OBJECTIVE: To assess the effect of performing vestibular rehabilitation using the Cawthorne & Cooksey exercises supplemented by training of the breathing rhythm or proprioception exercises on self-reported disability and postural control, in patients with chronic, peripheral, vestibular disease.
METHODS: Fifty one patients with peripheral vestibular disease and abnormal caloric test participated in the study (mean age 43 +/- S.D. 9 years). They were assigned to one of 3 treatment groups: I. Cawthorne &} Cooksey exercises with training of the breathing rhythm (n=17); II. Cawthorne & Cooksey exercises with proprioception exercises (n=17) and III. Cawthorne & Cooksey exercises with no additional intervention (n=17). The Dizziness Handicap Inventory and static posturography were evaluated prior to treatment and at week 8 of follow-up.
RESULTS: Prior to treatment, composite scores on the Dizziness Handicap Inventory and static posturography were similar in the 3 groups. After treatment, a decrease of the composite score of at least 18 points was observed more frequently in patients of the respiration group (94%), compared to the proprioception group (53%) and the Cawthorne & Cooksey group (70%) (p=0.03); while the proprioception group showed a significant decrease of oscillation during all sensory conditions of static posturography (p< 0.05).
CONCLUSION: The results suggest that regulation of the breathing pattern may have an influence on disability related to chronic vestibular disease, while proprioception exercises may improve postural control. However, further studies are needed to evaluate if training of the breathing rhythm could be an additional tool for vestibular rehabilitation.
PMID: 18219105

No. 385: August 2, 2017 

Naber CM, Water-Schmeder O, Bohrer PS, Matonak K, Bernstein AL, Merchant MA. Interdisciplinary treatment for vestibular dysfunction: the effectiveness of mindfulness, cognitive-behavioral techniques, and vestibular rehabilitation. Otolaryngol Head Neck Surg. 2011 Jul;145(1):117-24.

OBJECTIVE: To investigate whether an interdisciplinary program for vestibular patients improved health outcomes and health care utilization.
STUDY DESIGN: Case series with chart review.
SETTING: Outpatient neurotology clinic.
SUBJECTS AND METHODS: Patients (N = 167) with dizziness attended an interdisciplinary neurotology clinic; 129 were offered group treatment. After an introductory session, group treatment included 5 sessions incorporating mindfulness, cognitive-behavioral techniques, and vestibular rehabilitation. Physical and emotional functioning, depression, anxiety, dizziness, impairment, coping, skill use, and patient satisfaction were measured with rating scales pre- and post-group treatment. Data from 51 patients (male/female = 14/37; age range, 25-82 years) were analyzed with paired t tests or nonparametric tests. Logistic regression analyzed predictors of outcome and utilization for 116 patients (male/female = 81/35; age range, 11-86 years) attending the interdisciplinary clinic, introductory session, and/or group.
RESULTS: After group treatment, patients reported better mood (P = .0482); better physical (P = .0006) and mental (P = .0183) health; better functionality, coping, and skill use (Ps< .0001); less impairment (P < .0001); and fewer limitations from dizziness (P < .0001). Higher pretreatment levels of depression (P =.0216), poorer initial mental (P = .0164) or physical (P = .0059) health, and peripheral diagnosis (P = .0220) predicted better outcome. Group treatment decreased utilization more than the interdisciplinary clinic with (P = .0183) or without (P = .0196) the introductory session; 78% of patients with any level of participation showed less utilization. Clinic patients had fewer radiology procedures than group patients (P = .0365). Patients were highly satisfied with the program and found it more effective than previous treatment.
CONCLUSION: Interdisciplinary treatment improves patient coping, functionality, and satisfaction and decreases overall health care utilization in vestibular patients.
PMID: 21493331

No. 384: July 26, 2017 

Kontos AP1, Deitrick JM1, Collins MW1, Mucha A2. Review of Vestibual and Oculomotor Screening and Concussion Rehabilitation. J Athl Train. 2017 Mar;52(3):256-261

Vestibular and oculomotor impairment and symptoms may be associated with worse outcomes after sport-related concussion (SRC), including prolonged recovery. In this review, we evaluate current findings on vestibular and oculomotor impairments as well as treatment approaches after SRC, and we highlight areas in which investigation is needed. Clinical researchers have intimated that recovery from SRC may follow certain clinical profiles that affect the vestibular and oculomotor pathways. Identifying clinical profiles may help to inform better treatment and earlier intervention to reduce recovery time after SRC. As such, screening for and subsequent monitoring of vestibular and oculomotor impairment and symptoms are critical to assessing and informing subsequent referral, treatment, and return to play. However, until recently, no brief-screening vestibular and oculomotor tools were available to evaluate this injury. In response, researchers and clinicians partnered to develop the Vestibular/Ocular-Motor Screening, which assesses pursuits, saccades, vestibular ocular reflex, visual motion sensitivity, and convergence via symptom provocation and measurement of near-point convergence. Other specialized tools, such as the King-Devick test for saccadic eye movements and the Dizziness Handicap Inventory for dizziness, may provide additional information regarding specific impairments and symptoms. Tools such as the Vestibular/Ocular-Motor Screening provide information to guide specialized referrals for additional assessment and targeted rehabilitation. Vestibular rehabilitation and visual-oculomotor therapies involve an active, expose-recover approach to reduce impairment and symptoms. Initial results support the effectiveness of both vestibular and visual-oculomotor therapies, especially those that target specific impairments. However, the evidence supporting rehabilitation strategies for both vestibular and oculomotor impairment and symptoms is limited and involves small sample sizes, combined therapies, nonrandomized treatment groups, and lack of controls. Additional studies on the effectiveness of screening tools and rehabilitation strategies for both vestibular and oculomotor impairment and symptoms after SRC are warranted. 
PMID: 28387548

