Richard A. Clendaniel

Vestibular Adaptation Exercises and Recovery: Acute Stage after Acoustic Neuroma Resection

The use of exercises in the treatment of patients with vestibular deficits has become increasingly popular, and evidence exists that these exercises are beneficial in patients with chronic vestibular deficits. The question as to whether patients with acute unilateral vestibular loss would benefit from vestibular adaptation exercises is particularly compelling, however, because animal studies have demonstrated that the acute stage after unilateral vestibular loss is a critical period for recovery. Deprivation of visuomotor experience during that period can delay the onset of recovery as well as prolong the recovery period. Patients often avoid movement during the early stage because, with movement, they experience an increase in dysequilibrium and nausea. We examined the recovery of postural stability in patients during the acute stage after resection of acoustic neuroma to determine whether vestibular adaptation exercises facilitate the onset of recovery and improve the rate of recovery. The results suggest that vestibular adaptation exercises result in improved postural stability and in a diminished perception of dysequilibrium.

Mechanism of Dynamic Visual Acuity Recovery With Vestibular Rehabilitation

OBJECTIVE To determine why dynamic visual acuity (DVA) improves after vestibular rehabilitation in people with vestibular hypofunction. DESIGN Combined descriptive and intervention study. SETTING Outpatient department in an academic medical institution. PARTICIPANTS Five patients (age, 42-66 y) and 4 age-matched controls (age, 39-67 y) were studied. Patients had vestibular hypofunction (mean duration, 177+/-188 d) identified by clinical (positive head thrust test, abnormal DVA), physiologic (reduced angular vestibulo-ocular reflex [aVOR] gain during passive head thrust testing), and imaging examinations (absence of tumor in the internal auditory canals or cerebellopontine angle). INTERVENTION Vestibular rehabilitation focused on gaze and gait stabilization (mean, 5.0+/-1.4 visits; mean, 66+/-24 d). The control group did not receive any intervention. MAIN OUTCOME MEASURES aVOR gain (eye velocity/head velocity) during DVA testing (active head rotation) and horizontal head thrust testing (passive head rotation) to control for spontaneous recovery. RESULTS For all patients, DVA improved (mean, 51%+/-25%; range, 21%-81%). aVOR gain during the active DVA test increased in each of the patients (mean range, 0.7+/-0.2 to 0.9+/-0.2 [35%]). aVOR gain during passive head thrust did not improve in 3 patients and improved only partially in the other 2. For control subjects, aVOR gain during DVA was near 1. CONCLUSIONS Our data suggest that vestibular rehabilitation increases aVOR gain during active head rotation independent of peripheral aVOR gain recovery.

Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Evidence-Based Clinical Practice Guideline: FROM THE AMERICAN PHYSICAL THERAPY ASSOCIATION NEUROLOGY SECTION.

Background: Uncompensated vestibular hypofunction results in postural instability, visual blurring with head movement, and subjective complaints of dizziness and/or imbalance. We sought to answer the question, “Is vestibular exercise effective at enhancing recovery of function in people with peripheral (unilateral or bilateral) vestibular hypofunction?” Methods: A systematic review of the literature was performed in 5 databases published after 1985 and 5 additional sources for relevant publications were searched. Article types included meta-analyses, systematic reviews, randomized controlled trials, cohort studies, case control series, and case series for human subjects, published in English. One hundred thirty-five articles were identified as relevant to this clinical practice guideline. Results/Discussion: Based on strong evidence and a preponderance of benefit over harm, clinicians should offer vestibular rehabilitation to persons with unilateral and bilateral vestibular hypofunction with impairments and functional limitations related to the vestibular deficit. Based on strong evidence and a preponderance of harm over benefit, clinicians should not include voluntary saccadic or smooth-pursuit eye movements in isolation (ie, without head movement) as specific exercises for gaze stability. Based on moderate evidence, clinicians may offer specific exercise techniques to target identified impairments or functional limitations. Based on moderate evidence and in consideration of patient preference, clinicians may provide supervised vestibular rehabilitation. Based on expert opinion extrapolated from the evidence, clinicians may prescribe a minimum of 3 times per day for the performance of gaze stability exercises as 1 component of a home exercise program. Based on expert opinion extrapolated from the evidence (range of supervised visits: 2-38 weeks, mean = 10 weeks), clinicians may consider providing adequate supervised vestibular rehabilitation sessions for the patient to understand the goals of the program and how to manage and progress themselves independently. As a general guide, persons without significant comorbidities that affect mobility and with acute or subacute unilateral vestibular hypofunction may need once a week supervised sessions for 2 to 3 weeks; persons with chronic unilateral vestibular hypofunction may need once a week sessions for 4 to 6 weeks; and persons with bilateral vestibular hypofunction may need once a week sessions for 8 to 12 weeks. In addition to supervised sessions, patients are provided a daily home exercise program. Disclaimer: These recommendations are intended as a guide for physical therapists and clinicians to optimize rehabilitation outcomes for persons with peripheral vestibular hypofunction undergoing vestibular rehabilitation. Video Abstract available for more insights from the author (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A124).

