Marousa Pavlou

Simulator based rehabilitation in refractory dizziness

Abstract.Patients with chronic vestibular symptoms are common in neurological practice but the most effective treatment remains an open question. The purpose of our study was to conduct a controlled, between–group comparison of patients’ responses to a customised exercise regime (Group C, for customised) versus treatment additionally incorporating simulator based desensitisation exposure (Group S, for simulator) integrating whole–body or visual environment rotators. Forty chronic peripheral vestibular patients who had previously undergone conventional vestibular rehabilitation without notable improvement were randomly assigned into Group C or S. Individuals attended therapy sessions twice weekly for eight weeks and were provided with a customised home programme. Response to treatment was assessed at four–week intervals with dynamic posturography, vestibular time constants, and questionnaires concerning symptoms, symptom–triggers and emotional status. At final assessment posturography and subjective scores had significantly improved for both groups, although Group S showed greater improvement. A statistically significant improvement for visual vertigo symptom scores was noted only for Group S (p < 0.01; total improvement 53.5 %). Anxiety and depression levels significantly decreased for both groups; improvements were significantly correlated particularly to improvements in visual vertigo (SCQ) (p < 0.01; r = 0.53 and r = 0.57, respectively). Significant differences were noted between groups (p = 0.02) for posturography scores. Vestibular time constants showed no notable change in either group. Conclusions: Both groups improved but exposure to simulator motion gave overall better results. These effects were also observed in psychological symptoms and partly relate to simulator effects on visual vertigo symptoms. Visual motion and visuo–vestibular conflict situations should be incorporated in the rehabilitation of patients with refractory dizziness.

Randomized Trial of Supervised Versus Unsupervised Optokinetic Exercise in Persons With Peripheral Vestibular Disorders

Background. Visual vertigo (VV) symptoms improve only when customized vestibular rehabilitation (VR) integrates exposure to optokinetic stimuli (OK). However, equipment is expensive, biweekly sessions are not standard practice, and therapy is often unsupervised. Methods. A controlled, parallel-group comparison was made of patients’ responses to an 8-week customized program incorporating OK training via a full-field visual environment rotator (group OKF) or DVD (an optokinetic disc or drum rotating at 40° or 60° s−1), supervised (group OKS) or unsupervised (group OKU). A total of 60 participants with chronic peripheral vestibular symptoms were randomly allocated to 1 of 3 treatment groups: group OKF (n = 20) or OKS (n = 20), in which participants attended weekly sessions and were prescribed customized home exercises incorporating the DVD, or group OKU (n = 20) who practiced customized exercises and the DVD unsupervised. Treatment response was assessed at baseline and at 8 weeks with dynamic posturography, Functional Gait Assessment (FGA), and questionnaires for symptoms, symptom triggers, and psychological state. Results. No significant between-group differences were present at baseline or at post interventions. All groups showed significant within-group improvements for vestibular (ie, lightheadedness), VV, and autonomic symptoms (P < .05). Posturography and FGA improved significantly for groups OKF and OKS (P ≤ .01) as well as anxiety scores for group OKS (P < .05) and depression for group OKF (P < .05). Migraine significantly affected VV improvement (migraineurs improved more; P = .01). The drop-out rate was 55% for group OKU and 10% for each supervised group (P < .01). Conclusions. The DVD may be an effective and economical method of integrating OK into VR. However, rehabilitation should be supervised for greater compliance and improvements, particularly for postural stability and psychological state.

The effect of virtual reality on visual vertigo symptoms in patients with peripheral vestibular dysfunction: A pilot study