No. 383: July 19, 2017 

Murray DA1, Meldrum D2, Lennon O1. Can vestibular rehabilitation exercises help patients with concussion? A systematic review of efficacy, prescription and progression patterns. Br J Sports Med. 2016 Sep 21. pii: bjsports-2016-096081

OBJECTIVE: Concussion symptoms normally resolve within 7-10 days but vertigo, dizziness and balance dysfunction persist in 10-30% of cases causing significant morbidity. This study systematically evaluated the evidence supporting the efficacy, prescription and progression patterns of vestibular rehabilitation therapy (VRT) in patients with concussion.
DESIGN: Systematic Review, guided by PRISMA guidelines and presenting a best evidence synthesis.
DATA SOURCES: Electronic databases PubMed (1949 to May 2015), CINAHL (1982 to May 2015), EMBASE (1947 to May 2015), SPORTDiscus (1985 to May 2015), Web of Science (1945 to May 2015) and PEDRO (1999 to May 2015), supplemented by manual searches and grey literature.
ELIGIBILITY CRITERIA FOR STUDY SELECTION: Article or abstract of original research, population of patients with concussion/mild traumatic brain injury (mTBI) with vestibular symptoms, interventions detailing VRT, measurement of outcomes pre-VRT/post-VRT. Study type was not specified.
RESULTS: Following a double review of abstract and full-text articles, 10 studies met the inclusion criteria: randomised controlled trial (n=2), uncontrolled studies (n=3) and case studies (n=5). 4 studies evaluated VRT as a single intervention. 6 studies incorporated VRT in multimodal interventions (including manual therapy, strength training, occupational tasks, counselling or medication). 9 studies reported improvement in outcomes but level I evidence from only 1 study was found that demonstrated increased rates (OR 3.91; 95% CI 1.34 to 11.34; p=0.002) of medical clearance for return to sport within 8 weeks, when VRT (combined with cervical therapy) was compared with usual care. Heterogeneity in study type and outcomes precluded meta-analysis. Habituation and adaptation exercises were employed in 8 studies and balance exercises in 9 studies. Prescription and progression patterns lacked standardisation.
CONCLUSIONS: Current evidence for optimal prescription and efficacy of VRT in patients with mTBI/concussion is limited. Available evidence, although weak, shows promise in this population. Further high-level studies evaluating the effects of VRT in patients with mTBI/concussion with vestibular and/or balance dysfunction are required.
PMID: 27655831

No. 382: July 12, 2017

Schneider KJ1, Meeuwisse WH2, Nettel-Aguirre A3, Barlow K4, Boyd L5, Kang J6, Emery CA7. Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial. Br J Sports Med. 2014 Sep;48(17):1294-8. 

BACKGROUND/AIM: Concussion is a common injury in sport. Most individuals recover in 7-10 days but some have persistent symptoms. The objective of this study was to determine if a combination of vestibular rehabilitation and cervical spine physiotherapy decreased the time until medical clearance in individuals with prolonged postconcussion symptoms.
METHODS: This study was a randomised controlled trial. Consecutive patients with persistent symptoms of dizziness, neck pain and/or headaches following a sport-related concussion (12-30 years, 18 male and 13 female) were randomised to the control or intervention group. Both groups received weekly sessions with a physiotherapist for 8 weeks or until the time of medical clearance. Both groups received postural education, range of motion exercises and cognitive and physical rest until asymptomatic followed by a protocol of graded exertion. The intervention group also received cervical spine and vestibular rehabilitation. The primary outcome of interest was medical clearance to return to sport, which was evaluated by a study sport medicine physician who was blinded to the treatment group.
RESULTS: In the treatment group, 73% (11/15) of the participants were medically cleared within 8 weeks of initiation of treatment, compared with 7% (1/14) in the control group. Using an intention to treat analysis, individuals in the treatment group were 3.91 (95% CI 1.34 to 11.34) times more likely to be medically cleared by 8 weeks.
CONCLUSIONS: A combination of cervical and vestibular physiotherapy decreased time to medical clearance to return to sport in youth and young adults with persistent symptoms of dizziness, neck pain and/or headaches following a sport-related concussion.
PMID: 24855132

No. 381: July 6, 2017

Valovich McLeod TC1, Hale TD. Vestibular and balance issues following sport-related concussion. Brain Inj. 2015;29(2):175-84