Context-specific adaptation of saccade gain

Previous studies established that vestibular reflexes can have two adapted states (e.g., gain) simultaneously, and that a context cue (e.g., vertical eye position) can switch between the two states. The present study examined this phenomenon of context-specific adaptation for horizontal saccades, using a variety of contexts. Our overall goal was to assess the efficacy of different context cues in switching between adapted states. A standard double-step paradigm was used to adapt saccade gain. In each experiment, we asked for a simultaneous gain decrease in one context and gain increase in another context, and then determined if a change in the context would invoke switching between the adapted states. Horizontal eye position worked well as a context cue: saccades with the eyes deviated to the right could be made to have higher gains while saccades with the eyes deviated to the left could be made to have lower gains. Vertical eye position was less effective. This suggests that the more closely related a context cue is to the response being adapted, the more effective it is. Roll tilt of the head, and upright versus supine orientations, were somewhat effective in context switching; these paradigms contain orientation of gravity with respect to the head as part of the context.

The effect of the canalith repositioning maneuver on resolving postural instability in patients with benign paroxysmal positional vertigo

OBJECTIVE Patients with benign paroxysmal positional vertigo (BPPV) often experience postural instability as well as brief episodes of vertigo. The purpose of this study was to determine whether successful resolution of the episodic vertigo, through use of the canalith repositioning treatment, would be accompanied by improvement in postural stability. STUDY DESIGN Prospective clinical study. SETTING Outpatient tertiary care facility in a university. PATIENTS Thirty-three patients with a diagnosis of the canalithiasis form of BPPV affecting the posterior canal unilaterally. All patients had complete remission of the positional vertigo after treatment. Patients with abnormal caloric or rotary chair test results were excluded from the study. INTERVENTION The posterior canal BPPV was treated by the canalith repositioning treatment. MAIN OUTCOME MEASURES Postural stability was assessed by computerized dynamic posturography before and 1 to 2 weeks after treatment. Six different subtests were used. RESULTS A significant number of patients had abnormal stability, as measured with computerized dynamic posturography, before treatment. After treatment there was a significant increase in the number of subjects with normal results on the different subtests; however, not all patients had normal postural stability. Younger subjects were more likely to show improved stability. CONCLUSIONS Treatment of BPPV using the canalith repositioning treatment results in improved postural stability in patients with BPPV. Not all patients have normal stability after treatment, however, and assessment and treatment of the balance problems may be necessary.

OUTCOME MEASURES FOR ASSESSMENT OF TREATMENT OF THE DIZZY AND BALANCE DISORDER PATIENT

There are a variety of measurement tools available for assessing the treatment outcomes for patients with dizziness and imbalance. Some of these tools, however, may not be appropriate or valid for the patients in question. In this article, the various outcome measures are described and evaluated in terms of their reliability, validity, and sensitivity. There is no clearly superior outcome measure at this time, and the choice of the measurement tool depends on the patient and the aims of the treatment.

The effects of habituation and gaze stability exercises in the treatment of unilateral vestibular hypofunction: a preliminary results.

