Terapia de rehabilitación vestibular en alteración mixta (central y periférica). Reporte de un caso / Vestibular rehabilitation therapy in mixed (central and peripheral) disorder. A case report

La terapia de rehabilitación vestibular es el tratamiento con mayor evidencia en la recuperación para la mayoría de los trastornos de equilibrio. En los casos que presentan una alteración estable del procesamiento central del equilibrio, o mixta, es decir, acompañada de una alteración a nivel del sistema nervioso periférico, la terapia de rehabilitación vestibular no se excluye como tratamiento. No obstante, los progresos suelen ser limitados y requieren de una mayor cantidad de sesiones. En este trabajo analizaremos un caso mixto, un paciente con síndrome de núcleo fastigial y el vértigo posicional paroxístico benigno (VPPB), desde la pesquisa y evaluación hasta el tratamiento y alta, en el Hospital Clínico Universidad de Chile.

Vestibular rehabilitation therapy is the treatment with the greatest evidence of recovery for most balance disorders. In the cases that have a loss of central balance processing, or mixed, that is, stable accompanied by a disorder of the peripheral nervous system the vestibular rehabilitation therapy is not excluded as a treatment; however, progress is usually limited and requires a greater number of sessions. In this work we will analyse a mixed case, a patient with nucleus fastigial syndrome and a benign paroxysmal positional vertigo, from the investigation and evaluation to the treatment and discharge, at the Hospital Clínico Universidad de Chile.

Effectiveness of conventional versus virtual reality-based vestibular rehabilitation exercises in elderly patients with dizziness: a randomized controlled study with 6-month follow-up

Abstract Objectives: To investigate the effect of vestibular rehabilitation exercises supported with virtual reality containing real-life environments on dizziness, static and dynamic balance, functional mobility, fear of falling, anxiety, and depression in elderly patients with dizziness. Methods: In this prospective randomized controlled study, 32-patients aged 65-years and older who applied to the otorhinolaryngology clinic with dizziness complaint randomly assigned to 2 groups. In Group 1 (n = 16), vestibular rehabilitation program, supported with virtual reality, and in Group 2 (n = 16), conventional vestibular rehabilitation program was applied 30-min a day, 5 sessions per week, 15 sessions in total for 3 weeks. Subjects were evaluated with The Vertigo Symptom Scale (VSS), Dizziness Handicap Inventory (DHI), Berg Balance Test (BBT) and Timed Up & Go Test (TUG), Falls Efficacy Scale-International (FES-I), Postural Stability Test (PST), Geriatric Depression Scale (GDS), Hamilton Anxiety Scale (HAS) at baseline, at the end of the treatment and 6-months after the treatment. Results: Statistically significant improvements were seen in the DHI emotional subscale and TUG in Group 1 compared to Group 2 at the end of the treatment in elderly with dizziness (p<0.05). Also, there were significant improvements in the VSS, all DHI subgroups, and total scores, BBT, HAS in Group 1 compared to Group 2 at the 6-months after the treatment (p<0.05). Conclusion: The application of vestibular rehabilitation in a virtual reality environment can lead to additional improvements especially in dizziness symptoms, disability, balance, and mobility in the elderly with chronic dizziness.

Effects of vestibular rehabilitation in the management of patients with and without vestibular migraine

Abstract Objective: Vestibular Migraine (VM) is the second most common cause in patients with vertigo. Patients with VM complain about vestibular symptoms during a headache attack or during the period between attacks. Vestibular Rehabilitation (VR), an exercised based therapy to treat dizziness and balance dysfunction has been shown to be effective in vestibular diseases. In this study, we aimed to assess the effect of VR for vestibular symptoms and quality of life in VM patients, and to compare the results with patients with vestibular disorders without migraine. Methods: Sixty (60) patients who received VR treatment were divided into two groups: vestibular migraine group (30 patients) and non-migraine vestibular dysfunction group (30 patients). All patients received VR for 18 sessions and the program was completed in 1.5 months. Preand post-treatment Dizziness Handicap Inventory (DHI) scores, Vestibular Disorders Activities of Daily Living Scale (VADL) scores, the frequency of dizziness and headache, and Computerized Dynamic Posturography (CDP) scores were assessed and compared retrospectively. Results: With VR in both the vestibular migraine group and vestibular dysfunction group, DHI score, VADL score, the frequency of dizziness and headache scores significantly impaired. Post-treatment CDP results were higher than pre- treatment results for both patient groups. Conclusion: With VR, a significant improvement was observed in subjective and objective balance assessment measurement. Vestibular Rehabilitation must be considered in patients who do not benefit from medical therapy or have limited benefit. Level of evidence: Level III (evidence obtained from well-designed controlled trials without randomization).