PRIMARY OBJECTIVE: To review relevant literature regarding the effect of concussion on vestibular function, impairments, assessments and management strategies. REASONING: Dizziness and balance impairments are common following sport-related concussion. Recommendations regarding the management of sport-related concussion suggest including tests of balance within the multifactorial assessment paradigm for concussive injuries.
ANALYSIS: The literature was searched for guidelines and original studies related to vestibular impairments following concussion, oculomotor and balance assessments and treatment or rehabilitation of vestibular impairments. The databases searched included Medline, CINAHL, Sport Discus and the Cochrane Database of Systematic Reviews through October 2013.
MAIN OUTCOMES AND RESULTS: Dizziness following concussion occurs in ∼67-77% of cases and has been implicated as a risk factor for a prolonged recovery. Balance impairments also occur after concussion and last 3-10 days post-injury. Assessments of balance can be done using both clinical and instrumented measures with success. Vestibular rehabilitation has been shown to improve outcomes in patients with vestibular impairments, with one study demonstrating success in decreasing symptoms and increasing function following concussion.
CONCLUSIONS: Best practices suggest that the assessment of vestibular function through cranial nerve, oculomotor and balance assessments are an important aspect of concussion management. Future studies should evaluate the effectiveness of vestibular rehabilitation for improving patient outcomes.
PMID: 25291297

No. 380: June 28, 2017

Chiarella G, Petrolo C, Riccelli R, Giofrè L, Olivadese G, Gioacchini FM, Scarpa A, Cassandro E, Passamonti L,. Chronic subjective dizziness: Analysis of underlying personality factors. J Vestib Res. 2016 Nov 3;26(4):403-408.

BACKGROUND: Chronic subjective dizziness (CSD) is characterized by persistent dizziness, unsteadiness, and hypersensitivity to one's own motion or exposure to complex visual stimuli. CSD may be triggered, in predisposed individuals with specific personality traits, by acute vestibular diseases. CSD is also thought to arise from failure to re-establish normal balance strategies after resolution of acute vestibular events which may be modulated by diathesis to develop anxiety and depression.
OBJECTIVE: To confirm the role of personality traits linked to anxiety and depression (i.e., neuroticism, introversion, low openness) as predisposing factors for CSD and to evaluate how individual differences in these personality traits are associated with CSD severity.
METHODS: We compared 19 CSD patients with 24 individuals who had suffered from periferal vestibular disorders (PVD) (i.e., Benign Paroxysmal Postural Vertigo or Vestibular Neuritis) but had not developed CSD as well as with 25 healthy controls (HC) in terms of personality traits, assessed via the NEO-PI-R questionnaire.
RESULTS: CSD patients, relative to PVD patients and HCs, scored higher on the anxiety facet of neuroticism. Total neuroticism scores were also significantly associated with dizziness severity in CSD patients but not PVD patients.
CONCLUSIONS: Pre-existing anxiety-related personality traits may promote and sustain the initial etiophatogenetic mechanisms linked with the development of CSD. Targeting anxiety-related mechanisms in CSD may be therefore a promising way to reduce the disability associated with CSD.
PMID: 27814314

No. 379:  June 21, 2017

Bittar RS, Lins EM.  Clinical characteristics of patients with persistent postural-perceptual dizziness. Braz J Otorhinolaryngol. 2015 May-Jun;81(3):276-82

INTRODUCTION: Persistent postural-perceptual dizziness is the dizziness that lasts for over three months with no clinical explanation for its persistence. The patient's motor response pattern presents changes and most patients manifest significant anxiety.
OBJECTIVE: To evaluate the clinical characteristics of patients with persistent postural and perceptual dizziness.
METHODS: statistical analysis of clinical aspects of patients with persistent postural-perceptual dizziness.
RESULTS: 81 patients, average age: 50.06±12.16 years; female/male ratio: 5.7/1; main reasons for dizziness: visual stimuli (74%), body movements (52%), and sleep deprivation (38%). The most prevalent comorbidities were hypercholesterolemia (31%), migraine headaches (26%), carbohydrate metabolism disorders (22%) and cervical syndrome (21%). DHI, State-Trait Anxiety Inventory - Trait, Beck Depression Inventory, and Hospital Anxiety and Depression Scale questionnaires were statistically different (p<0.05) when compared to controls. 68% demonstrated clinical improvement after treatment with serotonin reuptake inhibitors.
CONCLUSION: Persistent postural-perceptual dizziness affects more women than men, with a high associated prevalence of metabolic disorders and migraine. Questionnaires help to identify the predisposition to persistent postural-perceptual dizziness. The prognosis is good with adequate treatment.
PMID: 25382427

No. 378: June 14, 2017

Holle D, Schulte-Steinberg B, Wurthmann S, Naegel S, Ayzenberg I, Diener HC, Katsarava Z, Obermann M.  Persistent Postural-Perceptual Dizziness: A Matter of Higher, Central Dysfunction? PLoS One. 2015 Nov 16;10(11):e0142468