UNLABELLED Individuals with vestibular dysfunction may experience visual vertigo (VV), in which symptoms are provoked or exacerbated by excessive or disorientating visual stimuli (e.g. supermarkets). VV can significantly improve when customized vestibular rehabilitation exercises are combined with exposure to optokinetic stimuli. Virtual reality (VR), which immerses patients in realistic, visually challenging environments, has also been suggested as an adjunct to VR to improve VV symptoms. This pilot study compared the responses of sixteen patients with unilateral peripheral vestibular disorder randomly allocated to a VR regime incorporating exposure to a static (Group S) or dynamic (Group D) VR environment. Participants practiced vestibular exercises, twice weekly for four weeks, inside a static (Group S) or dynamic (Group D) virtual crowded square environment, presented in an immersive projection theatre (IPT), and received a vestibular exercise program to practice on days not attending clinic. A third Group D1 completed both the static and dynamic VR training. Treatment response was assessed with the Dynamic Gait Index and questionnaires concerning symptom triggers and psychological state. At final assessment, significant between-group differences were noted between Groups D (p=0.001) and D1 (p=0.03) compared to Group S for VV symptoms with the former two showing a significant 59.2% and 25.8% improvement respectively compared to 1.6% for the latter. Depression scores improved only for Group S (p=0.01) while a trend towards significance was noted for Group D regarding anxiety scores (p=0.07). CONCLUSION Exposure to dynamic VR environments should be considered as a useful adjunct to vestibular rehabilitation programs for patients with peripheral vestibular disorders and VV symptoms.

The use of optokinetic stimulation in vestibular rehabilitation.

Individuals with vestibular dysfunction may experience visual vertigo (VV), in which symptoms are provoked or exacerbated by excessive or disorienting visual stimuli (eg, supermarkets). Individuals with VV are believed to be overly reliant on visual input for balance (ie, visually dependent). VV can significantly improve when customized vestibular rehabilitation exercises are combined with exposure to optokinetic stimuli. However, the frequency of treatment sessions (twice weekly for 8 weeks) and the equipment used (expensive and space consuming) make it difficult to incorporate these techniques into everyday clinical practice where exercises may be practiced unsupervised. The aim of this focused review is to provide an overview of recent findings investigating (a) responses of individuals with vestibular deficits to a customized exercise program incorporating exposure to optokinetic stimuli via a “high-tech” visual environment rotator or a “low-tech” DVD with and without supervision, and (b) the mechanism of recovery. Optokinetic stimulation will also be discussed in relation to other new innovations in vestibular rehabilitation techniques and future work.

Peripheral vestibular dysfunction is prevalent in older adults experiencing multiple non-syncopal falls versus age-matched non-fallers: a pilot study

BACKGROUND vestibular disorders are common in the general population, increasing with age. However, it is unknown whether older adults who fall have a higher proportion of vestibular impairment compared with age-matched older adult non-fallers. OBJECTIVE to identify whether a greater proportion of older adult fallers have a peripheral vestibular impairment compared with age-matched healthy controls. DESIGN case-controlled study. SETTING tertiary falls and neuro-otology clinics and local community centres, London, UK. PARTICIPANTS AND METHODS community-dwelling older adults experiencing: (i) ≥2 unexplained falls within the previous 12-months (Group F, n = 25), (ii) a confirmed peripheral vestibular disorder (Group PV, n = 15) and (iii) healthy non-fallers (Group H, n = 16). All the participants completed quantitative vestibular function tests, the functional gait assessment (FGA), physiological profile assessment (PPA) and subjective measures for common vestibular symptoms (i.e. giddiness), balance confidence during daily activities and psychological state. RESULTS a clinically significant vestibular impairment was noted for 80% (20/25) of Group F compared with 18.75% (3/16) for Group H (P < 0.01). Group F performed less well in complex gait tasks (FGA), and reported a greater number of falls than both Groups H and PV (P < 0.05). Vestibular symptom scores showed no significant difference between Groups F and PV. CONCLUSION vestibular dysfunction is significantly more prevalent in older adult fallers versus non-fallers. Individuals referred to a falls clinic are older, more impaired and report more falls than those referred to a neuro-otology department. A greater awareness of vestibular impairments may lead to more effective management and treatment for older adult fallers.