Vestibular rehabilitation therapy in combination with transcranial direct current stimulation (tDCS) for treatment of chronic vestibular dysfunction in the elderly: a double-blind randomized controlled trial / Terapia de reabilitação vestibular em combinação com estimulação transcraniana por corrente contínua (ETCC) para o tratamento de disfunção vestibular crônica em idosos: um ensaio clínico duplo‐cego randomizado

Abstract Introduction Dizziness and imbalance are common dysfunctions in the elderly. Vestibular rehabilitation therapy is an effective method to alleviate chronic dizziness in patients with vestibular dysfunction. Transcranial direct current stimulation has reportedly improved balance function in patients with vestibular dysfunction. Objective This study was conducted to investigate the therapeutic efficacy of vestibular rehabilitation combined with transcranial direct current stimulation in elderly patients with vestibular dysfunction. Methods In a double-blinded randomized controlled trial, 36 elderly patients with chronic vestibular dysfunction were randomly assigned to either vestibular rehabilitation and transcranial direct current stimulation (n = 18) or vestibular rehabilitation alone (n = 18) group. The transcranial stimulation protocol consisted of multisession bifrontal electrical stimulation of the dorsolateral prefrontal cortex (2 mA intensity and 20 min duration), followed by rehabilitation exercises. The vestibular rehabilitation protocol consisted of habituation and adaptation exercises combined with gait exercises during a three week period. The primary outcome of this study was the dizziness handicap inventory score, and the secondary outcomes were activities-specific balance confidence and Beck anxiety inventory scores. Results For the dizziness handicap score, the repeated-measures analysis of variance showed a significant main effect of "time", "stimulation" and stimulation × time interaction effect. There was a significant reduction in the overall dizziness handicap score with "time" for both the groups, which was more pronounced in the vestibular rehabilitation and electrical stimulation group. In terms of activities-specific balance confidence change scores, we found a significant main effect of "time" and "stimulation" main factors, but this effect for stimulation × time interaction was not significant. For the Beck anxiety score, we observed a significant main effect of "time", but no evidence for the main effect of the "stimulation" factor. Conclusion Bifrontal transcranial direct current stimulation in combination with vestibular rehabilitation therapy is a promising approach to improve chronic vestibular symptoms in the elderly.

Resumo Introdução Tontura e desequilíbrio são disfunções comuns em idosos. A terapia de reabilitação vestibular é um método eficaz para o alívio da tontura crônica em pacientes com disfunção vestibular. A estimulação transcraniana por corrente contínua tem melhorado a função de equilíbrio em pacientes com disfunção vestibular. Objetivo Investigar a eficácia terapêutica da reabilitação vestibular combinada com a estimulação transcraniana por corrente contínua em pacientes idosos com disfunção vestibular. Método Em um estudo duplo‐cego randomizado e controlado, 36 idosos com disfunção vestibular crônica foram aleatoriamente designados para o grupo reabilitação vestibular e estimulação transcraniana por corrente contínua (n = 18) ou reabilitação vestibular isolada (n = 18). O protocolo de estimulação transcraniana consistiu em estimulação elétrica bifrontal multissessão do córtex pré‐frontal dorsolateral (intensidade de 2 mA e duração de 20 minutos), seguida de exercícios de reabilitação. O protocolo de reabilitação vestibular consistiu em exercícios de habituação e adaptação combinados com exercícios de marcha por um período de três semanas. O desfecho primário deste estudo foi o escore do dizziness handicap inventory e os desfechos secundários foram os escores da escala activities‐specific balance confidence e Beck anxiety inventory. Resultados Em relação ao escore do dizziness handicap inventory, a análise de variância de medidas repetidas mostrou um efeito principal significativo do efeito de interação do "tempo", "estimulação"' e estimulação x tempo. Houve redução significativa do escore geral do dizziness handicap com o "tempo" em ambos os grupos, foi mais pronunciada no grupo reabilitação vestibular e estimulação elétrica. Em relação à mudança nos escores do activities‐specific balance confidence, encontramos um efeito principal significativo dos fatores principais de "tempo" e "estimulação", mas esse efeito não foi significativo para a interação estimulação × tempo. Para o escore do Beck anxiety inventory, observamos um efeito principal significativo do "tempo", mas nenhuma evidência do efeito principal do fator "estimulação". Conclusão A estimulação transcraniana por corrente contínua bifrontal em combinação com a terapia de reabilitação vestibular é uma abordagem promissora para melhorar os sintomas vestibulares crônicos em idosos.

Aplicabilidade e considerações clínicas do Sistema Contralateral Routing of Signal (CROS): revisão sistemática / Applicability and clinical considerations of the Contralateral Routing of Signal System (CROS): systematic review / Aplicabilidad y consideraciones clínicas del sistema de enrutamiento de señal contralateral (CROS): revisión sistemática

Introdução: O Sistema Contralateral Routing of Signal (CROS) é uma opção de intervenção auditiva com propósito de melhorar a percepção monoaural e minimizar as dificuldades da perda auditiva unilateral. Objetivo: analisar e descrever o público-alvo, o tempo de adaptação, o controle de uso do Sistema CROS, as avaliações utilizadas para medir os seus benefícios, sua efetividade e limitações. Método: Este estudo foi conduzido de acordo com as diretrizes PRISMA. A pesquisa bibliográfica foi realizada através dos bancos de dados científicos online na área da saúde, PubMed e Scopus, foram utilizadas as palavras-chave "Unilateral hearing loss", "Hearing aid", "CROS" e "Contralateral Routing of Signal". Os resultados da pesquisa limitaram-se a artigos científicos experimentais, que abordavam diretamente o sistema CROS, publicados em inglês, português ou espanhol. Resultados: Onze artigos foram selecionados para a revisão do texto completo. Quanto aos usuários do CROS, a faixa etária variou entre nove a 84 anos; prevalência do sexo masculino. Observou-se grande diversidade nas avaliações, sendo realizadas com tempo de uso inferior a 30 dias e superior a seis meses, após adaptação do CROS. Tal avaliação era realizada por meio de questionários não padronizados e avaliações objetivas com estímulos controlados. O uso do CROS proporcionou benefícios na localização sonora, efeito sombra da cabeça e inteligibilidade de fala, porém não mostrou eficácia em situações ruidosas. Conclusão: Por ser um dispositivo, não invasivo, de fácil adaptação e manuseio que traz benefícios imediatos, o CROS deve ser a primeira opção na reabilitação da perda auditiva unilateral.