OBJECTIVE: Persistent postural-perceptual dizziness (PPPD) is the most common vestibular disorder in the age group between 30 and 50 years. It is considered to be based on a multisensory maladjustment involving alterations of sensory response pattern including vestibular, visual and motion stimuli. Previous data supported a link between vestibular and pain mechanism. The aim of the study was to investigate whether other sensory inputs such as pain stimuli might be altered in terms of a more widespread central perception dysfunction in this disorder.
METHODS: Nociceptive blink reflex was measured in 27 patients with PPPD and compared with 27 healthy, age and gender matched controls. The habituation of the R2 component of the blink reflex was evaluated as the percentage area-under-the curve (AUC) decrease in ten consecutive blocks of five averaged rectified responses. Additionally, clinical characteristics were evaluated.
RESULTS: In patients with PPPD a lack of habituation was observed compared to healthy controls. Relative AUC decreased between the first and the tenth block by 19.48% in PPPD patients and by 31.63% (p = 0.035) in healthy controls. There was no correlation between clinical data (course of disease, comorbid depression, medication, trigger factors) or electrophysiological data (perception threshold, pain threshold, stimulus intensity) and habituation pattern. No trigeminal sensitization in terms of facilitation of absolute values could be detected.
CONCLUSION: Our study results supports the hypothesis of the multisensory dimension of impaired sensory processing in patients with PPPD extends beyond vestibular/visual motion stimuli and reflexive postural/oculomotor control mechanisms to other sensory inputs such as pain perception in terms of a more generalized disturbed habituation pattern.
PMID: 26569392 
PMCID: PMC4646356

No. 377: June 4, 2017

Dieterich M, Staab JP.  Functional dizziness: from phobic postural vertigo and chronic subjective dizziness to persistent postural-perceptual dizziness.  Curr Opin Neurol. 2017 Feb;30(1):107-113. 

PURPOSE OF REVIEW: Functional dizziness is the new term for somatoform or psychogenic dizziness. The aim of this study is to review arguments for the new nomenclature, clinical features, possible pathomechanisms, and comorbidities of functional dizziness.
RECENT FINDINGS: The prevalence of functional dizziness as a primary cause of vestibular symptoms amounts to 10% in neuro-otology centers. Rates of psychiatric comorbidity in patients with structural vestibular syndromes are much higher with nearly 50% and with highest rates in patients with vestibular migraine, vestibular paroxysmia, and Ménière's disease. Pathophysiologic processes seem to include precipitating events that trigger anxiety-related changes in postural strategies with an increased attention to head and body motion and a cocontraction of leg muscles. Personality traits with high levels of neuroticism and low levels of extraversion appear as risk factors for anxiety and depressive disorders and increased morbidity in functional disorders.
SUMMARY: Correct and early diagnosis of functional dizziness, as primary cause or secondary disorder after a structural vestibular syndrome, is very important to prevent further chronification and enable adequate treatment. Treatment plans that include patient education, vestibular rehabilitation, cognitive and behavioral therapies, and medications substantially reduce morbidity and offer the potential for sustained remission when applied systematically
PMID: 28002135

No. 376: May 31, 2017

Isaac V, Olmedo D, Aboitiz F, Delano PH. Altered Cervical Vestibular-Evoked Myogenic Potential in Children with Attention Deficit and Hyperactivity Disorder. Frontiers in Neurology. 2017;8:90. 

OBJECTIVE: Emerging evidence suggests that children with attention deficit and hyperactivity disorder (ADHD) present more difficulties in standing and walking balance than typically developing children. Most of previous studies have assessed these functions using postural and sensory organization tests showing differences in balance performance between control and ADHD children. However, to date, it is unknown whether these balance alterations are accompanied with vestibular dysfunction. The principal aim of this study is to evaluate vestibular otolith function in ADHD and matched control children.
METHODS: We assessed vestibular otolith function in children with ADHD and controls using the subjective visual vertical (SVV) bucket test and cervical vestibular-evoked myogenic potentials (cVEMPs). In addition, gait and balance were evaluated using the dynamic gait index (DGI) and computerized posturography.
RESULTS: Non-significant differences between groups were obtained in SVV evaluation. DGI results show lower scores for overall test performance in children with ADHD (p<0.001), while computerized postural recordings showed significant differences for the limit of stability between groups (p=0.02). cVEMPs in response to 500 Hz tone bursts presented at 100dB were absent or reduced in children with ADHD, as revealed by differences in P1 and N1 peak-to-peak amplitudes between groups (p<0.01).
CONCLUSION: These findings suggest that vestibular brainstem reflexes are altered in a subset of children with ADHD. We propose to include cVEMP reflexes in the clinical evaluation of ADHD patients.
PMID: 28348547

No. 375: May 24, 2017

Hunter JB et al. Cervical and Ocular VEMP Testing in Diagnosing Superior Semicircular Canal Dehiscence. Otolaryngol Head Neck Surg. 2017 Feb 1:194599817690720. 