Postural prioritization is differentially altered in healthy older compared to younger adults during visual and auditory coded spatial multitasking

Many daily activities require appropriate allocation of attention between postural and cognitive tasks (i.e. dual-tasking) to be carried out effectively. Processing multiple streams of spatial information is important for everyday tasks such as road crossing. Fifteen community-dwelling healthy older (mean age=78.3, male=1) and twenty younger adults (mean age=25.3, male=6) completed a novel bimodal spatial multi-task test providing contextually similar spatial information via separate sensory modalities to investigate effects on postural prioritization. Two tasks, a temporally random visually coded spatial step navigation task (VS) and a regular auditory-coded spatial congruency task (AS) were performed independently (single task) and in combination (multi-task). Response time, accuracy and dual-task costs (% change in multi-task condition) were determined. Results showed a significant 3-way interaction between task type (VS vs. AS), complexity (single vs. multi) and age group for both response time (p ≤ 0.01) and response accuracy (p ≤ 0.05) with older adults performing significantly worse than younger adults. Dual-task costs were significantly greater for older compared to younger adults in the VS step task for both response time (p ≤ 0.01) and accuracy (p ≤ 0.05) indicating prioritization of the AS over the VS stepping task in older adults. Younger adults display greater AS task response time dual task costs compared to older adults (p ≤ 0.05) indicating VS task prioritization in agreement with the posture first strategy. Findings suggest that novel dual modality spatial testing may lead to adoption of postural strategies that deviate from posture first, particularly in older people. Adoption of previously unreported postural prioritization strategies may influence balance control in older people.

Feasibility and effect of supplementing a modified OTAGO intervention with multisensory balance exercises in older people who fall: a pilot randomized controlled trial:

Objective: To investigate the feasibility and comparative effect of supplementing a modified OTAGO falls rehabilitation programme with multisensory balance exercises and informed sample size calculation for a definitive trial. Design: Single-blinded randomized controlled trial with pre/postcomparisons using a per-protocol analysis. Setting: Secondary care-based falls clinic, London, UK. Subjects: Community-dwelling older people (n = 21) experiencing ≥2 non-syncopal falls during previous 12 months. Intervention: Modified OTAGO exercise classes supplemented with supervised home-based rehabilitation consisting of multisensory balance or stretching exercises. Group classes and home sessions each occurred twice-weekly for eight weeks. Measurements: A computerised randomization was used for group allocation. A rater, blinded to intervention, performed the assessment including the Functional Gait Assessment (primary outcome), Physiological Profile Assessment, and questionnaires relating to symptoms, balance confidence, and psychological state (secondary outcomes). Results: Significant within-group improvements were noted for the Functional Gait (p < 0.01, r = −0.63) and Physiological Profile Assessments (p < 0.05, r = −0.63) in the OTAGO+multisensory rehabilitation group only and for balance confidence scores in the OTAGO+stretching group (p < 0.01, r = −0.63). Between-group differences were noted for the Functional Gait (p < 0.01, r = −0.71) and Physiological Profile (p < 0.05, r = −0.54) assessments with the OTAGO+multisensory group showing significantly greater improvement. The drop-out rate was similar for both groups (~30%). No serious adverse events were reported. Conclusions: Supplementing the OTAGO programme with multisensory balance exercises is feasible in older people who fall and may have a beneficial effect on falls risk as measured using the Functional Gait and Short-form Physiological Profile Assessments. An adequately powered randomized controlled trial would require 36 participants to detect an effect size of 1.35 on the Functional Gait Assessment.

Effect of Developmental Binocular Vision Abnormalities on Visual Vertigo Symptoms and Treatment Outcome

Background and Purpose: Customized vestibular rehabilitation incorporating optokinetic (OK) stimulation improves visual vertigo (VV) symptoms; however, the degree of improvement varies among individuals. Binocular vision abnormalities (misalignment of ocular axis, ie, strabismus) may be a potential risk factor. This study aimed to investigate the influence of binocular vision abnormalities on VV symptoms and treatment outcome. Methods: Sixty subjects with refractory peripheral vestibular symptoms underwent an orthoptic assessment after being recruited for participation in an 8-week customized program incorporating OK training via a full-field visual environment rotator or video display, supervised or unsupervised. Treatment response was assessed at baseline and at 8 weeks with dynamic posturography, Functional Gait Assessment (FGA), and questionnaires for symptoms, symptom triggers, and psychological state. As no significant effect of OK training type was noted for any variables, data were combined and new groups identified on the basis of the absence or presence of a binocular vision abnormality. Results: A total of 34 among 60 subjects consented to the orthoptic assessment, of whom 8 of the 34 had binocular vision abnormalities and 30 of the 34 subjects completed both the binocular function assessment and vestibular rehabilitation program. No significant between-group differences were noted at baseline. The only significant between-group difference was observed for pre-/post-VV symptom change (P = 0.01), with significant improvements noted only for the group without binocular vision abnormalities (P < 0.0005). Common vestibular symptoms, posturography, and the FGA improved significantly for both groups (P < 0.05). Discussion and Conclusions: Binocular vision abnormalities may affect VV symptom improvement. These findings may have important implications for the management of subjects with refractory vestibular symptoms. Video Abstract available for insights from the authors regarding clinical implication of the study findings (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A115).