Introducción: El Sistema Contralateral Routing of Signal (CROS) es una opción de intervención auditiva con el propósito de mejorar la percepción monoaural y minimizar las dificultades de la pérdida auditiva unilateral. Objetivo: analizar y describir el público objetivo, el tiempo de adaptación, el control del uso del Sistema CROS, las evaluaciones utilizadas para medir sus beneficios, su efectividad y limitaciones. Metodo: Este estudio se realizó de acuerdo con las pautas PRISMA. La búsqueda bibliográfica se realizó a través de bases de datos científicas online del área de salud, PubMed y Scopus, utilizando las palabras clave "Unilateral hearing loss", "Hearing aid", "CROS" y "Contralateral Routing of Signal". Los resultados de la investigación se limitaron a artículos científicos experimentales, que abordaron directamente el sistema CROS, publicados en inglés, portugués o español. Resultados: Se seleccionaron once artículos para revisión de texto completo. En cuanto a los usuarios de CROS, la edad osciló entre los nueve y los 84 años; prevalencia masculina. Hub gran diversidad en las evaluaciones, realizadas con tiempos de uso de menos de 30 días y más de seis meses tras la adaptación del CROS. Dicha evaluación se realizó mediante cuestionarios no estandarizados y evaluaciones objetivas con estímulos controlados. El uso de CROS proporcionó beneficios en la localización del sonido, el efecto de sombra de la cabeza y la inteligibilidad del habla, pero no fue efectivo en situaciones ruidosas. Conclusión: Al tratarse de un dispositivo no invasivo, de fácil adaptación y manejo que aporta beneficios inmediatos, CROS debería ser la primera opción en la rehabilitación de la hipoacusia unilateral.

Introduction: The system Contralateral Routing of Signal (CROS) is an option of auditory intervention in order to improve the monaural perception and minimize the difficulties of unilateral hearing loss. Objective: to analyze and describe the target users, the adaptation time and the control use of CROS system, the evaluations utilized to measure its benefits, as well as its effectiveness and limitations. Method: This study was conducted according to the PRISMA guidelines. The bibliographic research was through the scientific data online banks in the health area, PubMed and Scopus, using the keywords "Unilateral hearing loss", "Hearing aid", "CROS" and "Contralateral Routing of Signal". The results of the research were limited to experimental scientific articles, which address directly the CROS system, published in English, Portuguese or Spanish. Results: Eleven studies were selected to review. The age of CROS users ranged from nine to 84 years and male sex prevalence. There was great diversity in the evaluations being carried out. The performance's evaluation date varied between less than 30 days and more than six months after the adaptation. Such assessments were performed using non-standardized questionnaires and objective evaluations with controlled stimuli. The use of CROS provides benefits in sound localization, head shadow effect and speech intelligibility, but it is not effective in noisy situations. Conclusion: CROS should be the first option in unilateral hearing loss rehabilitation for being a non-invasive, easy adaption, handling dispositive and with good benefits to the client.

Técnicas de reposicionamiento canalicular efectivas para rehabilitación del vértigo posicional paroxístico benigno / Técnicas de reposicionamiento canalicular efectivas para rehabilitación del vértigo posicional paroxístico benigno / Effective canalicular repositioning techniques for rehabilitation of benign paroxysmal positional vertigo

El Vértigo Posicional Paroxístico Benigno es uno de los diagnósticos más comunes y consultados en la práctica clínica de patologías de vértigo, por lo tanto, el presente artículo tiene como finalidad, describir las técnicas de reposicionamiento canalicular más utilizadas por Audiólogos expertos en rehabilitación vestibular específicamente para los conductos semicirculares de mayor prevalencia que se ven afectados en esta patología, los cuales son; el conducto semicircular posterior y el conducto semicircular horizontal, en contraste con las técnicas de mayor efectividad reportadas en la literatura. Lo anterior, sustentado en la aplicación de una encuesta, y, revisión de literatura especializada a través de una metodología con enfoque cualitativo y alcance descriptivo, se encuestó a doce Audiólogos especialistas en rehabilitación vestibular mediante la técnica bola de nieve. En cuanto a la revisión de literatura científica se tuvo en cuenta publicaciones de los últimos cinco años de bases de datos especializadas, seleccionando quince artículos de acuerdo con los criterios de inclusión, obteniendo como resultado que actualmente existe correspondencia entre las técnicas recomendadas en la literatura y las aplicadas en la práctica audiológica.

Benign Paroxysmal Positional Vertigo is one of the most common and consulted diagnoses in the clinical practice of vertigo pathologies, therefore, the purpose of this article is to describe the Canalicular repositioning techniques most used by expert Audiologists in vestibular rehabilitation specifically for the most prevalent semicircular canals that are affected in this pathology, which are the posterior semicircular canal and the horizontal semicircular canal, in contrast to the most effective techniques reported in the literature. The above, based on the application of a survey and review of specialized literature through a qualitative approach methodology with descriptive scope, twelve Audiologists specialized in vestibular rehabilitation were surveyed by means of the snowball technique. As for the review of scientific literature, publications of the last five years of specialized databases were taken into account, selecting fifteen articles according to the inclusion criteria, obtaining as a result that currently there is correspondence between the techniques recommended in the literature and those applied in audiological practice.