Objective To determine the sensitivity and specificity of ocular and cervical vestibular evoked myogenic potentials (VEMPs) in the diagnosis of superior semicircular canal dehiscence (SCD) and to describe the VEMP response characteristics that are most sensitive to SCD and compare the findings to previous reports. Study Design Case series with chart review. Setting Two tertiary neurotologic referral centers. Subjects and Methods Cervical and ocular VEMP peak-to-peak amplitudes and thresholds from 39 adult patients older than 18 years with surgically confirmed SCD were compared with 84 age-matched controls. Results Using receiver operating characteristic (ROC) curves, cervical VEMP (cVEMP) amplitudes, cVEMP thresholds, and ocular VEMP (oVEMP) amplitudes had areas under the curve of 0.731, 0.912, and 0.856, respectively, all of which were statistically significant ( P < .0001). For cVEMP thresholds, at the clinical equivalent ≤85-dB normalized hearing level (nHL) threshold, the sensitivity and specificity were 97.3% and 31.3%, respectively. At the ≤70-dB nHL threshold, the sensitivity and specificity were 73.0% and 94.0%, respectively. For oVEMP amplitudes >12.0 µV, the sensitivity and specificity were 78.6% and 81.7%, respectively. Conclusion Data from this multicenter study suggest that both cVEMP thresholds and oVEMP amplitudes remain good diagnostic tests for identifying SCD, with each test dependent on a number of factors. The sensitivity and specificity of these individual tests may vary slightly between centers depending on testing parameters used.
PMID: 28168887

No. 374: May 17, 2017

Dabiri S et al. Analysis of Saccular Function With Vestibular Evoked Myogenic Potential Test in Meniere's Disease. Acta Med Iran. 2017 Feb;55(2):123-127.

The aim of this study was to compare vestibular evoked myogenic potentials (VEMP) and video head impulse test (vHIT) results in patients presenting with vertigo and dizziness. We retrospectively analyzed data of all patients with the chief complaint of vertigo, dizziness, or imbalance that underwent VEMP and vHIT from January 2015 to January 2016. A total of 117 patients (73 females, mean age 53.92±16.76) fulfilled inclusion criteria: group 1 included patients with the final diagnosis of vestibular neuritis (VN) (N=31 (16 right and 15 left VN)), group 2 included patients with the final diagnosis of vertigo of central origin (N=23) and group 3 included patients with the final diagnosis of unspecified dizziness (N=63). There was significant correlation between oVEMP asymmetry and asymmetry of the lateral canals 60ms gains on vHIT (r=0.225, p=0.026). Significant correlation between oVEMP and vHIT asymmetry was present in VN patients (r=0.749, p<0.001), while no correlation was found in the groups 2 and 3. oVEMP and vHIT lateral canals asymmetries were significantly greater in patients with vestibular neuritis. Furthermore, positive correlations of oVEMP amplitudes with 60ms gain of the lateral semicircular canal and slope of the anterior semicircular canal on vHIT, and cVEMP with slope of the posterior semicircular canal on the vHIT were found. These changes were significantly more pronounced in patients with vestibular neuritis. In conclusion, VEMPs and vHIT data should be used complementarily; asymmetry on both tests strongly supports peripheral vestibular system involvement.
PMID: 28242131

No. 373: May 11, 2017

Dabiri S et al. Analysis of Saccular Function With Vestibular Evoked Myogenic Potential Test in Meniere's Disease. Acta Med Iran. 2017 Feb;55(2):123-127.

Meniere's disease is the disorder of inner ear characterized by vertigo, tinnitus and sensorineural hearing loss. The vestibular evoked myogenic potential (VEMP) test could be useful in the analysis of saccular function, and diagnosis of Meniere's disease. In this study, we've analyzed the saccular function, using VEMP test in different groups of Meniere's disease. Patients were categorized as possible, probable or definite Meniere's disease groups according to the guideline of American Academy of Otolaryngology-Head and Neck Surgery. The exclusion criteria were neuromuscular system diseases, diseases of central nervous system, inner ear disorders, conductive hearing loss, a history of ototoxic drug consumption, being a drug abuser and a positive history of inner ear surgery or manipulations. The VEMP test is the recording of positive and negative waves from sternocleidomastoid muscle that is made by an auditory click to the ear. From the total of 100 patients, the waves of VEMP test was seen in 59 patients which 19 patients had abnormal amplitude, and latency and 40 patients were with normally recorded waves. There was a significant relationship between the severity of hearing loss and a VEMP test without any recorded waves. Most of the cases with 'no wave recorded' VEMP test, were patients with severe hearing loss. However, there wasn't any relation between the pattern of hearing loss and 'no wave recorded' VEMP test. VEMP test could be a valuable diagnostic clue especially in patients with definite Meniere's disease.
PMID: 28282709

No. 372: May 3, 2017

Crnosija L et al. Vestibular evoked myogenic potentials and MRI in early multiple sclerosis: Validation of the VEMP score. J Neurol Sci. 2017 Jan 15;372:28-32. 

BACKGROUND: To validate the VEMP score as a measure of brainstem dysfunction in patients with the first symptom of multiple sclerosis (MS) (clinically isolated syndrome (CIS)) and to investigate the correlation between VEMP and brainstem MRI results.
METHODS: 121 consecutive CIS patients were enrolled and brainstem functional system score (BSFS) was determined. Ocular VEMP (oVEMP) and cervical VEMP (cVEMP) were analyzed for latencies, conduction block and amplitude asymmetry ratio and the VEMP score was calculated. MRI was analyzed for the presence of brainstem lesions as a whole and separately for the presence of pontine, midbrain and medulla oblongata lesions.
RESULTS: Patients with signs of brainstem involvement during the neurological examination (with BSFS ≥1) had a higher oVEMP score compared to patients with no signs of brainstem involvement. A binary logistic regression model showed that patients with brainstem lesion on the MRI are 6.780 times more likely to have BSFS ≥1 (p=0.001); and also, a higher VEMP score is associated with BSFS ≥1 (p=0.042). Furthermore, significant correlations were found between clinical brainstem involvement and brainstem and pontine MRI lesions, and prolonged latencies and/or absent VEMP responses.
CONCLUSIONS: The VEMP score is a valuable tool in evaluation of brainstem involvement in patients with early MS.
PMID: 28017229

No. 371: April 26, 2017

Yahia A, Ghroubi S, Jribi S, Mâlla J, Baklouti S, Ghorbel A, Elleuch MH. Chronic neck pain and vertigo: Is a true balance disorder present? Ann Phys Rehabil Med. 2009 Sep-Oct;52(7-8):556-67.