Visually induced dizziness in children and validation of the Pediatric Visually Induced Dizziness Questionnaire

Aims To develop and validate the Pediatric Visually Induced Dizziness Questionnaire (PVID) and quantify the presence and severity of visually induced dizziness (ViD), i.e., symptoms induced by visual motion stimuli including crowds and scrolling computer screens in children. Methods 169 healthy (female n = 89; recruited from mainstream schools, London, UK) and 114 children with a primary migraine, concussion, or vestibular disorder diagnosis (female n = 62), aged 6–17 years, were included. Children with primary migraine were recruited from mainstream schools while children with concussion or vestibular disorder were recruited from tertiary balance centers in London, UK, and Pittsburgh, PA, USA. Children completed the PVID, which assesses the frequency of dizziness and unsteadiness experienced in specific environmental situations, and Strength and Difficulties Questionnaire (SDQ), a brief behavioral screening instrument. Results The PVID showed high internal consistency (11 items; α = 0.90). A significant between-group difference was noted with higher (i.e., worse) PVID scores for patients vs. healthy participants (U = 2,436.5, z = −10.719, p < 0.001); a significant difference was noted between individual patient groups [χ2(2) = 11.014, p = 0.004] but post hoc analysis showed no significant pairwise comparisons. The optimal cut-off score for discriminating between individuals with and without abnormal ViD levels was 0.45 out of 3 (sensitivity 83%, specificity 75%). Self-rated emotional (U = 2,730.0, z = −6.169) and hyperactivity (U = 3,445.0, z = −4.506) SDQ subscale as well as informant (U = 188.5, z = −3.916) and self-rated (U = 3,178.5, z = −5.083) total scores were significantly worse for patients compared to healthy participants (p < 0.001). Conclusion ViD is common in children with a primary concussion, migraine, or vestibular diagnosis. The PVID is a valid measure for identifying the presence of ViD in children and should be used to identify and quantify these symptoms, which require specific management incorporating exposure to optokinetic stimuli.

Non-invasive brain stimulation for the lower limb after stroke: what do we know so far and what should we be doing next?

Abstract Background: Non-invasive brain stimulation (NIBS) is promising as an adjuvant to rehabilitation of motor function after stroke. Despite numerous studies and reviews for the upper limb, NIBS targeting the lower limb and gait recovery after stroke is a newly emerging field of research. Purpose: To summarize findings from studies using NIBS to target the lower limb in stroke survivors. Methods: This narrative review describes studies of repetitive transcranial magnetic stimulation, paired associative stimulation and transcranial direct current stimulation with survivors of stroke. Results: NIBS appears capable of inducing changes in cortical excitability and lower limb function, but stimulation parameters and study designs vary considerably making it difficult to determine effectiveness. Conclusions: Future research should systematically assess differences in response with different stimulation parameters, test measures for determining who would be most likely to benefit and assess effectiveness with large samples before NIBS can be considered for use in clinical practice. Implications for Rehabilitation Stroke is a leading cause of disability, often resulting in dependency in activities of daily living and reduced quality of life. Non-invasive brain stimulation has received considerable interest as a potential adjuvant to rehabilitation after stroke and this review summarizes studies targeting the lower limb and gait recovery. Non-invasive brain stimulation can be used to modulate excitability of lower limb muscle representations and can lead to improvements in motor performance in stroke survivors. Non-invasive brain stimulation for gait recovery needs further investigation before translation to clinical practice is possible.