Gaze stabilization exercises can improve balance after a stroke / 中华物理医学与康复杂志

Objective:To observe the effect of gaze stabilization exercises on the balance of stroke patients.Methods:Forty stroke patients were randomly divided into an experimental group ( n=20) and a control group ( n=20). Both groups were given conventional rehabilitation therapy, while the experimental group was additionally provided with gaze stabilization exercises, once a day, five days a week, for a total of four weeks. Each session lasted 30 minutes. Before and after the four weeks, both groups were evaluated in terms of their envelope ellipse area and the plantar pressure distribution on the affected side in static standing and using the anterior-posterior center of pressure displacement velocity (AP-COPV). They were also assessed using the Berg Balance Scale (BBS), the timed up-and-go test (TUGT), and the Activities-specific Balance Confidence Scale (ABC). Results:After the gaze stabilization exercises, the average envelope ellipse area, the plantar pressure distribution of the affected side with the eyes open and closed, AP-COPV, BBS score, TUGT time and ABC score of the experimental group were significantly superior to the control group′s averages and to the results four weeks previously.Conclusions:Gaze stabilization exercises can improve balance, weight shifting and one-leg standing after a stroke. That should enhance balance confidence and reduce the risk of falling.

Effects of Customized Vestibular Rehabilitation on Static balance among Adults with Benign Paroxysmal Positional Vertigo (Kesan Rehabilitasi Vestibular Disesuaikan Ke Atas Keseimbangan Static Dalam Kalangan Dewasa Dengan Masalah Benign Paroxysmal Positional Vertigo) / Jurnal Sains Kesihatan Malaysia

@#The aim of this study was to detemine the effectiveness of Customized vestibular rehabilitation (CVR) in addition to the standard Canalith repositioning maneuver (CRM) on static balance among adults with posterior canal Benign Paroxysmal Positional Vertigo (BPPV). In this randomised controlled trial, 28 adults with idiopathic unilateral posterior canal BPPV were randomized to either the control or experimental group. The experimental group (n=14, mean age: 50.71±9.88 years) received CVR in addition to CRM, and the control group (n=14, mean age: 54.36±8.55 years) received only CRM for 6 weeks. Measurements of static balance (postural sway) using a portable kinematic sensor were performed at baseline, four and six weeks after treatment for both groups while standing on firm and foam surface with eyes open (EO) and closed (EC). Only standing on foam surface with EC was observed to have a significant interaction effect, F (2, 52) =5.28, p<0.05. This suggest that the groups were affected differently by the intervention and greater improvement was demonstrated in the experimental group. Post hoc test showed that a significant difference (p<0.05) in static balance was shown between baseline and 6th week after intervention. The results of our study indicate that CVR in addition to CRM improved static balance in adults with UPC BPPV at 6th week after intervention for persons with BPPV.

Aquatic physiotherapy: a vestibular rehabilitation option / Fisioterapia aquática: uma opção de reabilitação vestibular

Abstract Introduction: Vestibular rehabilitation is a fundamental resource for vestibular symptom control. Its performance in the aquatic environment is considered safe for the physical activities of the elderly, because they act simultaneously on musculoskeletal disorders and balance improvement. Objective: To evaluate the effects of an aquatic physiotherapy protocol in individuals with peripheral vestibular alterations. Methods: This was an interventional case study with a paired intentional sample of four subjects, who were selected for convenience. The subjects, all of them diagnosed with peripheral vestibulopathy, were submitted to twelve sessions of aquatic physiotherapy for vestibular rehabilitation, being evaluated for dizziness in three moments: initial, after six sessions and at the end of the sessions. The tests applied were: unipodal support to measure static balance, the Fukuda stepping test, which estimates the dynamic balance and the dizziness handicap inventory protocol, aimed at verifying how dizziness influences daily life. Results: When analyzing the static balance, initially the individuals were in the adaptive and abnormal dimensions, and all reached normality at the end of the protocol. Regarding the dynamic balance, the individuals initially showed marked impairment in the angular deviation, mainly to the side of pathology (75% to the left and 25% to the right), achieving improvement at the end of the study. However, it failed to reach statistical significance. The dizziness handicap inventory showed a statistically significant difference in its totality (p = 0.0414), which addresses the physical, functional and emotional factors. Conclusion: In conclusion, the aquatic physiotherapy protocol for vestibular rehabilitation of patients with peripheral impairment was positively assessed by the participants, considering the improvement in dizziness (static and dynamic) and its impact on daily activities.