OBJECTIVE: We sought to establish whether chronic neck pain patients suffering from vertigo and instability have true balance disorders.
PATIENTS AND METHODS: Ninety-two patients having suffered from chronic neck pain for at least 3 months were enrolled in the present study. Patients with a history of neck trauma or ear, nose and throat, ophthalmological or neurological abnormalities were excluded. The patients were evaluated in a clinical examination (neck mobility) and a test of dynamic and static balance on the Satel((R)) platform in which mediolateral (Long X) and anterior-posterior deviations (Long Y) were monitored. Our patients were divided into three groups: a group of 32 patients with neck pain and vertigo (G1), a group of 30 patients with chronic neck pain but no vertigo (G2) and a group of 30 healthy controls.
RESULTS: All groups were comparable in terms of age, gender, weight and shoe size. Osteoarthritis was found in 75% and 70% of the subjects in G1 and G2, respectively. Neck-related headache was more frequent in G1 than in G2 (65.5% versus 40%, respectively; p=0.043). Restricted neck movement was more frequent in G1 and concerned flexion (p<0.001), extension (p<0.001), rotation (p<0.001), right inclination (p<0.001) and left inclination (p<0.001). Balance abnormalities were found more frequently in G1 than in G2 or G3. Static and dynamic posturographic assessments (under "eyes open" and "eyes shut" conditions) revealed abnormalities in statokinetic parameters (Long X and Long Y) in G1.
CONCLUSION: Our study evidenced abnormal static and dynamic balance parameters in chronic neck pain patients with vertigo. These disorders can be explained by impaired cervical proprioception and neck movement limitations. Headache was more frequent in these patients.
PMID: 19747892
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No. 370: April 19, 2017

Juul-Kristensen B, Clausen B, Ris I, Jensen RV, Steffensen RF, Chreiteh SS, Jørgensen MB, Søgaard K. Increased neck muscle activity and impaired balance among females with whiplash-related chronic neck pain: a cross-sectional study. J Rehabil Med. 2013 Apr;45(4):376-84

OBJECTIVE: To investigate neck muscle activity and postural control in patients with whiplash-associated disorder compared with healthy controls.
DESIGN: Cross-sectional study with convenience sampling.
SUBJECTS: Ten females with whiplash-associated disorder (age 37.7 years  (21-58), neck pain >2 years and neck disability index (NDI) >10) and 10 healthy female controls (age 35.9 years (21-53), NDI <6).
METHODS: Surface electromyography measured muscle activity of the anterior scalene, sternocleidomastoid, neck extensors and upper trapezius muscles, expressed as mean relative activity related to maximum voluntary electromyography (%MVE). On a force plate, 3 balance tasks (Romberg stance with open and closed eyes, 1-legged stance) and a perturbation task with sudden unloading, were performed. The total area, areas from slow and fast components, and range of displacements were calculated from decomposed centre of pressure anterior-posterior and medial-lateral signals.
RESULTS: During balance tasks with closed eyes and one-legged stance, the relative mean activity of all 4 muscles was significantly increased in whiplash-associated disorder compared with healthy controls. Postural sway was also significantly increased.
CONCLUSION: Increased neck muscle activity and increased postural sway during simple balance tasks indicate disturbed sensory feedback patterns in people with whiplash-associated disorder, which may have negative consequences when performing daily activities.
PMID: 23467989
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No. 369: April 12, 2017

