Ítalo Roberto Torres de Medeiros

Balance control in hemiparetic stroke patients: Main tools for evaluation

Balance problems in hemiparetic patients after stroke can be caused by different impairments in the physiological systems involved in postural control, including sensory afferents, movement strategies, biomechanical constraints, cognitive processing, and perception of verticality. Balance impairments and disabilities must be appropriately addressed. This article reviews the most common balance abnormalities in hemiparetic patients with stroke and the main tools used to diagnose them.

Zumbido em pacientes com audiometria normal: caracterização clínica e repercussões

Pacientes com zumbido e audiometria normal constituem um grupo importante, pois seus achados nao sofrem influencia da perda auditiva. Apesar disso, este grupo e pouco estudado e nao sabemos se suas caracteristicas clinicas e repercussoes sao semelhantes as dos individuos com perda auditiva. OBJETIVOS: Comparar as caracteristicas clinicas do zumbido e sua interferencia nas atividades diarias em pacientes com e sem perda auditiva. FORMA DE ESTUDO: coorte historica. MATERIAL E METODO: Entre 744 pacientes atendidos no Grupo de Pesquisa em Zumbido do HCFMUSP, avaliou-se retrospectivamente com um corte transversal os 55 individuos com audiometria tonal normal. O grupo controle correspondeu a 198 pacientes com zumbido e perda auditiva atendidos sob o mesmo protocolo. Analisou-se os dados dos pacientes, as caracteristicas clinicas do zumbido e sua repercussao na vida do paciente. RESULTADOS: A idade media no grupo de estudo (43,1 ± 13,4 anos) foi significantemente menor do que a do grupo controle (49,9 ± 14,5 anos). Em ambos os grupos houve predominio do sexo feminino e o zumbido foi predominantemente bilateral, unico e constante, porem sem diferenca entre os grupos. A interferencia na concentracao e no equilibrio emocional foi significantemente menor no grupo de estudo (25,5% e 36,4%) do que no controle (46% e 61,6%), porem sem diferenca quanto a interferencia no sono e na atividade social. CONCLUSOES: O grupo de pacientes com zumbido e audicao normal apresentou caracteristicas clinicas semelhantes em relacao ao grupo com perda auditiva. Entretanto, a faixa etaria acometida e a interferencia sobre a concentracao e o equilibrio emocional foram significantemente menores nestes.

ABNORMAL SENSORY INTEGRATION AFFECTS BALANCE CONTROL IN HEMIPARETIC PATIENTS WITHIN THE FIRST YEAR AFTER STROKE

OBJECTIVE: Impairments in balance can be a consequence of changes in the motor, sensory, and integrative aspects of motor control. Abnormal sensory reweighting, i.e., the ability to select the most appropriate sensory information to achieve postural stability, may contribute to balance impairment. The Sensory Organization Test is a component of Computerized Dynamic Posturography that evaluates the impact of visual, vestibular, and somatosensory inputs, as well as sensory reweighting, under conditions of sensory conflict. The aim of this study is to compare balance control in hemiparetic patients during the first year post-stroke and in age-matched neurologically normal subjects using the Berg Balance Scale and Computerized Dynamic Posturography. METHODS: We compared the Berg Balance Scale and Sensory Organization Test scores in 21 patients with hemiparesis after first-ever ischemic stroke and in 21 age-matched, neurologically normal subjects. An equilibrium score was defined for each Sensory Organization Test condition. RESULTS: Berg Balance Scale scores were significantly lower in the patients than in the neurologically normal subjects. Equilibrium scores were significantly lower in the patients than in the neurologically normal subjects for those Sensory Organization Test conditions that did not provide appropriate somatosensory information and under conditions of sensory conflict. A history of falls was more frequent in patients with lower equilibrium scores. CONCLUSION: During the first year after a stroke, defective sensory reweighting significantly impacts balance control in hemiparetic patients. These results are important for the planning of effective rehabilitation interventions.