Resumo Introdução: A reabilitação vestibular se consolida como um recurso fundamental para o controle de sintomas vestibulares e sua feitura no meio aquático é considerada segura para as atividades físicas dos idosos, atua simultaneamente nas desordens musculoesqueléticas e na melhoria do equilíbrio. Objetivo: Avaliar os efeitos de um protocolo de fisioterapia aquática em indivíduos com alterações vestibulares periféricas. Método: Estudo de caso intervencional com amostra intencional pareada de quatro sujeitos, selecionados por conveniência, diagnosticados com vestibulopatias periféricas. Os sujeitos foram submetidos a 12 sessões de fisioterapia aquática para reabilitação vestibular. Foram avaliados quanto à tontura em três momentos: inicial, após seis sessões e ao término dos atendimentos. Os testes aplicados foram: o apoio unipodal para mensurar o equilíbrio estático, a prova dos passos de Fukuda que estima o equilíbrio dinâmico e o protocolo dizziness handicap inventory com o objetivo de verificar o quanto a tontura influencia na vida cotidiana. Resultados: Ao analisar o equilíbrio estático, inicialmente os indivíduos se encontravam nas dimensões adaptativas e anormais e ao término do protocolo todos atingiram a normalidade. Em relação ao equilíbrio dinâmico, os indivíduos inicialmente apresentavam grande comprometimento no desvio angular principalmente para o lado da patologia (75% à esquerda e 25% à direita), conseguiram uma melhoria no fim do estudo. Todavia, não conseguiu atingir a significância estatística. O dizziness handicap inventory obteve diferença estatisticamente significante em sua totalidade (p = 0,0414), onde aborda os fatores físicos, funcionais e emocionais. Conclusão: O protocolo de fisioterapia aquática voltado para reabilitação vestibular de pacientes com comprometimento periférico foi avaliado de forma positiva pelos participantes, considerando-se a melhoria no quadro de tontura (estática e dinâmica) e do seu impacto nas atividades cotidianas.

Reflexiones sobre rehabilitación vestibular a propósito de un caso con uso de paradigma de tareas dobles / Insights on vestibular rehabilitation concerning one case with the use of dual task paradigm

Resumen Se presenta una reflexión producto de la introducción del paradigma de tareas dobles en el abordaje terapéutico en un caso de vestibulopatía unilateral periférica. Se aplicaron pautas de autovaloración de la discapacidad y riesgo de caídas, complementándose con una completa evaluación del equilibrio funcional y la marcha. Se planificó una terapia personalizada, jerarquizándose objetivos con un criterio funcional. Se incorporó el paradigma de tareas dobles, incluyéndose tareas cognitivas simples a la terapia tradicional de rehabilitación vestibular, con el fin de reducir la influencia cortical sobre la ejecución motora, potenciar la ganancia y funcionalidad de los reflejos remanentes, estimular funciones cognitivas superiores y potenciar procesos atencionales subyacentes, necesarios para lograr la compensación. Los resultados de la reevaluación mostraron una evolución favorable, con remisión de la sintomatología, disminución significativa de los puntajes obtenidos en las diferentes pautas empleadas y una mejoría subjetiva en el equilibrio y marcha funcional después de la terapia. Lo anterior se asoció a la recuperación de la autonomía e independencia para la ejecución de actividades diarias, incidiendo favorablemente en la calidad de vida de la paciente. Los hallazgos confirman los beneficios del programa de rehabilitación vestibular diseñado. Se requieren estudios adicionales, orientados a evidenciar y corroborar el impacto específico de la incorporación del paradigma de tareas dobles en la rehabilitación de los trastornos del equilibrio y especialmente, en procesos de estimulación o rehabilitación vestibular en adultos mayores.

Abstract This article presents the analysis and reflections evoked from an experience in vestibular rehabilitation with the introduction of the paradigm of dual task in a unilateral peripheral vestibulopathy case. First, disability self-assessment guidelines, risk of falls scales and assessment tools of functional balance and gait were applied in order to determine the main symptoms and the main difficulties observed. Afterwards, a personalized therapy was planned, in which work objectives were hierarchized based on a functional criterion, introducing "dual-task" strategies as tools for diminish cortical influence on motor performances, allowing the automation of the required task; enhance the gain and functionality of the remaining reflexes, especially vestibulo ocular and vestibulospinal reflex and stimulate superior cognitive functions and underlying attentional processes, necessary to achieve central compensation. The final assessment showed a favorable evolution, with a significant decrease in the after-therapy scores obtained in fear of falling and disability self-perception protocols, before and after therapy and, finally, an improvement in functional balance and gait, through the pre and post therapy performance in the timed up and go and assessment of unipedal stand tests. This allowed the patient to regain her autonomy and independence in daily life activities improving her quality of life, confirming the benefits of the designed vestibular rehabilitation program. However, more studies are needed to corroborate the specific contribution of the dual-task paradigm in vestibular rehabilitation and specially, in vestibular stimulation or rehabilitation processes in older adults.

Mareo residual, una condición clínica frecuente posterior a maniobra de reposición exitosa en vértigo posicional paroxístico benigno: una revisión / Residual dizziness, a frequent clinical condition following successful repositioning maneuver for benign paroxysmal positional vertigo: a review

El vértigo posicional paroxístico benigno (VPPB) es reconocido como la principal causa de vértigo de origen periférico en adultos, ya que, si bien la etiología del VPPB aún no se ha demostrado plenamente y se clasifica como la mayoría de los casos, se puede identificar el desprendimiento de otolitos y su desplazamiento en uno de los tres canales semicirculares. Una anamnesis cuidadosa puede abordar el diagnóstico clínico del VPPB, pero la confirmación se obtendrá por medio de maniobras de diagnóstico especificas de acuerdo a cuál de los canales está involucrado. Este trastorno altera la capacidad de llevar a cabo actividades de la vida cotidiana que determinan un aumento significativo en el riesgo de caídas y las consiguientes lesiones. La mayoría de los pacientes se recuperan después del tratamiento, sin embargo, hasta dos tercios de éstos pueden percibir inestabilidad prolongada, aturdimiento y malestar definidos como mareo residual. Esta sintomatología residual después de la resolución del VPPB es variable entre los pacientes, siendo el tiempo de duración de los síntomas residuales de aproximadamente de 1 a 3 semanas, existiendo algunos pacientes que pueden recuperarse más tardíamente. En esta revisión analizaremos el mareo residual, describiendo su expresión clínica, diagnóstica, fisiopatológica y tratamientos actuales de esta entidad clínica.