Kogler A, Lindfors J, Odkvist LM, Ledin T. Postural stability using different neck positions in normal subjects and patients with neck trauma. Acta Otolaryngol. 2000 Mar;120(2):151-5.
Subjects with neck problems, such as whiplash injuries, often complain of disturbed equilibrium and, in some instances, provocation of the neck position can elicit such problems. The importance of neck proprioceptors for maintaining balance is gaining increased interest, moreover the function or malfunction of the otoliths may disturb equilibrium in certain head positions. The aim of the study was to create a reference material for postural control and its dependence on head position in healthy subjects and to compare this with a set of patients with known neck problems and associated vertiginous problems. A total of 32 healthy subjects (16 men, 16 women, age range 21-58 years) as well as 10 patients age range 27-62 years (mean 44 years) with neck problems and associated balance problems since a whiplash injury were tested for postural control using the EquiTest dynamic posturographic model. The normal subjects were initially split into four age groups in order to estimate the effects of age on performance. The postural stability was evaluated for dependence of support surface conditions (stable or sway-referenced), visual input (eyes open or closed) and head position (neutral, left rotated, right rotated, extended backwards or flexed forward) using analysis of variance (ANOVA) with Tukey's post hoc test in case of a significant factor effect. As expected, visual cues as well as stable support surface improve postural stability (p < 0.001). Postural stability is statistically different in the head extended backwards condition compared with the other four head positions (p < 0.001 in all cases) in both patients and controls. Eliminating this test condition from the analysis, only a slight (p < 0.05) difference between head forwards and head turned left remained. This pattern of results remained if the normal subjects were only split into two age groups instead of four. Finally, the patient group exhibited significantly lower postural performance than all the groups of normal subjects (p <0.01), but none of the normal groups differed significantly from each other. It is concluded that the postural control system is significantly challenged in the head extended backwards condition in both normal subjects and patients with previous whiplash injury and persistent neck problems. The patient group differed statistically from all groups of normal subjects. This suggests that neck problems impair postural control, and that the head extended position is a more challenging task for the postural system to adapt to. Whether this is due to utricular malpositioning, central integrative functions or cervical proprioceptive afferents is not within the scope of this study to answer.
PMID: 11603761

No. 368: April 7, 2017

Treleaven J. Sensorimotor disturbances in neck disorders affecting postural stability, head and eye movement control. Man Ther. 2008 Feb;13(1):2-11. Epub 2007 Aug 16.

The receptors in the cervical spine have important connections to the vestibular and visual apparatus as well as several areas of the central nervous system. Dysfunction of the cervical receptors in neck disorders can alter afferent input subsequently changing the integration, timing and tuning of sensorimotor control. Measurable changes in cervical joint position sense, eye movement control and postural stability and reports of dizziness and unsteadiness by patients with neck disorders can be related to such alterations to sensorimotor control. It is advocated that assessment and management of abnormal cervical somatosensory input and sensorimotor control in neck pain patients is as important as considering lower limb proprioceptive retraining following an ankle or knee injury. Afferent information from the cervical receptors can be altered via a number of mechanisms such as trauma, functional impairment of the receptors, changes in muscle spindle sensitivity and the vast effects of pain at many levels of the nervous system. Recommendations for clinical assessment and management of such sensorimotor control disturbances in neck disorders are presented based on the evidence available to date.
PMID: 17702636

No. 367:  March 29, 2017

Leddy JJ, Baker JG, Merchant A, Picano J, Gaile D, Matuszak J, Willer B.  Brain or strain? Symptoms alone do not distinguish physiologic concussion from cervical/vestibular injury.  Clin J Sport Med. 2015 May;25(3):237-42

OBJECTIVE: To compare symptoms in patients with physiologic postconcussion disorder (PCD) versus cervicogenic/vestibular PCD. We hypothesized that most symptoms would not be equivalent. In particular, we hypothesized that cognitive symptoms would be more often associated with physiologic PCD.
DESIGN: Retrospective review of symptom reports from patients who completed a 22-item symptom questionnaire.
SETTING: University-based concussion clinic.
PATIENTS: Convenience sample of 128 patients who had symptoms after head injury for more than 3 weeks and who had provocative treadmill exercise testing.
INDEPENDENT VARIABLES: Subjects were classified as either physiologic PCD (abnormal treadmill performance and a normal cervical/vestibular physical examination) or cervicogenic/vestibular PCD (CGV, normal treadmill performance, and an abnormal cervical/vestibular physical examination).
MAIN OUTCOME MEASURES: Self-reported symptoms. Univariate and multivariate methods, including t tests, tests of equivalence, a logistic regression model, k-nearest neighbor analysis, multidimensional scaling, and principle components analysis were used to see whether symptoms could distinguish PCD from CGV.
RESULTS: None of the statistical methods used to analyze self-reported symptoms was able to adequately distinguish patients with PCD from patients with CGV.
CONCLUSIONS: Symptoms after head injury, including cognitive symptoms, have traditionally been ascribed to brain injury, but they do not reliably discriminate between physiologic PCD and cervicogenic/vestibular PCD. Clinicians should consider specific testing of exercise tolerance and perform a physical examination of the cervical spine and the vestibular/ocular systems to determine the etiology of postconcussion symptoms.
CLINICAL RELEVANCE: Symptoms after head injury, including cognitive symptoms, do not discriminate between concussion and cervical/vestibular injury.
PMID: 25051194

No. 366: March 22, 2017

Nielsen G, Buszewicz M, Stevenson F, Hunter R, Holt K, Dudziec M, Ricciardi L, Marsden J, Joyce E, Edwards MJ. Randomised feasibility study of physiotherapy for patients with functional motor symptoms. J Neurol Neurosurg Psychiatry. 2016 Sep 30. pii: jnnp-2016-314408. 