Background and Purpose: The efficacy of both habituation and adaptation exercise interventions in the treatment of unilateral vestibular hypofunction has been demonstrated by previous studies. The purpose of this article is to describe the preliminary results of an ongoing study that compares the effects of these 2 different exercise approaches on outcomes related to vestibular function. Methods: Seven participants with unilateral vestibular hypofunction completed a 6-week exercise intervention after random assignment to either habituation exercises or gaze stability (GS) adaptation exercises. The following measures were performed pre- and posttreatment: Dizziness Handicap Inventory to measure the symptom impact, motion sensitivity quotient (MSQ) to assess sensitivity to head movements, and the dynamic visual acuity (DVA) test as a measure of GS during head movements. Results: After the 6-week intervention, there was an overall improvement in the Dizziness Handicap Inventory, the MSQ score, and both the active and passive DVA. The habituation and GS intervention group participants each demonstrated similar improvements in both the MSQ score and the active and passive DVA measures. Discussion and Conclusions: The improvement in the MSQ score for the GS group and the improvement in the DVA measures for the habituation group were unexpected findings. Head movement, which is required by both exercise interventions, rather than the specific type of exercise may be the critical factor underlying the observed improvements in motion sensitivity and DVA.

Sensory, motor, and combined contexts for context-specific adaptation of saccade gain in humans

Saccadic eye movements can be adapted in a context-specific manner such that their gain can be made to depend on the state of a prevailing context cue. We asked whether context cues are more effective if their nature is primarily sensory, motor, or a combination of sensory and motor. Subjects underwent context-specific adaptation using one of three different context cues: a pure sensory context (head roll-tilt right or left); a pure motor context (changes in saccade direction); or a combined sensory-motor context (head roll-tilt and changes in saccade direction). We observed context-specific adaptation in each condition; the greatest degree of context-specificity occurred in paradigms that used the motor cue, alone or in conjunction with the sensory cue.

Context-specific adaptation of saccade gain is enhanced with rest intervals between changes in context state.

Abstract: Dual‐state adaptation of motor responses has been known for some time. A more recent development is a form of dual‐state adaptation known as “context‐specific adaptation,” which was explored through the use of saccade gain adaptation. In this model, two different adapted saccade gains are associated with two different states of a context cue, and the gain switches between the two adapted states when the context cue changes state. Such adaptation is imposed by alternating context/adaptation states over the course of an adaptation session. Here, vertical eye position as a context cue for adaptation of horizontal saccade gain is used: gain increase is induced with the eyes up 10°, and gain decrease with the eyes down 10°. This context cue is not very effective: there is interference between context/adaptation conditions such that gain‐decrease adaptation with eyes down transfers to the eyes‐up (gain‐increase) context. It was hypothesized that the juxtaposition in time of the alternating adaptation states exacerbated this interference. In order to test this, one‐minute rest breaks were inserted between each change in context/adaptation state. The resulting context‐specific adaptation improved dramatically: gain‐increase and gain‐decrease adaptations were more rapid and more complete. This resembles consolidation of motor learning, which, however, occurs over much longer time spans (hours rather than minutes). Thus, the results may reflect the operation of a novel “short‐term” motor consolidation process.

Acquisition of context-specific adaptation is enhanced with rest intervals between changes in context state, suggesting a new form of motor consolidation

We previously showed that the saccadic system could be adapted in a context-specific manner: two different adapted gains could be associated with two different context cues, with the gain state switched when the context state was switched. This was accomplished by alternating context/adaptation states several times over the course of an adaptation session, and assessing saccade gain in each context state before and after adaptation. One context cue we studied was vertical eye position; an adaptive gain increase was induced with the eyes up 10 degrees, and an adaptive gain decrease with the eyes down 10 degrees. This context cue was only partially effective: there was considerable undesired transfer of adaptation from the eyes-down condition (gain-decrease) to the eyes-up condition (gain-increase), with the result that there was little or no gain-increase adaptation. One explanation for this is that the two context/adaptation states, presented one after the other, interfered with each other. In the present study, we tested this hypothesis by interposing one-minute rest intervals between each alternation in context/adaptation state. The resulting context-specific adaptation is greatly improved (relative to the case when there are no rest intervals): both gain-increase and gain-decrease adaptations are stronger and occur more rapidly. This effect resembles that found in studies on the consolidation of motor learning, although such consolidation is believed to occur over much longer time spans (hours rather than minutes).