Benign paroxysmal positional vertigo (BPPV) is recognized as the main cause of peripheral vertigo in adults, although the etiology of BPPV has not yet been fully demonstrated and is classified as idiopathicin most cases, detachment of otoliths and their displacement in one of the three semicircular canals can be identifie. A careful history can address the clinical diagnosis of BPPV, but confirmation will be obtained through specific diagnostic maneuvers according to which canal is involved. This disorder alters the ability to carry out activities of daily living that determine a significant increase in the risk of falls and consequent injuries. Most patients recover after treatment, however, up to two thirds of these patients may perceive prolonged instability, dizziness and discomfort defined as residual dizziness. This residual symptomatology following BPPV resolution is variable among patients, the duration of residual symptoms can last 1 to 3 weeks, with some patients may recover later on. In this review, we will analyze residual dizziness, describing its clinical presentation, diagnosis, pathophysiology and current treatments of this clinical entity.

Impacto de la rehabilitación vestibular en el riesgo de caída y la confianza del paciente / Impact of vestibular rehabilitation on the risk of falling and patient confidence

RESUMEN Introducción: Las alteraciones del sistema vestibular como la hipofunción vestibular unilateral, predisponen al usuario a sufrir caídas alterando así su confianza. Objetivo: Determinar el impacto de la rehabilitación vestibular en el riesgo de caídas y el grado de confianza en mujeres con hipofunción vestibular unilateral. Material y método: Se realiza estudio prospectivo en 20 pacientes de género femenino mayores de 60 años con diagnóstico de patología vestibular periférica. Se evalúa el riesgo de caídas con escala Tinetti y el grado de confianza al realizar actividades de la vida diaria por medio de la escala ABC (Activities-specific Balance Confidence), antes y después de realizar terapia de rehabilitación vestibular (RV). Resultados: Las dos variables estudiadas Tinetti y escala ABC demostraron mejoras significativas en la mayoría de las pacientes, demostrando que a medida que aumenta el grado de confianza disminuye el riesgo de caídas. Conclusión: Los resultados obtenidos de este estudio sugieren que la terapia de RV es eficiente en mejorar el riesgo de caídas y favorecer el aumento de confianza en las actividades de la vida diaria en el grupo de pacientes estudiadas.

ABSTRACT Introduction: Changes in the vestibular system, such as unilateral vestibular hypo-function, predispose the user to suffer falls, thus altering his confidence. Aim: To determine the impact of vestibular rehabilitation on the risk of falls and the degree of confidence in women with unilateral vestibular hypofunction. Material and method: A prospective study was conducted in 20 female patients over 60 years of age with a diagnosis of peripheral vestibular pathology. The risk of falls with a Tinetti scale and the degree of confidence in carrying out activities of daily living are evaluated through the ABC scale (Activities-specific Balance Confidence), before and after performing vestibular rehabilitation therapy (VRT). Results: The two variables studied, Tinetti and ABC scale showed significant improvements in most of the patients, demonstrating that as the degree of confidence increases the risk of falls decreases. Conclusion: The results obtained from this study suggest that VRT is efficient in improving the risk of falls and favoring an increase in confidence in the activities of daily life in the group of patients studied.

Dependencia visual en otoneurología: consideraciones clínicas para la rehabilitación vestibular / Visual dependence in otoneurology: clinical considerations for vestibular rehabilitation

RESUMEN Los sistemas vestibular, visual y somatosensorial coordinan el control postural y se adaptan a las actividades cotidianas en diferentes contextos, sin embargo, cuando existe un cuadro clínico con sintomatología vestibular, las ponderaciones de estos sistemas cambian mayoritariamente al sistema visual, creando una dependencia visual. El cerebelo, que es el principal encargado de generar una compensación vestibular en casos de hipofunción vestibular, juega un rol destacado en el aprendizaje motor generando comportamientos adaptativos que se transforman en puntos claves en la rehabilitación vestibular. Este artículo pretende exponer lo que la literatura informa en relación a la dependencia visual en pacientes con hipofunción vestibular.

ABSTRACT The vestibular, visual and somatosensory systems coordinate postural control and adapt to daily activities in different contexts, however, when there is a clinical picture with vestibular symptoms, the weights of these systems change mainly to the visual system, creating a visual dependence. The cerebellum, which is the main responsible for generating vestibular compensation in cases of vestibular hypofunction, plays a prominent role in motor learning generating adaptive behaviors that become key points in vestibular rehabilitation. This article aims to expose what the literature reports in relation to visual dependence in patients with vestibular hypofunction.

Mecanismos neurofisiológicos de la rehabilitación vestibular / Neurophysiological mechanisms of vestibular rehabilitation

RESUMEN La rehabilitación vestibular es un concepto terapéutico utilizado en pacientes que presentan síntomas como vértigos y/o mareos, asociados a una afectación vestibular, además de otras manifestaciones clínicas. Este artículo busca entregar un análisis amplio de los elementos que interactúan para definir una patología, como a su vez intervenir en su compensación. Serán presentados elementos neuroanatómicos, fisiológicos y conceptuales de la rehabilitación para este tipo de pacientes con un enfoque clínico basados en la evidencia.