Vestibular Rehabilitation Therapy in Children

Objectives: Vestibular disturbances are underdiagnosed in children. However, balance impairment may compromise the normal development of affected children. The appropriate therapeutic approach has not been agreed on for this age group. Vestibular rehabilitation therapy has excellent results in adults, but very few data exist regarding its results in children. We evaluated through clinical assessment and computerized dynamic posturography the outcome of children with peripheral vestibular disturbances undergoing vestibular rehabilitation therapy and observed the influence of learning and of central nervous system maturation on posturography retest results. Methods: Sixteen children (10 boys and 6 girls) with peripheral vestibular disorders (mean age, 8 yr 7 mo) constituted the cohort and were consecutively treated with vestibular rehabilitation therapy. Symptomatic children underwent pre- and posttreatment computerized dynamic posturography. Their outcome was clinically assessed. Another 16 asymptomatic children, paired by sex and age, underwent two computerized dynamic posturography procedures with the same time interval as that of the symptomatic group. Results: All children completed the treatment. Total recovery of symptoms occurred in nine (56.3%) patients, whereas a dramatic partial recovery was observed in the remaining seven (43.7%) children. Posturography Conditions 5 and 6, the vestibular ratio of the sensory analysis, and the composite equilibrium score had a significant quantitative improvement after vestibular rehabilitation therapy. No adverse reactions occurred to the exercises. No statistically significant posturography changes were observed in the asymptomatic children. Conclusion: Vestibular rehabilitation therapy seems to be a safe and efficacious therapeutic option in children with peripheral vestibular disturbances.

Evaluation of the treatment of vestibular disorders in children with computerized dynamic posturography: preliminary results

OBJECTIVE This study aimed at evaluating dynamic posturography as an evaluation method in children with balance problems due to peripheral vestibulopathy, before and after treatment with vestibular rehabilitation, establishing its correlation with classical clinical evaluation. METHOD Ten children (six boys and four girls) with vestibular symptoms of peripheral origin were evaluated through a complete clinical history and with dynamic computerized posturography after being treated by vestibular rehabilitation therapy. Posturographic data were analyzed and compared to standard clinical evaluation parameters. RESULTS Dynamic posturography showed a significant improvement of condition 1 (orthostatic position, fixed support and open eyes) and 5 (orthostatic position, sway-referenced support and closed eyes) of the vestibular function and of the composite balance score. The data showed significant correlation with the clinical improvement observed. A significant reduction of proprioceptive influence was also observed. CONCLUSIONS Data showed that the dynamic posturography adds important quantitative information to the conventional clinical evaluation of vestibular symptoms, especially in children.

Reabilitação vestibular na criança: estudo preliminar

Study design: Clinical prospective. Aim: The authors analyze prospectively 22 children (mean age 8,6 years) with vestibulopathy treated with Vestibular Rehabilitation in order to verify its results. Material and methody: Twenty two children with peripheral vestibular disorders associated or not to central symptoms were submitted to vestibular stimulation by the method of Cawthorne & Cooksey. The methods used to quantify the vestibular abnormalities were the electronystagmography and rotational chair testing, but a suggestive history of vestibular disorder was accepted even the exams were normal. Results: All the patients improved and our results suggest that VR is a therapeutic alternative for the treatment of vestibular disorders in the children.

The Influence of Sound Generator Associated With Conventional Amplification for Tinnitus Control: Randomized Blind Clinical Trial

Hearing aids with an integrated sound generator have been used to enhance the treatment of tinnitus. The main aim of this study was to verify whether the combined use of amplification and sound generator is more effective than conventional amplification alone in reducing tinnitus annoyance by means of the use of a new hearing aid with an integrated sound generator. A total of 49 patients underwent a blind randomized clinical trial. Tinnitus annoyance was measured by Tinnitus Handicap Inventory and numerical scales, and psychoacoustic measures of tinnitus were also performed. The sound generator was set at the lowest intensity capable of providing relief from tinnitus. Results showed that 62.5% of the patients presented a reduction in tinnitus annoyance in the combined fitting group and in the group with amplification alone, 78% showed a reduction. This difference between the groups was not statistically significant.