To determine the feasibility of conducting a randomised controlled trial of a specialist physiotherapy intervention for functional motor symptoms (FMS).
A randomised feasibility study was conducted recruiting patients with a clinically established diagnosis of FMS from a tertiary neurology clinic in London, UK. Participants were randomised to the intervention or a treatment as usual control. Measures of feasibility and clinical outcome were collected and assessed at 6 months.
60 individuals were recruited over a 9-month period. Three withdrew, leaving 29 intervention and 28 controls participants in the final analysis. 32% of patients with FMS met the inclusion criteria, of which 90% enrolled. Acceptability of the intervention was high and there were no adverse events. At 6 months, 72% of the intervention group rated their symptoms as improved, compared to 18% in the control group. There was a moderate to large treatment effect across a range of outcomes, including three of eight Short Form 36 (SF36) domains (d=0.46-0.79). The SF36 Physical function was found to be a suitable primary outcome measure for a future trial; adjusted mean difference 19.8 (95% CI 10.2 to 29.5). The additional quality adjusted life years (QALY) with intervention was 0.08 (95% CI 0.03 to 0.13), the mean incremental cost per QALY gained was £ 12 087.
This feasibility study demonstrated high rates of recruitment, retention and acceptability. Clinical effect size was moderate to large with high probability of being cost-effective. A randomised controlled trial is needed.
PMID: 27694498

No. 365: March 15, 2017

Cha YH.  Mal de debarquement syndrome: new insights.  Ann N Y Acad Sci. 2015 Apr;1343:63-8. doi: 10.1111/nyas.12701

Mal de Debarquement Syndrome (MdDS) is an enigmatic neurotological disorder with high morbidity, psychosocial burden, and few treatment options. Fortunately, there has been recent growth in scientific interest in understanding the biological basis of and in treating MdDS. Recent studies using functional neuroimaging have shown increased glucose metabolism in the left entorhinal cortex (EC) and amygdala in the setting of decreased prefrontal and temporal cortex metabolism in subjects with persistent MdDS. The EC is a key player in processing and gating spatial information to be stored in the hippocampus and is a major driver of brain oscillations. A limbic focus may also be key to spontaneous MdDS-like symptoms occurring in individuals with a history of anxiety or chronic stress. Treatment with repetitive transcranial magnetic stimulation over the dorsolateral prefrontal cortex can decrease the rocking dizziness of MdDS, with successful responses associated with decreases in the coherence between brain networks with nodes in the parietal and occipital lobes. A new theory of MdDS is proposed as pathology secondary to entrainment of intrinsic brain networks driven by oscillatory motion exposure coupled with an inability to subsequently desynchronize the activity of these nodes. Future treatment strategies may be directed toward unyoking these networks.
PMID: 25726862
PMCID: PMC4409476 
Link to free Article: 

No. 364: March 8, 2017

Yetiser S, Ince D.  Diagnostic Role of Head-Bending and Lying-Down Tests in Lateral Canal Benign 

OBJECTIVES: To compare the diagnostic value of the head-bending test (HBT), lying-down positioning test (LDPT) and patient's report to identify the affected canal in video-nystagmographically (VNG) confirmed patients with lateral canal benign paroxysmal positional vertigo (LC-BPPV).
STUDY DESIGN: Case series with chart review.
SETTING: Head-bending, lying-down positioning and the head-roll maneuver (HRM) under VNG guidance. The data were collected in a referral community hospital.
PATIENTS: Seventy-eight patients (32 apogeotropic and 46 geotropic nystagmus) with LC-BPPV who had been recruited between 2009 and 2013 were enrolled in the study.
MAIN OUTCOME MEASURES: Patients were tested with the HRM and then were asked about subjectively worse side. Later, they were subjected to HBT when sitting and the LDPT. The results were compared and studied with the 1-way ANOVA and chi-square tests. Statistical significance was set at p < 0.05.
RESULTS: Affected side was identified by HRM in 75% of patients with apogeotropic nystagmus and 95.6% of patients with geotropic nystagmus. Approximately 65.6% of patients with apogeotropic and 52% of patients with geotropic nystagmus had nystagmus during LDPT. However, its comparability with HRM was low. However, treatment plan based on LDPT results alone provided relief of symptoms in additional 12.5% of patients with apogeotropic and in 2.2% of patients with geotropic nystagmus. Approximately 63% of patients with apogeotropic and 56% of patients with geotropic nystagmus were able to tell the worse side. Nystagmus comparable with HRM during HBT was low and not diagnostic.
CONCLUSION: HRM has the greatest diagnostic value of positioning tests in LC-BPPV in this study. LDPT provides some contribution in the diagnosis of LC-BPPV but much less than HRM. Patients' subjective feeling of vertigo was also a useful test. However, HBT was not as sensitive as other measures in uncertain cases.
PMID: 25938792
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No. 363: March 1, 2017

Ichimura A, Otsuka K.  Persistent Down-Beating Torsional Positional Nystagmus: Posterior Semicircular Canal Light Cupula?  Case Rep Otolaryngol. 2016;2016:1249325. doi: 10.1155/2016/1249325. Epub 2016 Sep 7.

A 16-year-old boy with rotatory positional vertigo and nausea, particularly when lying down, visited our clinic. Initially, we observed vertical/torsional (downward/leftward) nystagmus in the supine position, and it did not diminish. In the sitting position, nystagmus was not provoked. Neurological examinations were normal. We speculated that persistent torsional down-beating nystagmus was caused by the light cupula of the posterior semicircular canal. This case provides novel insights into the light cupula pathophysiology.
PMID: 27668113 
PMCID: PMC5030422 
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