ABSTRACT Vestibular rehabilitation is a therapeutic concept used in patients suffering from dizziness and/or dizziness, in addition to other clinical manifestations. This article gives a broad analysis of the elements that interact to define a pathology, as well as to intervene in their compensation. Neuro anatomical, physiological and conceptual elements of rehabilitation for this type of patients will be presented with a clinical approach based on evidence.

Vestibular rehabilitation improves the balance of persons with Parkinson's disease / 中华物理医学与康复杂志

Objective To explore the effect of vestibular rehabilitation on the balance function of patients with Parkinson's disease.Methods Sixty-one patients with Parkinson's disease were randomly divided into a treatment group of 30 and a control group of 31.Both groups were given the usual health education about fall prevention,while the treatment group was additionally provided with 50 to 70 minutes of vestibular rehabilitation training 6 times a week for 8 weeks.The training included the adaptability training,balance training and gait training.Before and after the treatment,both groups were evaluated with the unified Parkinson's disease rating scale (part Ⅲ)(UPDRS Ⅲ),the Berg balance scale (BBS),the Timed Up and Go test (TUGT) and the 39-item Parkinson's disease questionnaire (PDQ39).Results There were no significant differences in the average UPDRS Ⅲ,BBS or PDQ39 scores nor in the average TUGT times between the two groups before the treatment.After the treatment there was still no significant difference in groups' average UPDRS Ⅲ and PDQ39 scores,but the average TUGT times and BBS scores of the treatment group were then significantly improved and significantly better than the control group's averages.Conclusion Vestibular rehabilitation training can improve the balance and walking ability of those with Parkinson's disease.It can serve as an important ancillary treatment to drug therapy.

Customized Vestibular Rehabilitation in the Patients with Bilateral Vestibulopathy: A Pilot Study in One Referred Center / 대한평형의학회지

OBJECTIVES: Bilateral vestibulopathy is characterized with unsteadiness and oscillopsia when walking or standing, worsening in darkness and/or on uneven ground. To establish the effect of customized vestibular rehabilitation in bilateral vestibulopathy, we analyzed the questionnaires and functional status before and after treatment. METHODS: Among 53 patients with customized vestibular rehabilitation from January 1st to November 30th in 2018, 6 patients (3 males; median age, 71 years; range, 54–75 years) who regularly exercised with good compliance were retrospectively enrolled. They were educated and trained the customized vestibular rehabilitation once a month or two by a supervisor during 40 minutes, and then exercised at home for 30 minutes over 5 days in a week. Dizziness handicap inventory (DHI), Korean vestibular disorders activities of daily living scale (vADL), Beck's depression index (BDI), test for dynamic visual acuity (DVA), and Timed Up and Go test (TUG) were performed before and after the customized vestibular rehabilitation. RESULTS: The patients exercised for median 5.5 months (range, 2–10 months) with the customized methods of vestibular rehabilitation, which included gaze and posture stabilization and gait control exercises. DHI score and TUG was improved after rehabilitation (DHI before vs. after rehabilitation=33 vs. 16, p=0.027, TUG before vs. after rehabilitation=12 vs. 10, p=0.026). BDI, DVA, and vADL scores did not differ between before and after treatment. CONCLUSIONS: Customized vestibular rehabilitation can improve dizziness and balance state in bilateral vestibulopathy. The steady exercises adapted individual peculiarities is the most important for vestibular rehabilitation.

Factors Associated with Patient Satisfaction in Customized Vestibular Exercise: A Pilot Study / 대한평형의학회지

OBJECTIVES: Numerous studies have been reported on the effect of customized vestibular exercise (cVE), but only a few studies have been reported on the satisfaction of cVE. Therefore, this study aims to investigate the factors that affect the satisfaction of cVE. METHODS: A telephone survey was conducted on 37 patients who underwent cVE from January to November 2018. The questionnaire consisted of a total of 10 items, including subjective symptom, compliance and satisfaction of exercise, preferred methods of exercise, and appropriate costs. Based on the questionnaire of satisfaction, the clinical features, improvement of symptom, compliance, preferred methods of exercise were compared between satisfactory and unsatisfactory groups. RESULTS: Of the 20 patients who responded to the telephone survey (response rate 57%), 10 patients were included in the satisfactory group and the remaining 10 were included in the unsatisfactory group. There were no significant differences between the 2 groups in age, sex, severity of subjective symptom before cVE, preferred methods of exercise. However, patients in the unsatisfactory group were significantly more likely to have chronic vestibulopathy and abnormal findings in dynamic posturography test than those in the satisfactory group. Subjective dizziness after cVE was significantly decreased in the satisfactory group, but there was no significant difference in the unsatisfactory group. These patients in the unsatisfactory group still had dizziness, but tended not to continue to exercise. CONCLUSIONS: The satisfaction of cVE was significantly lower in patients with chronic vestibulopathy, postural instability, less improvement of dizziness, and poor compliance.