Tinnitus in normal hearing patients: An uncommon group

Objectives: Tinnitus usually appears in patients with some degree of hearing loss. Just a few papers studied tinnitus in normal hearing patients, usually involving less than 20 cases. The objective of this study is to describe the main characteristics of a significant sample of tinnitus patients with normal pure tone audiometry. Methods: The files of 744 tinnitus patients following the same medical audiological protocol were reviewed, excluding those with hearing thresholds above 25dBHL in at least one frequency. Thus, 66 (8.8%) files belonging to patients with tinnitus and normal audiometry were enrolled in this study, analyzing their main characteristics (sex, gender, laterality, severity, laboratories alterations). Results: There was a high prevalence of female patients in 71.2% of the cases. The mean age was 42 ± 13 years (minimum 7, maximum 72). Tinnitus was a single tone in 71.2%. There were 11 patients with pulsatile tinnitus. Bilateral in 51.5% and constant in 66.7%. According to the visual analogue scale, the tinnitus severity was mild in 6 cases, moderate in 27 and severe in 32. Caffeine abuse was detected in 45.4%, sweet compulsion in 45.4%, and lipid disturbances in 36.3%. Blood glucose and thyroid hormones levels were altered in 27.3% and 13.6%, respectively. Conclusion: Tinnitus in normal hearing patients may also evoke an important annoyance and showed an association with metabolic disorders. Trying to find the main characteristics of these patients and other possible etiologies can be fundamental for therapeutic approach.

A afecção vestibular infantil: estudo da orientação espacial

PURPOSE: to check how is the childs spatial perception in vestibular disorder. METHODS: prospective study of 18 children, between 3 and 15-year old, under treatment in Ambulatorio de Otorrinolaringologia/Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo. Space perception was assessed through a free activity (free drawing) and two directed activities: the Frostig test and an adaptation of the Token Test. Of the 18 evaluated children, 09 composed the study group (diagnosed as having a vestibular disorder) and 09 composed the control group (with no history of vestibular disorder or dizziness). Children who showed central nervous system impairments were excluded. RESULTS: in relation to the free drawing, 77.78% of the control group and 55.55% in the study group used the whole sheet of paper provided. Regarding the proportion of the objects, 100% of the control group showed an adequate proportion in their drawings and it was found in 48.86% of the study group. In the adapted Token Test, the study group showed a major difficulty. In the Frostig test, a small difference between the groups in the Perceptual quotient was observed. CONCLUSION: the children with vestibular disorders, while drawing, used the sheet of paper in a less homogeneous way, showing more difficulty to draw human pictures and an inadequate proportion among the drawn objects. In this way, it is important that the vestibular diagnosis should be done the earliest possible in order to anticipate the treatment/rehabilitation. This may prevent the impairment of spatial perception from negatively influencing the learning process.

Diagnostic Criteria for Somatosensory Tinnitus: A Delphi Process and Face-to-Face Meeting to Establish Consensus

Since somatic or somatosensory tinnitus (ST) was first described as a subtype of subjective tinnitus, where altered somatosensory afference from the cervical spine or temporomandibular area causes or changes a patient’s tinnitus perception, several studies in humans and animals have provided a neurophysiological explanation for this type of tinnitus. Due to a lack of unambiguous clinical tests, many authors and clinicians use their own criteria for diagnosing ST. This resulted in large differences in prevalence figures in different studies and limits the comparison of clinical trials on ST treatment. This study aimed to reach an international consensus on diagnostic criteria for ST among experts, scientists and clinicians using a Delphi survey and face-to-face consensus meeting strategy. Following recommended procedures to gain expert consensus, a two-round Delphi survey was delivered online, followed by an in-person consensus meeting. Experts agreed upon a set of criteria that strongly suggest ST. These criteria comprise items on somatosensory modulation, specific tinnitus characteristics, and symptoms that can accompany the tinnitus. None of these criteria have to be present in every single patient with ST, but in case they are present, they strongly suggest the presence of ST. Because of the international nature of the survey, we expect these criteria to gain wide acceptance in the research field and to serve as a guideline for clinicians across all disciplines. Criteria developed in this consensus paper should now allow further investigation of the extent of somatosensory influence in individual tinnitus patients and tinnitus populations.