Abordaje translaberíntico y rehabilitación vestibular: eficacia en el tratamiento de la disfunción vestibular en pacientes con schwannoma vestibular / Translabyrinthine approach and vestibular rehabilitation: efficacy in the treatment of vestibular dysfunction in patients with vestibular schwannoma

Introducción: En los schwannomas vestibulares (SV), la incidencia de disfunción vestibular como principal síntoma es del 10%, sin embargo, producen un notorio impacto en la calidad de vida de los pacientes. Objetivo: Evaluar el impacto funcional que produce la exéresis de SV por via translaberintica y la rehabilitación vestibular sobre los síntomas vestibulares, en los pacientes tratados en nuestro hospital. Material y Métodos: Se realizó un análisis prospectivo de 2 pacientes con diagnóstico de SV y disfunción vestibular agregada. En ambos pacientes, se realizó la resección a través de un abordaje translaberíntico. Los pacientes fueron evaluados funcionalmente antes y después de la cirugía. El impacto de la misma sobre la calidad de vida se evalúo mediante la Escala de Discapacidad por Mareo (DHI). Todos los pacientes realizaron un plan de rehabilitación vestibular personalizado y a los 12 meses postoperatorios presentaron una mejoría clínica significativa en comparación con el preoperatorio. Discusión: Las posibles opciones de tratamiento en estos pacientes resultan limitadas. En la literatura, se ha demostrado que la laberintectomía es un tratamiento eficaz para el tratamiento de síntomas vestibulares persistentes e incapacitantes, en los pacientes sin audición funcional. La calidad de vida de los mismos es reducida, y mejoraría significativamente después de la cirugía translaberintica y de un programa personalizado de rehabilitación vestibular. Conclusión: Debido a su eficacia comprobada, el abordaje translaberíntico y la resección de la lesión, acompañado de la realización un programa de rehabilitación vestibular, como estrategia de tratamiento para estos pacientes debe ser considerado.

Introduction: The incidence of disabling vestibular symptoms in vestibular schwannoma patients has been reported at roughly 10%. Despite their relative rarity, however, such symptoms can lead to physical and social limitations and reduce patients' quality of life. Unfortunately, published evidence on possible treatment options for vestibular schwannoma patients with disabling vestibular symptoms is limited. Objective: To report the functional impact of trans-labyrinthine microsurgery and vestibular rehabilitation, performed at our hospital, in two vestibular schwannoma patients with disabling vestibular symptoms. Methods: A prospective analysis was performed of two patients with a unilateral vestibular schwannoma, without serviceable hearing in their affected ear, and severely handicapped by attacks of rotatory vertigo and constant dizziness. Trans-labyrinthine surgery, with complete tumor resection, was performed in both patients. Preoperative and postoperative quality of life was measured using Dizziness Handicap Inventory (DHI) scores. Both patients also underwent a customized vestibular rehabilitation program and had a final evaluation 12 months post-operatively. Results: Relative to their preoperative evaluation, both patients experienced significant clinical improvement that persisted through 12 months of post-operative follow-up. Conclusions: Consistent with the few prior reports already published, we found that surgical removal of vestibular schwannomas by trans-labyrinthine surgery and vestibular rehabilitation was safe and effective for persistent, disabling vestibular symptoms. Postoperative vertigo and quality of life both improved significantly when microsurgery was combined with a personalized vestibular rehabilitation program. Disabling vestibular symptoms that impair quality of life in patients with vestibular schwannoma without serviceable hearing in the affected ear should be considered for trans-labyrinthine microsurgery and personalized vestibular rehabilitation.

The Effects of the Vestibular Rehabilitation on the Benign Paroxysmal Positional Vertigo Recurrence Rate in Patients with Otolith Dysfunction

BACKGROUND AND OBJECTIVES: Although repositioning maneuvers have shown remarkable success rate in treatments of benign paroxysmal positional vertigo (BPPV), the high recurrence rate of BPPV has been an important issue. The aims of present study were to examine the effects of otolith dysfunction on BPPV recurrence rate and to describe the effect of vestibular rehabilitation exercises on BPPV recurrence in BPPV patients with concomitant otolith dysfunction. SUBJECTS AND METHODS: Forty-five BPPV patients included in this study (three groups). Patients in group 1 had no otolith dysfunction and patients in groups 2 and 3 had concomitant otolith dysfunction. Otolith dysfunction was determined with ocular/cervical vestibular evoked myogenic potential (oVEMP and cVEMP) abnormalities. Epley’s maneuver was performed for the patients in all groups but patients in group 3 also received a 2-month vestibular rehabilitation program (habituation and otolith exercises). RESULTS: This study showed that BPPV recurrent rate was significantly higher in patients with otolith dysfunction in comparison to the group 1 (p < 0.05). Vestibular rehabilitation resulted in BPPV recurrence rate reduction. Utricular dysfunction showed significant correlation with BPPV recurrence rate. CONCLUSIONS: Otolith dysfunction can increase BPPV recurrence rate. Utricular dysfunction in comparison to saccular dysfunction leads to more BPPV recurrence rate. Vestibular rehabilitation program including habituation and otolith exercises may reduce the chance of BPPV recurrence.

Customized Vestibular Exercise / 대한이비인후과학회지

Vestibular rehabilitation is an excellent treatment option that can improve dizziness and balance through specific exercises in patients with dizziness who cannot be expected to improve with medication or surgical treatment. Vestibular rehabilitation treatment, especially customized exercise requires a long and complicated process of various evaluation processes, customized prescription of exercise, education, and training. Effective vestibular rehabilitation requires specialists with knowledge of vestibular rehabilitation, patient's commitment to recovery and understanding for the vestibular rehabilitation, and a medical system that can support the time, human resources, and place needed for vestibular rehabilitation. In 2017, customized vestibular exercise is finally approved as a new medical technology, and active treatment for dizziness has become possible for patients who need vestibular rehabilitation. Customized vestibular exercise is an individualized exercises in accordance with the symptoms and disabilities of the patient to improve dizziness and balance problem. Customized exercise consists of an evaluation process to find out the patient's problem, and exercise prescription and training.